Minnesota Physician • October 2020 by Minnesota Physician Publishing

MINNESOTA

OCTOBER 2020

PHYSICIAN

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXIV, No. 07

What’s 20% Over the National Norm? Health Care Costs in St. Cloud BY JULIE ANDERSON, M.D. AND DERIK WELDON, M.D.

ver the past several months, physicians and other healthcare providers, business representatives, and patients in Central Minnesota have gathered to promote patientcentered, transparent, personalized, cost-effective healthcare in our region. The communitybased group, which has organized as “Central Minnesotans for Healthcare Independence” (CMHI), is dedicated to a strong health care infrastructure in Central Minnesota.

Keeping Politics Out of Science and Public Health COVID-19 Shines a Light BY PENNY WHEELER, MD AND EMILY BARSON

OVID-19 has magnified the critical problems in our health care system, heightened people’s awareness of its flaws, as well as the need to improve it. One needn’t look further than the fact that the United States accounts for 22 percent of global COVID-19 deaths despite making up 4 percent of the global population. Amid this great resetting, we must take every opportunity to rethink the parts of the health care system that are not serving people and build a more reliable and robust health care system for the future. Keeping Politics Out of Science and Public Health to page 104

After several formal and informal discussions, the group concluded that there are many compelling reasons to take action and attempt to re-direct What’s 20% Over the National Norm? to page 124

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OCTOBER 2020 MINNESOTA PHYSICIAN

OCTOBER 2020

Volume XXXIV, Number 7

COVER FEATURES Keeping Politics Out of Science and Public Health COVID-19 Shines a Light

By Penny Wheeler, MD and Emily Barsen

What’s 20% Over the National Norm? Health Care Costs in St.Cloud By Julie Anderson, M.D. and Derik Weldon, M.D.

DEPARTMENTS CAPSULES .................................................................................. 4 INTERVIEW .................................................................................. 8 “The Patient Revolution” Victor Montori, MD Mayo Clinic

BEHAVIORAL HEALTH.................................................................. 14 Improving Patient Outcomes Tools for promoting healthy behavior

Stephanie A. Hooker, PhD, MPH, Michelle D. Sherman, PhD, ABPP and Andrew H. Slattengren, DO, FAAFP INFECTIOUS DISEASE.................................................................. 18 Treating COVID-19 with corticosteroids Positive worldwide collaboration By James W. Leatherman, MD, and John B. Pflugi, DO

RURAL HEALTH........................................................................... 22 COVID on the North Shore Establishing trust to meet the challenge Kurt Farchmin, MD

SENIOR CARE............................................................................. 24 Treating Underserved Aging Patients Never make presumptions Laura Pattison, MD and Morgan Weinert, RN, MSN, AGPCNP

HOME HEALTH CARE................................................................... 26 Private Duty An Essential Role During COVID-19 By Aaron Stromley

PEDIATRICS................................................................................ 28 Autism Spectrum Disorder Advances in diagnosis and treatment Rachel Bies, M.D., Angela Heitzman, PsyD, LP and Vanessa Slivken, MA, LMFT

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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.

CO N C E RT S FO R T V, R ADIO & STREAMING The Minnesota Orchestra, Twin Cities PBS (TPT) and Classical MPR have come together to bring you a new way to experience the Orchestra. THIS IS MINNESOTA ORCHESTRA is a series of Friday night concert broadcasts, live from Orchestra Hall. Get up-close-and-personal with musician interviews, insights into the music, behind-the-scenes content and much more. All from the comfort of home. FRI NOV 20 8PM FRI DEC 4 8PM FRI DEC 1 8 8PM Visit our website for the complete broadcast schedule and details.

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All artists, dates and programs are subject to change. PHOTO Courtney Perry.

