Minnesota Physician September 2022

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Treating Spinal Cord Injuries

Developing a new model of care

BY LESLIE MORSE, DO

According to the Administration for Community Living (ACL), an operating division of the U.S. Department of Health and Human Services, there is an ongoing need for research that can improve services and outcomes for people with spinal cord injury (SCI)–research that can improve health and function, community living and employment. ACL statistics indicate there are approximately 296,000 individuals living with SCI in the United States; the average age of injury is 43.

Perfect Occupancy

Why everyone needs coordinated care

BY JESSE BETHKE GOMEZ, MMA

According to the US Census Bureau’s American Community Survey 2020 estimates, there are 875,566 adults over 65 years of age and 603,886 people with disabilities in Minnesota. The State Demographer’s Office estimates that by 2030 the number of older adults will grow to over 1,260,000. Even adjusting for the fact that 30% of older adults also have some kind of disability, this still means that over 20% of our population is either older, disabled or both. These individuals regularly see several different health care providers for their often complex health conditions, which poses many unique challenges to the way our health care platform operates currently.

While SCI remains a low-incidence condition (estimates are that 17,900 individuals acquire new SCI in the United States each year), the ACL notes it has a profound impact on those who survive the initial trauma. In addition, increased survival rates

Treating Spinal Cord Injuries to page 124

Elevate everyday the

Sanford Health East Interstate Avenue Clinic has doubled down on its commitment to building hope through better mental and behavioral healthcare by reconfiguring three neighboring practices into more accessible, wellness-driven environments that preserve patient dignity. The JLG-designed new Behavioral Health practice gives patients privacy with an exclusive waiting area and entrance while giving providers a place of refuge in the centralized core, open gym, and outdoor courtyard. This is healthcare design that elevates the everyday — bridging the gap between silence and seeking help.

To learn more about JLG, contact Todd Medd, tmedd@jlgarchitects.com or Kristine Sallee, ksallee@jlgarchitects.com

SEPTEMBER 2022 | Volume XXXVI, Number 06

COVER FEATURES

Perfect Occupancy Why everyone needs coordinated care

By Jesse Bethke Gomez,

DEPARTMENTS

MMA,

Treating Spinal Cord Injuries Developing a new model of care

By Leslie Morse, DO

CAPSULES 4

INTERVIEW 8

The Architecture of Creating New Knowledge

Genevieve Melton-Meaux, MD, PhD, Center for Learning Health System Sciences

BEHAVIORAL HEALTH 14

Outstate Behavioral Health Care Meeting the challenges and needs

By

Thomas Otten, MA

EMERGENCY MEDICINE 18

Fluorescence Microangiography A new tool in the management of frostbite

By Thomas Masters, MD, FACEP,

FAAEM,

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PUBLISHER

Mike Starnes, mstarnes@mppub.com

ART DIRECTOR Scotty Town, stown@mppub.com

Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is PO Box 6674, Minneapolis, MN 55406; email comments@mppub.com; phone 612.728.8600;. 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.

CARE COORDINATION

Improving Communication and Outcomes

BACKGROUND AND FOCUS:

As health care faces rising costs, chronic workforce shortages and seemingly ever increasing administrative burdens, the pace of evolution is unparalleled. One example is the emergence of care teams; many different licensed and unlicensed providers working together to the top of their training. While this offers benefits it also creates new challenges. The two most critical are ensuring every provider is aware of the care a patient receives and the patient is aware of, and adheres to, his or her individual treatment plan. The complexities of these task have given rise to a new part of the care team, the care coordinator.

OBJECTIVES:

Our panel will examine the role of the care coordinator, how and why it is becoming an increasingly important part of health care delivery. When care coordination may be provided by clinic or health system staff, by third party payers, by private industry contracting out-of state employees, and even by state health agencies, utilization of this tool can present conflicts, confusion and frustration. We will look at the different aspects of care coordination and provide insight into how they work best in various practice settings.

JOIN THE DISCUSSION

We invite you to participate in the conference development process. If you have questions you would like to pose to the panel or have topics you would like the panel discuss, we welcome your input.

Please email: Comments@mppub.com and put “Roundtable Question” in the subject line.

New Name for Twin Cities Medical Society

The group of Minnesota-based physicians and medical students formerly known as Twin Cities Medical Society has recently announced they will now be called Advocates for Better Health, or ABH. The new name and identity reflect an ongoing evolution in the organization’s mission and vision toward physician and medical student advocacy dedicated to healthier, more equitable communities. The new brand will help position ABH as a forward-looking organization at the heart of the changes in medicine and public health that are sorely needed to address health care’s most critical issues. “Our organization is wholly focused on initiatives that support public health, including the most impactful for people in our communities here in Minnesota and across the U.S. ABH initiatives will advance the health of our Minnesota communities

while at the same time promote physician well-being,” said ABH President Zeke McKinney, MD, MHI, MPH. “As we move forward with our new vision, we’ll expand our issue advocacy and provide more ways for doctors and medical students to collaborate and grow in advocacy together.” Top priorities for ABH include initiatives to ban flavored commercial tobacco products and to promote healthier school meals. ABH will continue to support important programs including the Dr. Pete Dehnel Public Health Advocacy Fellowship. The Fellowship creates a connection between medicine and public health for medical students by offering opportunities for students to engage in local public health advocacy activities. “Our Board has worked hard as our organization continues our evolution as a new kind of medical society to meet the shifting realizes in public health,” said Becky Timm, CEO of ABH. “We selected Advocates for Better Health–ABH–as

a reflection of the ongoing evolution of our mission and vision, and to further cement our organization’s whole focus on public health.” CEO Timm added that The TCMS Foundation, the organization’s philanthropic arm, will now become The ABH Foundation. ABH currently represents approximately 4,500 physicians and medical students living and working in Minnesota. All physicians who live or practice in Minnesota are warmly invited to join ABH. You can now join ABH independent of your other professional memberships, making it easy be a member of ABH. Physician membership dues are $300 annually and can be covered by CME dollars by most employers. For more information visit “http//www.metrodoctors.com.

NIH Renews $48M Research Grant for Mayo

Mayo Clinic recently announced that its Center for Clinical and

Translational Science has successfully renewed funding of its research grant from the National Institutes of Health National (NIH) for five more years. The funding award, totaling $48.2 million, is one of Mayo’s largest NIH grants, supporting research and education across the institution that will accelerate innovation to improve patient care and health for all people. “We are very pleased with this news and the continued support from the National Center for Clinical and Translational Sciences,” says Claudia Lucchinetti, M.D., director of Mayo’s Center for Clinical and Translational Science and principal investigator on the grant. “This will allow Mayo to continue to provide core resources, mentoring and training, and opportunities to develop innovative approaches and technologies for our investigators.” Vibrant clinical and translational research is fundamental to advancing Mayo Clinic’s core patient care mission. The Center for

Clinical and Translational Science serves as the engine to accelerate the transformation of medical discoveries into treatments for unmet patient needs. The center also offers education programs designed to train and inspire the clinical and translational science workforce of the future. “Our clinical and translational science education programs attract learners from diverse backgrounds and at many different levels of experience,” says David Warner, M.D., director of education programs for the Center for Clinical and Translational Science. “When they graduate, they are well positioned to lead in their chosen fields of research and to bring the fruits of discovery back to their communities, improving health for all.” Mayo Clinic was one of 12 institutions to receive the NIH Clinical and Translational Science Award when the program began in 2006. Since then, the National Institutes of Health has renewed Mayo Clinic’s award three times, most recently in 2017. The Clinical and Translational Science Award program funds a national network of resources and education programs for clinical and translational research across the U.S. In the next five years, the Center for Clinical and Translational Science will transform clinical trials, digital health and rural health; strengthen community research partnerships and collaborations; train clinical trialists; enhance education and training programs; and expand and strengthen external collaborations. The goal is to accelerate medical research to improve patient care and health for all people.