MINNESOTA PHYSICIAN OCTOBER 2020

CAPSULES

North Memorial Leads Staff Flu Vaccine Initiative Minnesota was 44th out of 50 states in the rate of healthcare workers vaccinated against influenza, according to the most recent CDC data for the 2018-2019 flu season. While Minnesota often thinks of itself as a leader in healthcare due to the high-quality clinical care and cutting-edge treatments available in our state, when it comes to healthcare worker vaccinations, Minnesota is far from leading the way. “With COVID-19 in our communities, many of us are looking for simple steps we can take to stay healthier. As a healthcare organization, it is essential that we take a leadership role in caring for our community and creating the safest possible care environment. We want to take every possible measure to protect ourselves, our teammates

and our customers from preventable harm.” said Samantha Hanson, chief administrative officer, North Memorial Health. To address these concerns North Memorial Health’s team member influenza vaccination program now requires mandatory participation. Vaccination has been shown to be effective in reducing the incidence of influenza in hospital staff and the patients we care for. This year, steps to prevent the flu are even more critical as we will face it alongside COVID-19, which can present similar symptoms and make diagnosis and treatment more difficult. So far nearly 3,000 team members have already been vaccinated with a goal is achieve full participation by October 31. Of course, North Memorial also encourages community members to take the same step and get their flu vaccine and offer convenient options for flu

shots at their primary care clinics with an appointment.

Fairview Announces Closings Citing financial loss related to COVID, and other concerns, Fairview recently announced it would be closing Bethesda and St. Joseph’s hospitals, recent acquisitions in the HealthEast merger as well as several clinics and pharmacies statewide. Loses were projecting to the quarter of a billion dollar range. Bethesda had recently transitioned from focusing on post acute care to COVID specialty care and prior to the more recent spike in cases had seen a decline in patients. Several strategies, including converting Bethesda into a facility serving the homeless, have been discussed. St. Joseph’s is Minnesota’s oldest hospital dating to 1853.

It will take over the specialized COVID care until its closing and leaves St. Paul facing the loss of significant patient service. Clinic closings include Columbia Heights, Downtown St. Paul, Farmington, Grand Avenue, Hiawatha, Hugo (HealthEast - 14688 Everton Ave. N) Integrated Primary Care, Minneapolis, Lino Lakes, Milaca, Pine City, Roseville, Savage, Xerxes (Bloomington Lake, Xerxes), Zimmerman, Ellsworth (WI), and Spring Valley (WI). Pharmacy closings include Columbia Heights, Hiawatha (Minneapolis), Lino Lakes, Milaca, Rush City and Zimmerman. The Ways to Wellness Program will also be closed. The closings include the elimination of some 900 jobs and impact an unspecified very large number of patients. They come on the heels of HeatlthPartners closing several clinics and pose many serious

MEDICAL MALPRACTICE ATTORNEYS

Angela Nelson

OCTOBER 2020 MINNESOTA PHYSICIAN

Ryan Ellis

Marissa Linden

Jennifer Waterworth

CAPSULES

issues about the need for health care reform. Some of the clinics had been temporarily closed due to the pandemic and telemedicine has addressed some of the access issues. The closings do not impact the M Health Fairview partnership with the University of Minnesota.

free, over-the-phone help for individuals looking to apply and enroll into health coverage.

To address the closings Fairview plans to consolidate or repurpose some facilities, to expand services at other sites, and to increase hours at some of their remaining 40 locations.

University launches Center for Healthy Aging and Innovation

MNsure adds new health insurance company for 2021 Residents in southeastern Minnesota will have a new MNSure option for 2021 following the addition of Madison, Wis.-based health insurance company Quartz, which anticipates offering plans in Fillmore, Houston, Olmstead, Wabasha, and Winona counties, all part of MNsure’s Rating Area 1. Quartz will join MNsure’s six other partnering insurance companies: Blue Plus, HealthPartners, Medica, and UCare for medical coverage; and Dentegra and Delta Dental for dental coverage. MNsure’s open enrollment period for the 2021 plan year runs Sunday, Nov. 1, through Tuesday, Dec. 22. All plans selected during this time will have a Jan. 1, 2021, effective date. Consumers will be able to view and compare 2021 plans in mid-October.

Quartz Health Solutions, Inc. is jointly owned by UW Health, Gundersen Health System, and UnityPoint Health.