AMA Announces New 2023 CPT Code Set

Building on its efforts to reduce administrative tasks in medicine–a driver of burnout and a central pillar of its Recovery Plan for America’s Physicians–the American Medical Association recently released the 2023 Current Procedural Terminology (CPT®) code set. The new code set

contains burden-reducing revisions to the codes and guidelines for most evaluation and management (E/M) services. Based on the 2021 revisions made to the E/M codes for office visit services, the new modifications make coding and documentation easier and more flexible for other E/M services, freeing physicians and care teams from time-wasting administrative tasks that are clinically irrelevant to providing high-quality care to patients. The new modification to the E/M codes extends to inpatient and observation care services, consultations, emergency department services, nursing facility services, home and residence services and prolonged services. “The process for coding and documenting almost all E/M services is now simpler and more flexible,” said AMA President Jack Resneck Jr., M.D. “We want to ensure that physicians and other users get the full benefit of the administrative relief from

and technology so it can fulfill its vital role as the trusted language of medicine today and the code to its future. Please visit the Implementing CPT Evaluation and Management (E/M) revisions web page for a complete list of AMA resources.

University of St. Thomas Opens Nursing School

The University of St. Thomas has recently welcomed 50 master’s in nursing students into its new Susan S. Morrison School of Nursing. The school becomes part of the Morrison Family College of Health, which includes the Department of Health and Exercise Science, the School of Social Work, and the Graduate School of Professional Psychology Next year, the program will expand to include undergraduate education in nursing. The new school is focused on preparing a diverse group of highly skilled professional nurses who are culturally

responsive leaders working to improve whole person health and advance health equity. “Our School of Nursing has very distinct goals around closing health equity gaps,” said St. Thomas President Julie Sullivan. “We are dedicated to increasing access to culturally responsive care with a goal of enrolling at least 30% students of color and students from other underrepresented backgrounds. Our students will help to provide more care, to more people, in more diverse and rural communities.” At a time when nursing shortages are impacting all communities across the state, this new school is taking an innovative approach to nursing education through the utilization of hightech simulation technology, including medical mannequins, and fully-simulated clinical/home care settings. “A St. Thomas graduate from the School of Nursing will know how to advocate for systems change,” said. MayKao Hang, founding dean of the Morrison Family College of Health. “They’ll be

able to work well with others, understand how to use information to make good decisions and be comfortable caring for all.” The school will use simulation education to replace up to 50% of the 540 clinical hours that students are required to have in order to graduate. Students will have simulated clinical experiences where they will care for simulated patients within the Center of Simulation and conduct themselves as they would in any actual clinical environment. The School of Nursing at St. Thomas will follow criteria set forth by the Minnesota Board of Nursing to ensure that nursing programs that utilize simulation are providing a quality experience.

MDH Approves Fairview/ Acadia Mental Health Hospital

The Minnesota Department of Health (MDH) has found that moving forward with a new, free-standing

mental health hospital in Saint Paul is in the public interest due to a lack of inpatient mental health beds. Despite this conclusion, MDH acknowledged significant concerns about the new facility as proposed. Fairview Health Services and Acadia Healthcare have formed a partnership to finance and operate a new facility licensed for 144 inpatient beds at the former Bethesda Hospital site in St. Paul. MDH has determined that the project is in the public interest because it provides additional inpatient mental health beds in the midst of a bed capacity crisis. However, as documented by MDH’s analysis, the new standalone mental health hospital will not replace the comprehensive services previously offered at St. Joseph’s Hospital, which Fairview Health Services closed in July. There will be significant inpatient care gaps remaining after the establishment of the facility that other providers will need to fill. For example, the new facility lacks an

emergency department for receiving patients undergoing a mental health crisis, and because it does not offer a full complement of medical care, it will only serve a subset of mental health patients. In addition, the facility is scheduled to operate under a leaner staffing model than is the norm nationally and in Minnesota. Similar concerns were also raised in public comments about the proposal. In finding the project in the public interest, a key element was the recognition that the Minnesota Legislature expects close, ongoing scrutiny of how the new facility will impact care delivery and the economics of inpatient mental health services in the community. As part of that legislation (Minnesota Session Laws of 2022, Regular Session, chapter 99), MDH has been directed to monitor patient and payer mix, transfers and patient flow for inpatient mental health care in the state. In addition to granting the conditional exception in 2022, the Minnesota Legislature made other changes to the hospital construction moratorium (Minnesota Statutes, section 144.551). One significant element creates a process for establishing additional inpatient mental health capacity without a public interest review. This process includes additional oversight activity and a report on the impact of any expanded inpatient mental health capacity in 2027.

Allina to Acquire Part of Presbyterian Homes

Presbyterian Homes & Services (PHS) and Allina Health have announced that Interlude Restorative Suites, part of PHS, will be acquired by Allina effective this November. The two organizations collaborated to establish Interlude Restorative Suites in 2015. While PHS has decided to sell its interest in the collaboration and to rebalance its care portfolio, Interlude-Plymouth will remain an integral part in its care continuum as a skilled

nursing facility on the Plymouth (WestHealth) campus. PHS will continue to manage Interlude-Plymouth on a contract basis, with the goal of both organizations to ensure a smooth transition for guests and the excellent staff. “Allina Health and PHS are proud of our shared vision and collaboration in Interlude,” said Duane Larson, senior vice president of Operations at PHS. “The vision of Interlude was to introduce a new model for transitional care that combined clinical and therapeutic expertise with a soothing, hospitality-focused environment. The collaboration has achieved this vision, and we are proud of the teams who have accomplished this with purpose and excellence.” PHS has been taking steps to rebalance its care portfolio to increase its mix of independent living and right size its overall care center capacity where staffing shortages are greatest. The ownership transition involves two sites: Interlude-Fridley, located on the Allina Health Mercy Hospital-Unity campus, and Interlude-Plymouth, located on Allina’s Abbott Northwestern-WestHealth campus. Allina Health plans to repurpose the Interlude-Fridley building to expand its care model on the Mercy Hospital-Unity campus to best support the needs of the community. As that happens, PHS will be ramping down capacity at Interlude-Fridley ahead of the November transition. At the same time, PHS aims to retain its excellent team there and is ramping up capacity for both short term and long term care at its Langton Shores campus in Roseville. Emily Downing, MD, system clinical officer at Allina Health commented, “We are grateful for the dedication and outstanding work the staff at both Interlude locations have shown, including Interlude of Fridley’s role in COVID-19 recovery in 2020 when the site supported nearly 550 individuals who had been diagnosed with COVID-19. That commitment to care will remain a hallmark of Interlude well beyond November.”

The Architecture of Creating New Knowledge

Genevieve Melton-Meaux, MD, PhD, Center for Learning Health System Sciences

What are learning health system sciences?

There’s really two parts to this question: What is a learning health system (LHS) and from what sciences does an LHS draw? A Learning Health System (LHS) is a virtuous cycle of data, knowledge and practice driven by culture, incentives and leadership. The Institute of Medicine (National Academy of Medicine) describes an LHS as:

A system in which science, informatics, incentives and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the care process, patients and families as active participants in all elements, and new knowledge captured as an integral by-product of the care experience.

The Journal of Learning Health Systems explains it as a constant spiral of learning where data flows into knowledge, knowledge flows into practice, and practice flows into data, repeating again and again, improving and benefiting patients and clinicians along the way.

To answer the second question, the strands of science or research this spiral of learning draws from are multidisciplinary. For example, the programs and units in the Center for Learning Health System Sciences (Center) support patient engagement, implementation science, evidencebased care, evaluation with rapid learnings, infrastructure to engage practices in research, and the use of digital solutions and artificial intelligence in clinical care. Our Center creates unique blends of all these sciences, bringing them together to drive our work. (https://med.umn.edu/clhss).

What are some of the benefits they present?

Bottom line: the patients we serve can positively and more quickly benefit from advances in research. Right now, the average translation gap for new science to reach patients is 17 years. The work we are doing as an LHS dramatically reduces that gap. We want to get to a point where routinely evidence informs health care delivery and health care delivery informs evidence.

What are the biggest challenges of incorporating these ideas into the health care delivery system?

This question really gets at why the Center was created—to provide the resources and support providers need to address a known issue in care delivery with evidence and to study design and the deep connection between health care delivery and researchers to integrate and disseminate evidence and best practices. That said, establishing an LHS is a significant change for all stakeholders, requiring consistent engagement at all levels, promotion by leadership, new logistics in care and research operations, data infrastructure, etc. For health care providers and staff, there is limited bandwidth to engage in new non-clinical activities, especially in the pandemic environment. Another major challenge is finding and training researchers with the skills needed to do this interdisciplinary work, which is why AHRQ (Agency for Healthcare Research and Quality) and PCORI (Patient-Centered Outcomes Research Institute) created funding opportunities

to develop the skills of the next generation of LHS researchers. The Minnesota Learning Health System Mentored Career Development Program (MN-LHS) mentors junior faculty interested in gaining these skills.

What are some examples of how they can be incorporated now?

Most recently, MN-LHS Scholar Carolyn Bramante, MD, MPH, led the nation’s first study, a randomized controlled trial, on whether metformin, fluvoxamine and ivermectin, or their combinations could serve as possible treatments to prevent ER visits or hospitalization, as well as Long-COVID. The results of this clinical trial were published in the New England Journal of Medicine.

Our program for Digital Technology Innovation is currently evaluating tools for educating patients and clinicians about dermatology images, including a tool using artificial intelligence to narrow down the differential diagnosis when a patient presents with a skin condition. Together with M Health Fairview, researchers are also partnering with Q-rounds, a health care software, as a service (SaaS) company whose flagship product is an inpatient virtual rounding queue that hospitals use to provide rounding schedule transparency for the patients and care teams. By creating time transparency, everyone knows when to be present for rounds, resulting in a more efficient rounding process for providers by decreasing missed connections from family and care team members and an increase in patient satisfaction. This tool will be piloted at M Health Fairview Masonic Children’s Hospital NICU this fall.

Currently, the Rapid Prospective Evaluation program has six projects underway, ranging in variety from using decision aids to improve utilization of cardiac monitoring and reducing chemotherapy toxicity in older adults with cancer, to utilization of medication therapy management or reduction of opiate overuse/dependency and improved care through sepsis microlearning and expanding specialist telestroke care.

the average translation gap for new science to reach patients is 17 years. “...”

“...”

Additionally, we are committed to data and technology democratization for greater good. One example is a collaborative project focused on best practices with traumatic brain injury management and appropriate anticoagulation. The best practice tools and decision support will use an interoperable approach with the FHIR (Fast Health Interoperability Resources) standard so that the tools can be deployed at multiple organizations and multiple vendor systems.

What are the goals of the new Center?

The Center for Learning Health System Sciences (CLHSS) is a collaboration between the University of Minnesota Medical School and the School of Public Health to create value in health delivery systems by establishing an iterative cycle of leveraging existing evidence and gathering new knowledge, applying our work into direct population health action and developing the learning health system field through education.

More specifically, the Center has three goals:

• Build a research and education LHS program of distinction.

• Decrease the time for science to successfully make it into patient care and into direct population health action.

• Seamlessly integrate research, care delivery and continuous improvement to create new knowledge and directly improve care.

What is the Healthcare Innovation Program for Implementation & Evaluation (HI-PIE)?

HI-PIE studies how to translate and use evidence-based practices, interventions and policies effectively in real world settings within health care practices. The program is directed by Timothy Beebe, PhD, interim dean of the School of Public Health and consists of two units: Evidence Synthesis and Rapid Prospective Evaluation (RapidEval).

Evidence Synthesis is a collaboration of CLHSS and the Minnesota Evidence-Based Practice Center (EPC). The unit is co-led by Mary Butler, PhD, MBA, who also co-directs EPC and Josh Rhein, MD, assistant professor in the Division of Infectious Diseases and International Health. Together with their integration lead, Bronwyn Southwell, MD, assistant professor of Anesthesia, the team evaluates topic areas where

evidence is emerging or evidence gaps exist to inform and adapt clinical practice (https://med. umn.edu/clhss/hi-pie/evidence-synthesis).

RapidEval features the unique opportunity for providers with an idea for improving care to be supported in generating high quality new evidence on health care practices. The unit focuses on and fosters rapid, iterative learning that builds upon the natural innovation taking place 8 within the health care system. The activities of the RapidEval Unit are aimed at and designed to increase adoption of best practices. RapidEval is led by Michael Usher, MD, a hospitalist and “triagist” managing patient flow and capacity at the M Health Fairview Systems Operations Center (https://med.umn.edu/clhss/hi-pie/rapideval)

How does clinical AI differ from digital technology innovation?

While they are complementary, each plays a different role. Digital Technology Innovation

The

The pandemic has helped us see more clearly the true scope of this platform, especially when considering older adults, people with disabilities and individuals with complex heath conditions. On one end, it includes health care institutions, i.e., hospitals, clinics, primary and behavioral health care, and on the other, home and community based services, also referred to as long term services and supports. We have the opportunity to elevate patient-centric care by integrating and creating continuity within this otherwise bifurcated health care platform, especially for people with disabilities, with complex health conditions and older adults in order to attain better health outcomes.

The Health Care Platform

Whether through the Home and Community Based Services from the Minnesota Department of Human Services or by other service delivery providers, the role of long term services and supports has become an integral part of the health care platform in order to maintain daily living for many older adults, people with complex care conditions and many people with disabilities.

In essence, this integrated model, which is an emerging standard for physicians and clinicians as a patient-centric practice, recognizes the necessity of continuity of primary and behavioral health care coordination, when needed, with long term services and supports. Furthermore, they must all work in tandem for the patient’s health, well-being and daily living. It is optimal to assure that scope of practice integrates these key areas of concern that are essential for a patient’s health, well being and daily living. To do so advances a much-needed interoperability of our health care platform.