The University of Minnesota School of Public Health’s new Center for Healthy Aging and Innovation (CHAI) seeks to foster interdisciplinary, community-engaged approaches to support students, researchers, and the community when addressing critical issues related to aging. “CHAI will also be an open channel for policymakers who want to partner with the University and school to create legislation and programs to support our aging populations,” said Joseph Gaugler, Phd, director of the center. CHAI‘s immediate goals are to address issues related to dementia care and support, the geriatric workforce, safety in long-term care, and quality and equity in long-term services and supports. The center emerged from the school’s previous Center on Aging, which was founded by former Professor Robert Kane. It raised awareness across the University for the need to scientifically study aging.

Tax credits, cost-sharing reductions, or no-cost or low-cost coverage under Medical Assistance or MinnesotaCare is available to those who qualify. An individual earning up to $51,040 a year, or a family of four earning up to $104,800, a year may be eligible for financial assistance. Updated income guidelines for plan year 2021 are located on MNsure.org.

Gaugler wants CHAI to be accessible to everyone and is structuring the center around three core areas: research, education, and equity/ community engagement.

MNsure has a statewide network of over 1,600 assisters who provide

“I’m especially excited about the possibility for new opportunities to

Exceptional Personalized Neurologic Care Burnsville 952.435.8516

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The center’s associate director for research is Associate Professor Tetyana Shippee, Phd, a member of the former Center on Aging who partnered with Gaugler in envisioning CHAI.

MINNESOTA PHYSICIAN OCTOBER 2020

CAPSULES

create and engage in new topics in aging science, collaborate with other researchers on grant proposals, and offer professional development for scholars doing aging-related research,” said Shippee. Learn more at https://tinyurl. com/mp-chai-center.

Medicare Open Enrollment Begins The annual Medicare Open Enrollment period began October 15 and will continue until December 7. During this period enrollees may change plans and there are numerous options that cover Medicare Parts A, B, C, and D and more. There are a variety reasons an individual may wish to change plans and new coverage details with each annual enrollment period. The Senior Linkage Line and Metropolitan Area Agencies on

Aging provide a range of supportive resources for patients looking at options for themselves or loved ones. They offer non-biased information on what can be a complex and confusing topic. For example, Medicare provides patients a downloadable guide that is only 124 pages long. Besides serving the public they also offer programs for clinic staff members that may interface with senior patients who have questions. They are also able to provide educational materials and videos that clinics can offer patients onsite. For more information visit outreach@metroaging.com

Nurses Association Support Quarantine Pay Bill The Minnesota Nurses Association has announced their support for a Minnesota House bill that would

provide emergency paid leave for the time spent in quarantine for a worker who tests negatively for COVID-19.

take time away from work to treat a non-COVID illness or injury, or to take care of a family member.”

Minnesota nurses have had to burn through their own sick time while waiting inordinate amounts of time for a COVID-19 test result or because a family member tested positive, which forced them to quarantine. This bill ensures that nurses who are following public safety protocols and doing the right thing to protect patients and the public are able to afford to do so.

The bill would provide 100 hours of emergency paid leave to workers considered to be full time by their employer. This leave would cover nurses who have either been instructed to quarantine or exhibit symptoms while waiting for test results but later test negative. It would also cover caring for a family member that contracts COVID-19 or for the purpose of childcare if their school is closed.

“While Minnesota healthcare workers wait for a test, wait for results, or quarantine due to possible COVID exposure, they are expected to use their own sick time or PTO if their test comes back negative,” said MNA President Mary C. Turner. “Nurses are burning through their personal benefit time at alarming rates, which impacts their ability to

Presently, a healthcare worker can only qualify for Workers’ Compensation pay if they themselves test positive for COVID-19.