Coordinating Care

Ronna Linroth, PhD, worked with adults with disabilities for many years in a variety of settings. Dr. Linroth led the multidisciplinary team that developed a comprehensive rehabilitation clinic that offered coordinated services for adults with childhood onset conditions at Gillette Children’s Specialty Care in St. Paul, MN. Dr. Linroth’s Doctorate is in Applied Management and Decision Sciences with a focus on Leadership and Organizational Change. Dr. Linroth also holds a bachelor’s degree in Occupational Therapy and a master’s degree in Health and Human Services Administration. There is great need to coordinate care and assure the continuity of that care with a patient’s long term services and supports. Dr. Linroth, given her extensive career in health care and working with people with disabilities, offers profound insights on why this integrated model is greatly needed:

“The fragmentation of care for adults with disabilities is a primary barrier to supporting patients with disabilities. Unless an individual can see a physician specializing in the coordinated care of individuals with chronic care needs and familiar with the underlying childhood conditions or adultacquired disabling conditions, the individual or family are the interpreters bearing information from the various subspecialists involved in their care.”

Dr. Linroth further elaborates:

“The urologist addresses the urology needs, the orthopedist the orthopedic needs, the neurologist the neurology needs, the cardiologist the cardiology needs, etc., and may not see the review of the long term services and support systems as their area to address. Patients are often seeing a variety of specialists and the general practitioner, usually an internist or family practice physician, may not have the whole picture and may be the last on the list of appointments to make.”

Yet in order for this integrated and practical model to be scalable and sustainable, health care leaders, institutions, the insurance sector and policy makers need to provide for physicians and clinicians to evolve their practices and health care system delivery models in order to provide for the continuity of care coordination with long term services and supports for their patients.

Dr. Linroth speaks to workable ways to make this transition doable:

“Physicians have constraints on their clinical time, and documentation in an electronic record has become standardized in the industry. Currently, documentation formats are designed primarily to capture reimbursement for the majority of patients, but all are customizable to a degree. Building long term services and support reporting into the electronic record for people with disabilities would not only act as a trigger for review of targeted populations, but also provide an efficient format for capturing information needed by medical/rehabilitation team members, patients and payers.”

An integrated model also takes into account that the health and wellbeing of a patient changes with the aging process. Furthermore, specific disabilities, as well as complex health conditions, can also be progressive. There is no doubt that the continuity of primary health care, along with behavioral health care coordination and long term services and supports, need to adapt proscriptively in support of the patient as a result of aging, progressive conditions or both.

Integrating Perfect Occupancy

Minnesota’s health care platform is already arrayed along a continuum of primary care to behavioral care to long term services and supports. So, this is

really about a concept applied from the productivity sciences by the work of my colleague Mr. Tor Dahl, chairman emeritus of the World Confederation of the Productivity Sciences and chairman of Tor Dahl & Associates, who introduced the term perfect occupancy, which is doing the right thing, in the right way, at the right time.

For this integrated health care model, we can apply the concept of perfect occupancy to our health care platform with the following definition:

Put the patient in the driver’s seat for their health, well-being, safety and daily living, in which there is continuity of their primary and behavioral care coordination with their long term services and supports in real-time, all the time.

training requirements, take and pass the MnCAT Setp3-Part 3 Test, as well as maintain their certification by documenting completion of 45 CEUs. Physicians and other paid service providers may be involved by sharing information in writing or by phone before and/or after the assessment if the individual requesting the assessment gives their permission to be involved.”

Physicians are not usually involved in the county’s assessment process.

Dr. Linroth elaborates on the need for primary health care, and when needed, behavioral health care, to take into account the effects of aging, progressive conditions and the integration with long term services and supports as a patient-centric modality.

Pain, changes in functional performance, need for assistive technology devices and services, status of personal care assistance, transportation and housing are areas to consider. Best practices in prevention or minimization of further disability due to overuse syndromes, age-related changes or progression of an underlying condition should guide the care visit and referral to the appropriate services in mental health, physical and occupational therapy, social work and other community supports. Primary care visits may fall to the wayside with the number of appointments the individual has with the rest of their medical team.

Physician Involvement

According the Minnesota Department of Human Services, the MnCHOICES Assessment uses a person-centered approach to gather information to assist an individual to make decisions about their long term services and supports. It assesses the person’s general health, their ability to take care of routine daily tasks and help the individual receives from family and friends. Once their assessment is complete, they will receive a community plan. The MnChoices Support Plan provides coordinated services and support plans for people who are eligible for publicly funded services. The coordinated services and support plan outlines the decisions the person makes for the services and supports they are eligible to receive.

I asked Dr. Lithgow about the involvement of physicians when they are asked by their patients to be aware of their patients’ MnCHOICES assessment and subsequent support plans. Dr. Lithgow’s thoughts illuminate the value for the patient when the physician becomes involved:

“To my knowledge, physicians are not usually involved in the county’s assessment process, and unless their patient provides assessment results or their personal support plan, the physician would not be aware of either. The MnCHOICES Planning Assessment is meant to be conducted faceto-face with a certified assessor within 20 days of a request and follows a computerized program for information gathering.”

Linroth further states:

“The format is person-centered, giving the individual with disabilities (and older adults) to have their priorities identified. To promote standardization of the process, assessors are required to complete the

The importance of care coordination with long term services and supports are essential for the patient’s health, well-being and daily living. Elena Rosas, MD, is Medical Director and Adult Psychiatrist at Canvas Health in Oakdale, Minnesota. Dr. Rosas has worked at Canvas Health since 2010. She is board certified with the American Board of Psychiatry and Neurology. Dr. Rosas received her medical degree from the Medical School and Psychiatry Residency at the University of Minnesota.

Behavioral health is advancing the integration of dual diagnostic care for clients with co-occurring disorders. At the same time, behavioral health is making gains in care coordination with primary health care in addressing the health and well-being of clients. Dr Rosas elaborates on the awareness and importance of continuity of care coordination with long term services and supports for patients:

“As a psychiatrist who has worked in community mental health for the past 16 years, the awareness of and coordination with a patient’s long

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and aging of individuals with SCI have created the need for new researchbased information to improve clinical services, community support and a wide variety of outcomes for this population.

The relatively low incidence of SCI increases the need for collaboration that involves investigators with the necessary expertise and combines the number of research participants who are available for testing interventions and for achieving other rigorous research aims and approaches.

Hospitalization and rehospitalization

Even though lengths of stay in hospitals (11 days) and acute care units (31 days) have declined recently, these injuries place a significant burden on the health care system, the patients and their families. The financial burden depends on the SCI itself and the age at which it occurs. Estimated lifetime costs of treating the injury range from $1.2 million to $5.1 million in 2019 dollars (these estimates do not include any indirect costs such as losses in wages, fringe benefits and productivity). The average yearly expenses (health care costs and living expenses) and the estimated lifetime costs that are directly attributable to SCI vary greatly based on education, neurological impairment and pre-injury employment history.

Since 2015, about 30% of persons with SCI were rehospitalized one or more times during any given year following injury. Among those rehospitalized, the

length of hospital stay averaged about 18 days. Diseases of the genitourinary system are the leading cause of rehospitalization, followed by diseases of the skin. Respiratory, digestive, circulatory and musculoskeletal diseases are also common causes of rehospitalization. Despite improving mortality rates, individuals with SCI continue to be at increased risk of experiencing acute and long-term health complications, including secondary health conditions. Pain is a leading secondary complication after SCI and may significantly affect functional ability and independence, psychological well-being, ability to return to work and quality of life.

SCI Research

To improve the lives of those with SCI and to reduce the overall burden on the health care system from these injuries, the University of Minnesota’s Department of Rehabilitation Medicine led the process of receiving funding from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR), in partnership with regional health care experts, researchers and consultants who have SCI (lived experience). As a result, we were one of 14 recipients in the U.S. that received $2.2 million over five years to improve patient care, research SCI and broadly share our findings. The research will be done under the auspices of a Minnesota Spinal Cord Injury Center of Excellence; patient care will be managed under the Minnesota Regional Spinal Cord Injury Model System (MN Regional SCIMS). In addition to the NIDILRR grant, our work is partially funded by the University of Minnesota (U of M) Medical School, the U of M Department of Rehabilitation Medicine and Regions Hospital. We also have the support of local and national community and consumer advocacy organizations.

MN Regional SCIMS service activities

The MN Regional SCIMS is a multidisciplinary continuum of care for people with SCI, including the following services: emergency medical, acute care, acute rehabilitation and post-acute care. We will serve individuals with traumatic SCI in Minnesota, North Dakota, South Dakota, Iowa, Wisconsin and Northern Michigan.

Our catchment area serves a wide geographic region of medically underserved areas. Therefore, a model system gives us the opportunity to meet the needs of this population and add diversity to the national SCI database. The system of care —and our research— will be built on a foundation of diversity, equity and inclusion. We welcome and value the voices and perspectives from all individuals with intersecting identities and lived experiences, and we believe those diverse perspectives significantly contribute to excellence in medicine and rehabilitation. We view disability as an important aspect of diversity and are committed to providing equitable access to resources for all employees, students and research participants. To better serve diverse populations, we have assembled a leadership team that is representative of women (65%), people of color (29%) and individuals from other traditionally underrepresented groups, such as those with physical disabilities (18%).

Our core model system activities, including clinical care and research, are focused on improving health and function after SCI and reducing or mitigating secondary health complications. Acute care rehabilitation services and ongoing health maintenance are essential for preventing and managing

We view disability as an important aspect of diversity.

these complications. Care will be provided by the world-renowned resources of Courage Kenny Rehabilitation Institute (CKRI), Mayo Clinic, Regions Hospital and the University of Minnesota/M Health Fairview. Collectively, we provide the following services:

• Trauma care.

• Inpatient rehabilitation.

• Outpatient care.

• Health and wellness programs.

• Adaptive fitness and activity-based therapy.

• Vocational rehabilitation.

• State-of-the-art technology, such as neuromodulation, noninvasive magnetic stimulation, robotic devices and electrical stimulation, to support independent living.

Administration and collaboration

Our Executive Committee, led by myself and Dr. Kimberley Monden (UMN), oversees all project activities, including dissemination and implementation. The committee is comprised of the project directors, directors of clinical care, directors of research and representatives from the Community Engagement Committee, which includes individuals with lived experience, and leaders of SCI community organizations. Each member of this committee serves as a direct link to their site leadership and staff. We will include a rotating presence of individuals with lived experience from our Community Engagement Committee to ensure diverse perspectives from the

SCI community. This committee meets quarterly to monitor progress toward project goals. Other committees include the Clinical Care Committee, the Data Management and Analysis Committee and the Research Committee.

Research projects

Our research efforts are aligned with NIDILRR’s long-range plan focus area of health and function, which is aimed at developing an evidence base for interventions that maximize the independence of people with disabilities. Consistent with that agenda, the MN Regional SCIMS’s research activities focus on maintaining health, minimizing hospitalizations and maximizing community living outcomes. Our team collaborates with local, national and international members of the SCI research community in many ways, including serving on society committees, advisory boards, journal editorial boards and various SCI-specific research groups.

One of our initial research projects will focus on identifying an effective pharmacological treatment for severe neuropathic pain in SCI–a primary issue affecting quality of life. Identification of an oral medication that is effective, safe and well tolerated would represent a major improvement in the clinical approach to this kind of neuropathic pain. Part of our research will be to identify and validate predictive biomarkers of neuropathic pain after SCI and response to pharmacological therapy. This work is innovative as it seeks to develop a new, mechanism-based pharmacological intervention for neuropathic pain in SCI.

Outstate Behavioral Health Care

Meeting the challenges and needs

BY THOMAS OTTEN, MA

As medical science and the delivery of health care continue to evolve, there is a growing understanding of the impact mental health has in every physician-patient encounter. From routine health screenings to care for chronic conditions to cancer treatment, the mental health of a patient can make a big difference in outcomes. So much so, in fact, that the time has come for quick and minimal mental health assessment tools to be part of every patient intake process, just like blood pressure and weight measurements. Simple mental health baseline data should be a part of every patient’s medical record. While it is unfortunate that this is not a universal best practice standard, it is even more unfortunate that the lack of access to mental health care has reached the full-blown crisis we face today.

Prior to the pandemic, the demand for mental health care far exceeded the supply, and now that equation has been made worse with one in every four job openings in the field unfilled. This situation is even worse in outstate areas where patients face unique barriers to seeking care. In small towns, not only is it more likely for everyone to know everyone else’s business, and such things to travel quickly, but the stigma—internal or external—of dealing with mental health concerns can be higher. Farmers, for example, have an

ingrained can-do attitude of pulling themselves up by their boot straps, an admirable attitude but one that does not translate well, for example, to dealing with depression or anxiety disorder. As of mid 2022, nearly 30 farmers in America are dying by suicide every day, meaning they have one of the highest suicide rates of any occupational group. Though it may not help with climate change related drought or poor government policies, better access to mental health services would certainly help address this.

The Zero Suicide Initiative, a national program with the goal of reducing suicides to zero through use of a set of tools—one of those being screening and assessment in clinics and emergency departments—is a program we have been using since 2016. The majority of suicides—75%—take place within 60 to 90 days after a medical encounter. This doesn’t assess any blame; it’s just a reality check for all of us, and it points to an opportunity for prevention. We won’t always catch it—in fact, research tells us that the decision to take one’s own life is usually made only a couple of hours earlier. But if we can spot a downward trend and encourage that person to take action, we might save a life.

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Another element for concern relates to substance use disorder (SUD). Many people assume that large cities are havens for mind-altering drug use and alcohol abuse, however smaller communities have seen dramatic increases in opioid misuse and overdoses, and meth may be even more available there than in urban and suburban areas. What is not available are inpatient treatment beds, after care programs and certified counselors to help people understand and deal with these problems. While there are tools available to help start these kinds of programs, the infrastructure and staffing to accomplish this is rarely present. Some estimates suggest that as many as 50% of patients have SUD issues, no matter whatever other primary medical problem there might be. A basic mental heath patient in-take screening tool could help identify these concerns.

Increasing access to care

One recent positive development is the new 988 Lifeline. Going live on July, 16, 2022, this nationwide service follows NAMI’s standard of care and is billed as “a direct connection to compassionate accessible care.” Designed to strengthen and expand the National Suicide Prevention Hotline, this 24/7 service will serve and support anyone experiencing mental healthrelated distress. Funding for the program comes through the Substance Abuse and Mental Health Services Administration (SAMHSA). They envision a robust crisis care response system that will link callers across the country to community-based providers and resources that can deliver a full range of crisis care service. There are expected growing pains, as there were rolling out 911, but the hope is to help address the growing mental health crisis; this action is an example of the scope and serious nature of the challenges this presents.

Another area of emerging awareness, and crisis, involves pediatric mental health. It is now estimated that one in seven children aged 10-19 has some kind of mental illness with depression, anxiety or behavioral

disorders leading the way. Almost 20% of U.S. high school students have given serious thought to suicide and almost 10% have actually tried to kill themselves. Evidence clearly shows a sharp increase in pediatric behavioral issues over the past 15 years, despite some calling it a hoax. Many factors for the increase can be cited, but there have also been many outstanding responses. Children require a different approach to treating behavioral health issues, and many medications for adults are not appropriate for developing brains.