Send us your news comments@mppub.com

V Alzheimer’s is now an approved condition V

HAVE YOU REGISTERED WITH THE MINNESOTA MEDICAL CANNABIS PROGRAM? Registration can be done online; there is no fee and it takes only a few minutes. Visit the registry website: mn.gov/medicalcannabis Your account will provide access to medical cannabis purchasing information from patients you certify. Once you are registered, you will be able to certify patients with a variety of conditions, including: • Cancer, Glaucoma, Tourette Syndrome, HIV/AIDS, and ALS

• Inflammatory bowel disease, including Crohn’s disease

• Seizures, including those characteristic of Epilepsy

• Terminal illness, with a probable life expectancy of less than one year

• Severe and persistent muscle spasms, including those characteristic of MS

• Intractable Pain

• Obstructive sleep apnea

• Post-Traumatic Stress Disorder

• Alzheimer’s

• Autism

Cannabis Patient Centers are now open to approved patients in Minneapolis, Eagan, Rochester, St. Cloud, Moorhead, Bloomington, Hibbing, and St. Paul.

OFFICE OF MEDICAL CANNABIS (651) 201-5598: Metro (844) 879-3381: Non-metro P.O. Box 64882, St. Paul, MN 55164-0882 health.cannabis@state.mn.us

Many patients have reported improvement in their health status from medical cannabis — some describing dramatic improvements. Smoking cannabis is not allowed under the program. Visit our website for educational resources about cannabinoids and the endocannabinoid system and for scientific literature on the efficacy of medical cannabis in treating certain conditions.

See our website for a detailed first year report. mn.gov/medicalcannabis

OCTOBER 2020 MINNESOTA PHYSICIAN

Peter Schultz, MD, MPH Medical Director Nura Pain Clinics R. Scott Stayner, MD, PhD Medical Director Nura Surgery Centers David Schultz, MD Chief Executive Officer Nura Pain Clinics

1. Chronic pain doesn’t take holidays. Although the COVID-19 pandemic has captured the headlines, chronic pain does not relent. According to the CDC, high-impact chronic pain (pain that interferes with work or life most days or every day) affects approximately 20 million U.S. adults.

2. Opioids are a problem. They can also be part of the solution. According to the CDC, opioid overdose is now the leading cause of injury-related death in the United States. Yet opioids have a rightful place in treating chronic pain, as some patients achieve life-changing improvement with minimal side effects on long-term opioids. Even at high dosage levels, opioids do not harm the body’s organs, unlike NSAIDS and acetaminophen. And thanks to the micro-dosing capability off ered by implanted spinal drug pumps, many of the most challenging cases can be treated effectively without risk of addiction.

Our thoughts on chronic pain…

3. There is no silver bullet. One of the challenges in treating chronic pain is the patient’s sometimes-overwhelming desire for a silver bullet, a “cure” or a magic button to turn oﬀ their pain. While that desire is understandable, in complex chronic pain there is rarely a single perfect answer. At Nura, we’ve found that a comprehensive approach which addresses the physical and psychosocial components of chronic pain is the best solution. So in addition to earning national recognition for leadership in implantable pain technology, we oﬀer behavioral counseling, physical therapy and opioid management, all designed to help the most challenging pain patients.

If you have a patient struggling with chronic pain and you’d like to discuss the case, please call our Provider Hotline at 763-537-1000. If the situation is urgent, we will do our very best to see your patient the same or next day.

MINNESOTA PHYSICIAN OCTOBER 2020

INTERVIEW

“The Patient Revolution” Victor Montori, MD Mayo Clinic One of the central themes in your book is careful and kind care. Please tell us what you mean by this.

chronic conditions reported being overwhelmed. Clinicians interested in co-crafting programs of care that makes sense to patients must face not just time pressures but also the need to meet practice standards and performance metrics that are often in conflict with the notion of minimally disruptive medicine. Clinicians bear witness to this churning, how it limits access to care, how it overwhelms patients, how it often fails to improve their patients’ situation, and how it leaves them dissatisfied.

Health care should be careful in that the care plan should respond well to the patient’s situation, the response should be based on the best available research evidence, and it should be safely implemented. Health care should also be kind in that it must respect the patient’s precious and limited time, energy, and attention, avoid delegating unnecessary medical errands to patients and caregivers, and must form care plans that can be made to fit well within each patient’s daily routine. This often requires collaboration between clinicians and patients.