One recent response that is proving beneficial is the development of the school-based health center and incorporating behavioral health services into these centers. It is an expansion on school nurses who may have to visit several schools each week and can work with a variety of community resources. As an example of this, our organization has been working for the past five years with school teachers in Brookings to help them understand ways they can assist students who may be facing behavioral health issues. We have recently expanded this outreach to include a middle school in Sioux Falls.

The growing creation of dedicated adolescent behavioral health inpatient treatment facilities, and dedicating sections of hospitals to this use, further illustrates the scope and importance of the issue. Children whose issues can be identified and treated early in life can minimize the development of chronic conditions later in life that can have serious adverse effects on their overall health.

Dedicated facilities

Additionally, and importantly, the creation of new modern facilities addresses several issues. On a very basic level, these facilities build awareness around the serious nature of behavioral health treatment and foster acceptance replacing stigma. Depression is no different than high blood pressure or diabetes and should not be viewed as a weakness. Psychiatry was often confined to a broom closet at the back of the top floor of a hospital, a mistake leading to many downstream complications that are slowly being corrected. Our hospital, Avera Behavioral Health Hospital, was originally constructed in 2006 to serve all behavioral health care needs in our area; recently we added 60,000 square feet, which includes 24/7 behavioral health urgent care and youth addiction care services. We now have almost 150 inpatient beds and the facility is truly a world-class destination for mental health services. People come from all over the country to study our model, and we hope it will lead to similar advances in other markets.

Perhaps we have proven the Field of Dreams maxim of “if you build it, they will come,” but that does not address the lack of behavioral health providers, especially in the outstate areas. There it becomes the de facto proxy of primary care providers to prescribe medications around whose benefits

Outstate Behavioral Health Care to page 164

and uses they may have received minimal training. PAs, nurse practitioners, masters level social workers, psychologists and others are also called into service and must all work together with as much coordination as possible to address the workforce shortage crisis. There are phone counseling services available that can be accessed during a patient visit that can be very helpful.

Telemedicine applications to behavioral health have existed at Avera for 25 years, but that use was significantly increased during the pandemic. From the difficulties of the pandemic, it is important we use this as an opportunity to revolutionize the care of behavioral health patients. Developing the trust to make therapeutic progress can take time, but it is a pathway to care that is now more widely available. It should be explored and offered as an option, as it offers the flexibility to be incorporated into any clinical setting in a variety of ways. Most insurance continues to cover it, and while some patients simply do not have access to the internet or have limited literacy around computers and related technology, almost everyone can use a smart phone. The convenience of seeing a professional from their own home, or in the case of a farmer from their tractor, can have a significant appeal. In fact, research over the years has shown that some patients feel it is easier to build rapport with a therapist and to talk about difficult subjects via televideo instead of in person.

Addressing the future

Another challenge facing the delivery of behavioral health care is an increasingly diversified patient base. Different cultures perceive and respond to common diagnoses in different ways. In our practice, we see this most clearly

in serving the Native American population. We provide specialized training to providers and support staff around how to best communicate around sensitive and complex issues. Oftentimes, when dealing with behavioral health concerns, listening is as important, or even more important, than offering a care plan. Part of diversity training is learning what to listen for. It is also important to understand that diversity goes beyond race and must also include age, economic status, people with disabilities and more. People from all of these groups may have behavioral health concerns and must be treated with equity and awareness of the unique challenges they may face.

As we move forward, solving the many challenges facing the delivery of behavioral health care will require building new partnerships. As an industry, this will mean new ways of involving and working with employers, communities, payers and state government. Each of these entities has a vested interest in everyone’s individual health and, as we have discussed, behavioral health is a big part of overall health. Each of these entities must be encouraged to continue their work in removing the stigma a person may feel around seeking help for behavioral health care concerns. Public and private partnerships are an incredibly effective way to help meet this challenge. We must all work together to raise awareness of what these concerns are and how they may be treated.

Thomas Otten, MA, is the behavioral health service line administrator for Avera Health, where for the past 22 years he has held positions relating to managing, improving and expanding behavioral health care within the hospital, university health center and the region.

The impact of exceptional senior care

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Fluorescence Microangiography

BY THOMAS MASTERS, MD

Anyone who has spent a winter in Minnesota can speak to the severity of this season. The upper Midwest has a reputation throughout the rest of the country for an artic-like climate with extreme cold and protracted periods of winter weather. While this weather undoubtedly wears on the emotions of the “denizens of the north,” winters also present physical threats. Every season, hypothermia and frostbite cause mortality and morbidity to people who have been caught out in the cold too long.

Naturally, depending on the temperatures seen in the winter, hospitals may see greater or fewer victims of cold. In an average winter though, I suspect that every hospital in the state/region will see patients with hypothermia and frostbite, of varying degrees of severity. While there are no “hypothermia centers,” the standard of care is that severe frostbite will be managed at a burn center. This means that each winter, the state’s two burn centers (Regions Hospital in St Paul and Hennepin County Medical Center) will see dozens (if not hundreds) of patients with frostbite. These volumes have allowed these hospitals to develop expertise in the management of frostbite victims and to refine the care provided.

Frostbite is caused when skin is exposed to cold temperatures. Parts of the body such as hands, feet, nose, and ears that are most exposed to the cold environment are the most commonly afflicted areas. After a period of cold-induced vasoconstriction, ice crystals form in the tissues. This freezing process causes direct cellular damage and disrupts perfusion.

Traditional descriptions of frostbite have been comparable to burn descriptions in that both describe depth of tissue involved. Patients presenting with first degree frostbite are described as having loss of sensation with reddened skin. Second degree frostbite victims have clear blistering. In third degree frostbite, victims have hemorrhagic blisters and skin darkeningto-necrosis. Finally, in forth degree frostbite, patients will have discolored skin and digits will be hard and frozen.

Unreliable diagnoses

First and second degrees of frostbite are considered superficial whereas third and fourth degrees are considered deep. It is felt that the deeper the tissue involvement, the greater the threat of tissue and digit loss. Unfortunately, studies have shown that bedside evaluation of frostbite has proven unreliable.

Making the appropriate diagnosis of severity is important as it impacts the therapies given. Rewarming is the mainstay of all frostbite therapy, regardless of the depth of tissue involved. When a patient presents with suspected frostbite, affected extremities are placed in warm water baths until rewarmed. After rewarming, the challenge is then deciding if thrombolytic medication is needed.

Studies done in the early 2000s demonstrated that individuals with deep frostbite showed increased perfusion to digits using technetium (Tc)-99m agent through scintigraphy nuclear medicine bone scanning after receiving rTPA. Several additional subsequent studies have shown benefit of rTPA in improving patient outcomes and preventing amputations. At our facility, IV rTPA is the accepted therapy for individuals with deep frostbite when they present within 12 hours after rewarming.

The challenge though is making the diagnosis of deep frostbite. As noted earlier, determining deep frostbite is challenging when using clinical exam alone. As such, numerous other modalities have been used to confirm the involvement of deep tissues such as bones. These include angiography and bone scans. Unfortunately, studies like this that have shown the strongest correlation with eventual amputation are resource intensive. For example, nuclear medicine studies require specially trained technicians and nuclear material. Other more conventionally available studies such as x-rays have not shown to correlate well with clinical outcome.

Since the pioneering work on rTPA, our facility has used the bone scans to evaluate patients with suspected deep frostbite. Our burn service has long considered this the gold standard to make the diagnosis. However, even in a tertiary referral center such as ours with an exceptional radiology department, staffing and budgetary challenges have made continuous availability of bone

scan challenging. Invariably, we have our coldest days with the most victims of frostbite on weekend nights when staffing is tightest. As such for the past two winters, we have been working to refine our approach to frostbite to optimize and expedite diagnosis of deep frostbite.

Combing technologies

In 2015, the department of hyperbaric medicine (as a part of HCMC’s limb preservation program) began using fluorescence microangiography (Luna; Stryker Corporation; Kalamazoo, Michigan) to monitor the status of nonhealing wounds, compromised flaps and grafts, crush injuries and other injuries effecting perfusion. This study involves injecting patients with an iodine-based dye (ICG) that binds to blood proteins. This dye will fluoresce under infra-red light and a camera on the device will allow a clinician to visualize perfusion 3 – 5 mm below the skin. Images range from a bright white (denoting robust perfusion or inflammation) to a gray (suggesting compromised perfusion) to black (fully ischemic).

have found the device useful in monitoring a patient’s healing progress and helpful in assessing the efficacy of wound healing techniques.

Invariably, we have our coldest days with the most victims of frostbite on weekend nights when staffing is tightest.

After gaining multiple years of experience with fluorescence microangiography in wound patients, the hyperbaric and burn services began to collaborate to explore the role that hyperbaric medicine may play in patients who have been diagnosed with deep frostbite. The rationale behind this therapy was that arterial occlusion is a part of the pathophysiology of frostbite that leads to digit loss. Acute arterial occlusion is an approved indication for therapy with hyperbaric oxygen and it stood to reason that patients with severe deep frostbite might benefit from therapy with hyperbaric oxygen. However, knowing that patients do not always respond to therapies as expected, we utilized periodic microangiography as they were receiving therapies with hyperbaric oxygen to monitor patient’s response to therapy.

Improving decision-making.

Taking less than 5 minutes, the study is very well tolerated by the patients. The dye is metabolized by the liver and is therefore safe in patients with renal issues. There is no radiation involved. The only contra-indication is an iodine allergy. There have been multiple previous studies about the efficacy of fluorescence microangiography in plastic surgery patients and the device has been used intraoperatively evaluating bowel anastomoses. We

While we are still evaluating whether hyperbaric oxygen has a role in treating patients with frostbite, we did find that fluorescence microangiography correlated at least as well as bone scan with anticipating eventual amputation sites. As the physicians who work in the hyperbaric department also work in the emergency department, we felt that there may be an opportunity

Fluorescence Microangiography to page 204

to employ microangiography in the acute setting prior to receiving rTPA to evaluate patients for deep frostbite. The goal was to pair fluorescence microangiography (using a slightly different version of the Stryker device than we used in the subacute setting) with bone scans to help guide clinical decision making.

Given previous experience with microangiography and the importance of rewarming in the management of frostbite, the direction was to perform the study once the patient had been rewarmed. All emergency department physicians were oriented to the use of microangiography and the mechanics of the device itself. Hyperbaric physicians were available to provide real-time feedback, interpretations, and provided over-reads on each study.

(about 3 minutes) there were occasions where the ICG could be re-dosed to track reperfusion.

Many patients with frostbite also struggle with psychosocial and substance abuse issues.

We continue to learn about the role of microangiography in the management of frostbite, but the initial results seem encouraging. Certainly, the ease of access has been a benefit in obtaining relevant clinical data faster than the historical methods. Also, keeping the machine in the ED allows for round-the-clock availability. We are optimistic that microangiography may allow for more prompt appropriate administration of rTPA with benefit to patient morbidity.

In addition to the relative-safety of the study, microangiography has the additional benefit of being a performed at the bedside by the provider. This allows the clinician to evaluate the patient promptly and determine the appropriate course of action as it pertains to therapies. We found many instances where there was frank ischemia (with complete absence of fluorescence despite rewarming) in which the clinician felt compelled

Many patients with frostbite also struggle with psychosocial and substance abuse issues, which makes long term evaluation and management challenging. However, the difficulties inherent with life in the upper Midwest will present an opportunity to provide excellent cutting edge care to a disease with significant consequences.

Thomas Masters, MD, FACEP, FAAEM, specializes in Emergency Medicine and has a sub-specialty in Hyperbaric Medicine. His primary research interests include the use of hyperbaric oxygen for wound healing and limb preservation.

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Another initial research project seeks to answer the question: Is meeting the SCI physical activity guidelines associated with health-related and psychosocial outcomes? Since the development of the guidelines in 2011 and their refinement in 2018, no study has yet to demonstrate the health benefits of meeting the SCI physical activity guidelines versus not meeting them. To address this question, we will conduct a multi-site, cross-sectional observational study with the primary goal of determining whether SCI physical activity guidelines are associated with improved healthrelated and psychosocial outcomes. While crosssectional in nature, the findings from this study will be used to design future clinical trials testing the health benefits of meeting these guidelines.

Dissemination of information

Enabling valuable research findings to be used in the field requires a strategic approach to dissemination rather than simply making stakeholders aware of the information. To effectively convey information, it is necessary to make the information accessible for end-users and to ensure the information and dissemination strategies fit the target audience’s needs. This is achieved by direct involvement of stakeholders in planning and implementing these strategies.

Pain is a leading secondary complication after SCI.

As a model system, we will also collect high-quality, representative longitudinal data that will increase the racial, ethnic and socio-economic diversity of the National Spinal Cord Injury database. This database is hosted by the University of Alabama at Birmingham, the source of all the SCI data cited in this article. We will also advance a robust research portfolio focused on increasing the health and well-being of individuals with SCI. To ensure that our research findings are widely available, we will implement a multi-year dissemination plan to share our clinical expertise and scientific results with multiple audiences, e.g., clinicians, researchers, individuals with lived experience, advocates, payors, and policymakers.

We will use Integrated Knowledge Translation (IKT) guiding principles to ensure that our partnership with the community is relevant, useful and avoids tokenism. These principles were developed by a multidisciplinary group of SCI researchers, clinicians, people with SCI, representatives from SCI community organizations and funding agencies. They recommend that partners:

• Develop and maintain relationships based on trust, respect, dignity and transparency.

• Share in decision making.

• Foster open, honest and responsive communication.

• Recognize, value and share their diverse expertise and knowledge.

• Maintain flexibility and be receptive.

• Meaningfully benefit by participating in the partnership.

• Address ethical concerns.

• Respect the practical considerations and financial constraints of all partners.

Using the IKT guiding principles will ensure meaningful engagement of the right research users at the right time throughout the SCI research process. Our dissemination activities will be planned and executed by both our Executive Committee and Stakeholder Engagement Committee. Our dissemination vision is focused on multiple media through which we can best communicate appropriately tailored information with all our target audiences. We have included both a media/marketing specialist and medical writer in our dissemination strategy to ensure our communications are of high quality.

Conclusion

We expect the Minnesota Spinal Cord Injury Center of Excellence and the Minnesota Regional Spinal Cord Injury Model System to catalyze SCI work across Minnesota. It is the first step toward bringing together all these outstanding resources and expertise to operate as a team. It’s the way we will help improve outcomes for people with SCI. We welcome your participation and collaboration.