At the core of industrial health care is the notion that what happens at the point of care is the “delivery of care” by a provider (a person or an institution) and patient. Patients are expected to be engaged and activated to do their part in this care delivery. Payers judge the care delivered in terms of its quality and cost. Patients are not the reason for health care’s actions but are uncompensated employees. In this way, industrial health care has corrupted its mission. Typically, industrial health care focuses on care for “people like this” (not for this person), disregards continuity of care, promotes transactional interactions, focuses on documentation of care rather than on the care itself, and seeks to optimize financial outcomes rather than human ones. It is cruel to patients and clinicians alike. In industrial health care, whatever “value” is accrued flows away from the clinical encounter and to management and funders. Accountability is also inverted. Clinicians and patients are held accountable by the administration, rather than managers asking themselves, how might I enable care to be easier, better, safer, more equitable, and more effective today for patients and their clinicians?

OCTOBER 2020 MINNESOTA PHYSICIAN

“...”and innovation Reform are simply insufficient tools to address the problem. This is why we need a revolution. “...”

Please tell us what you mean by industrialized medicine and the problems it causes.

One of the problems you discuss in Why We Revolt is the corruption of evidencebased medicine (EBM). What are the signs of this corruption?

You speak widely about the burden of treatment on patients. How do physicians respond to that idea?

Clinicians respond with sympathy as they find themselves overwhelmed by industrial health care. They spend half the time with patients clicking on fields in the medical record, a task that must often continue at home. They experience workloads that exceed their capacity and sometimes key actions must be skipped to get through the day. This produces moral injury and burnout, with clinicians leaving the practice or cutting down on their patient care times. This burden is repeated with patients, particularly people living with multiple chronic conditions, who have to accommodate not only the demands of living but also the demands health care makes. When these demands exceed a patient’s capacity, they may not complete all the tasks and will be labeled, cruelly, as noncompliant. About 40% of patients living with

“Evidence-based” was added as an adjective to better describe a form of medicine in which we carefully and judiciously draw from the best available research to figure out with our patients how to respond to their problematic human situation. The main advance of EBM has been to note that not all observations and certainly not all research evidence are equally credible, and no matter how credible, no piece of evidence ever tells us how to care. Care is formed in response to this patient, not to patients like this. Research evidence alone is not enough. It must also include what we can glean from experience and expertise of the clinician and the patient. When research evidence is motivated by a purpose different from supporting patient care (i.e., to gain FDA approval or increase market share) the questions asked and the findings published are tainted by a desire to further industrial goals. In this way, the evidence base becomes corrupted because of biased methods, results, and publication. Clinicians and patients are left to make decisions based in part on the wrong information, making care less safe and effective, i.e., less careful. Another theme is “timelessness in care” and the problems time constraints create. Please share some of your thoughts on this.

Care is a fundamentally human activity. Humans process complex information through thoughtful contemplation: space to talk, observe,

reflect, and be silent. These actions take time and give care its natural tempo. This is why it is silly to demand for care to be efficient. We should not waste resources, time key among these. But we should also not accelerate the tempo of care arbitrarily. Like a ballerina, there is no wasted move, but also no haste in the movement. There is a certain length of care that enables time to become dense and deep. Sometimes this requires visits to be longer, but not excessively so. Sometimes what is necessary is the continuity of relationship— not with the institution, as industrial health care would have it—but with a caring clinician so that the time for care that matters spans across multiple moments. Careful and kind care takes time. This does not refer to length only, but also to depth. It does not refer to duration only, but also to rhythm.

for high efficiency reach education, mentorship, family care, friendships, craftmanship. This industrialization of human activities includes health care, and when it reaches those other ones, it often produces “value” while betraying and abandoning its essence, its purpose. Despite this corruption of its mission, whole economies—from clinician income to retirement funds—depend on the economic success of industrial health care, of having it remaining as it is. As we have seen during COVID-19, health care can collapse while health care payers celebrate unprecedented profits. It can celebrate the creation of value and yet fail to offer protective equipment to its clinicians and cruelly let patients die alone because their loved ones cannot be allowed at their bedside. This is why reform and innovation are simply insufficient tools to address the problem. This is why we need a revolution.

which resources are managed, strategies planned, and executions judged. It expects citizens to take the lead and clinicians to soon join an effort to upend what is there in exchange for something better. We are working to develop some larger initiatives in pursuit of this goal. In the meantime, our website (https://patientrevolution.org) offers some tools for patients and clinicians, not to compensate for the lack of care in industrial health care, but to offer glimpses of this future, and to let clinicians and patients experience together the possibility of a better alternative.