Leslie Morse, DO, is a physiastrist, department head, professor of rehabilitation and co-project director of the Minnesota Regional Spinal Cord Injury Model System Center. She also works with the U of M Medical School and M Health Fairview.

(DTI) evaluates and advances knowledge around the rapidly growing area of digital health and digital transformation, broadly defined as the use of technology to improve health and wellness. Digital health technologies cover a gamut of solutions such as wearable devices, virtual reality, mobile health apps, patient-reported data, smartphone-connected devices, etc. DTI is led by Rubina Rizvi, MD, PhD, as the Integration Lead, and myself (https://med.umn.edu/clhss/dti).

Think of the Program for Clinical AI as informational methods that crunch the data collected, so that health care delivery can be improved. The 9 Clinical AI team investigates AI-enabled tools in real-world settings, including monitoring AI model performance for drift, equity and fitness for answering questions across settings and subpopulations. A number of these Clinical AI algorithms may also be deployed into Digital Technology. Christopher Tignanelli, MD, MS, is a practicing trauma surgeon and leads this program (https://med. umn.edu/clhss/clinical-ai).

A helpful analogy is taking a road trip: while we know the basics of how to drive and read road signs, we can make better decisions, ones that improve the trip, when we use a GPS that has instant traffic monitoring and reroutes us to avoid delays and road closures.

Please tell us about the Practice-Based Research Network (PBRN).

Practice Based Research Networks (PBRNs) are groups of primary care clinicians and practices working together to answer community-based health care questions and translate research findings into evidence-based practice (https:// pbrn.ahrq.gov/). The strength of a PBRN lies in its focus on community-driven and equity-focused research carried out in settings where participants/ patients have pre-existing relationships with providers. This allows for research to be accessible, relevant and meaningful to communities.

The Primary Care Service Line (PCSL) PBRN is a partnership between the Department of Family Medicine and Community Health (DFMCH), CLHSS and M Health Fairview. The DFMCH is using their past success with their own PBRN to expand to all of the PCSL. Research facilitators

and research champion providers are embedded throughout M Health Fairview primary care clinics to support building practice-based research capacity, opportunities and scholarship. We are actively engaged right now with the PCSL in developing this PBRN, which is led by Jerica Berge, PhD, MPH, LMFT, CFLE (https://med.umn.edu/clhss/pbrn).

How are you interacting with other health learning systems around the country?

The collaboration between the University of Minnesota Medical School and School of Public Health is novel. The LHS philosophy is spreading throughout the country and continues the deep research-clinical care integrations, which increased throughout the COVID-19 pandemic. In promotion of creating awareness for LHS, we host a monthly seminar, CLHSS iMpact, where we feature national experts in population health, informatics, PBRN, etc., to present their work and share their experiences in advancing the work of learning health systems.

We also collaborate nationally on various research studies. Recently, Dr. Tignanelli and I received an AHRQ R18 grant award, Evaluation of the SCALED (SCaling AcceptabLE cDs) Approach

Opportunities throughout Greater Minnesota:

Ely VA Clinic

Hibbing VA Clinic

for the Implementation of Interoperable CDS for Venous Thromboembolism Prevention. The proposed project will adapt a currently deployed clinical decision support system (CDS) to scale, evaluate and maintain an interoperable CDS of venous thromboembolism prevention guideline for adult patients with traumatic brain injury across our collaborative network (Regenstrief Institute/Indiana University, University of California-Davis, Geisinger Health, Johns Hopkins University and Mayo Clinic Arizona). The current climate of each health care system developing “home-grown” CDS for the exact same guidelines is not tenable. Building capabilities to rapidly translate patient-centered outcomes research to the bedside at scale and share interoperable CDS routinely with an updated knowledge base (living evidence synthesis) is necessary.

Please tell us about the Clinical Translational Science Institute and how it interacts with the Community Engagement to Advance Research and Community Health (CEARCH) team.

The Clinical and Translational Science Institute (CTSI) is enhancing the way research is conducted

to make a meaningful impact on people’s lives by providing a comprehensive infrastructure of research services, training, grants, tools and more. One of the components of the CTSI is the Community Engagement to Advance Research and Community Health (CEARCH) team. CEARCH provides the architecture for University of Minnesota researchers and local organizations to collaborate so they can address health issues in ways that are truly relevant to the community. CLHSS collaborates with CEARCH primarily in development of the PCSL-PBRN.

The Center is celebrating its first anniversary, congratulations.

Thank you! It’s been quite a year, focused on the establishment of our operations, hiring a talented team, strengthening partnerships and building awareness of LHS. As you’ve heard, our programs have developed robust portfolios. Earlier this year, Evidence Synthesis was consulted in preparation for a Sepsis Summit at M Health Fairview and provided a review of the impact of the CMS Severe Sepsis and Septic Shock Management Bundle on patient

outcomes. This is an excellent example of how we would like to be engaging on a regular basis. We are looking ahead now to moving from development and starting to see the fruits of that labor deploy more interventions into practice, to learn from implementation and use that data to build new knowledge and eventually proliferate the LHS cycle throughout Minnesota.

Genevieve Melton-Meaux, MD, PhD, is a professor of surgery, director of the Center for Learning Health System Sciences and core faculty in the Institute for Health Informatics at the University of Minnesota (U of M). She is a practicing colorectal surgeon. She serves as the U of M associate director for the Clinical NLP-IE Research Group and nationally as president of the American College of Medical Informatics and as a board member for the American Medical Informatics Association.

term services and supports are essential. It is wonderful when patients with significant disabilities are able to access additional support services in their lives, such as housekeeping, personal care assistant services, and home health nursing support. To have this type of help can make all the difference in the world to the patient’s quality of life and overall health management.”

An Emerging Standard

In essence, this integrated model, which is an emerging standard for physicians and clinicians as a patient-centric practice, recognizes the necessity of continuity of primary health behavioral health coordination, when needed, with long term services and supports. Furthermore, they must all work in tandem for the patient’s health, well-being, and daily living. It is optimal to assure that scope of practice integrates these key areas of concern that are essential to a patient’s health, well-being and daily living. To do so advances a much-needed interoperability of our health care platform.

Dr. Rosas offers a profound example on why this model needs to become standardized throughout the health care system in the United States:

“In my experience, the very best care of the patient occurs when all services involved are coordinating with each other. I recently had a patient who gets confused often due to a persistent mental health condition. She was

struggling with daily living, such as attending medical appointments. My agency, Canvas Health, became a Certified Community Behavioral Health Center earlier this year, and as part of this dedication to comprehensive care, we have established a new program called Care Coordination. We were able to assign a care coordinator to this patient, who reached out and coordinated with all of the members of her team to have everyone work together to assist this patient to make it into the office to get the care she needed. Care coordination has made a positive difference for the patient. I am quite confident and hopeful for the future of community mental health care, if we as a health care system can increasingly prioritize and value this integrated model of continuity of care coordination with all services for the benefit of the patient, we will evidence better health outcomes in the United States.”

Jesse Bethke Gomez, MMA, is the executive director of the Metropolitan Center for Independent Living. Jesse is a thought leader on complex health care, human service and public health policy issues driving societal progress. He is a National Kellogg Fellow in Public Health at the University of North Carolina.

The importance of care coordination with long term services and supports are essential.

Some physicians rely on Nura for assistance pinpointing the cause of the pain. Some look to us for specific treatments, while others turn to Nura for total pain management of complex cases. In every case, our message is the same: We’re here for the long-term, with the resources and commitment to make a genuine difference in the lives of patients.

Holly Boyer, MD