What is the biggest challenge you are facing in building a movement?

How can physicians get involved?

and other chronic conditions. He is the author of

The biggest challenge is how well industrial health care fits with the rest of the world in which we are asked to flourish. In this world, we live distracted lives, pressed for time, and expected to achieve more, faster, and with less. Demands

The central requirement of a revolution is to visualize a better alternative and a path towards it. The Patient Revolution’s vision of careful and kind care for all puts care at the center. In this future, the ability to care becomes the guiding force by

the book Why We Revolt: A Patient Revolution for

Victor Montori, MD, is professor of medicine at Mayo Clinic. He is a practicing endocrinologist, researcher, and author and a recognized expert in evidence-based medicine and shared decisionmaking. Dr. Montori co-developed the concept of minimally disruptive medicine and works to advance person-centered care for patients with diabetes

Careful and Kind Care.

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MNGIPrint2020.indd 1

9 8/6/20 11:15 AM

3Keeping Politics Out of Science and Public Health from cover Public trust and faith in science are critical when it comes to population health, especially during a pandemic. Unfortunately, however, we have seen an unprecedented amount of politics injected into our health care delivery system. So much so that even masks and physical distancing have become political issues. Unlike previous national emergencies, such as 9/11 that brought the country together, the COVID-19 pandemic has only fueled our nation’s political divide. An example is the deluge of misinformation about the pandemic — whether it’s the constant downplaying of the dangers of COVID-19, attacks on public health institutions, or amplification of false medical treatments — spreading on social media and elsewhere, which we’ve seen create real-life consequences.

Our nation has a dire need for science-based, nonpartisan information about the pandemic and the critical nature of public health preparedness in general.

COVID-19 Magnifies Existing Problems in Our Health Care System Now more than ever, it’s time to put science and health care above politics by redefining the goal in human, not political terms and supporting a positive, practical, and lasting approach.

Our nation has a dire need for science-based, nonpartisan information

Every day we are confronted with headlines that remind us of the reality that COVID-19 does not care if you’re a Republican or Democrat. It also doesn’t care if you, or your patients, are tired of it or think the threat is overblown. Building trust is enormously important in neutralizing misinformation and overcoming increasing skepticism around an eventual COVID19 vaccine, and we all share a responsibility in this critical work. Health officials are doubling down on calls for flu shots to prevent systems from being overrun in the coming months.

United States of Care is a nonpartisan nonprofit co-headquartered in Minneapolis and founded in 2018 by Minnesotan Andy Slavitt, a former Acting Administrator of the Centers for Medicare and Medicaid Services. Its mission is to ensure that every American has access to quality, affordable health care regardless of health status, social need, or income.

Since March 2020, our work has been oriented around COVID-19. Specifically, the need for practical solutions that address both the immediate challenges of the crisis and long-term gaps in our health care systems — laid bare by COVID-19 — to ensure people can access affordable, high-quality care. Looking ahead, the pandemic, economic recession, and national discussion on race have created a renewed call for action in America. It simply isn’t enough to get “through the crisis” and go back to the system we had before. We believe this moment is an opportunity to work together to build a health care system that serves all of us better. That starts by understanding and addressing health care disparities, examining the role of virtual care, investing in communities to improve health, and reimagining job-connected health care. The invaluable perspectives of physicians on the frontlines of COVID-19 are especially important in the larger policy conversations to come, post-election.

Health Disparities

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OCTOBER 2020 MINNESOTA PHYSICIAN

Sadly, it isn’t a surprise that people of color have disproportionately experienced the pandemic’s burden. Despite some perceptions that systemic racism is not a public health issue, overwhelming facts prove otherwise. COVID-19 simply magnified the problem that already existed. Two years ago, USofCare launched an initiative with Minnesota health systems, community leaders, and Wilder Research to develop a roadmap to end disparities in health outcomes throughout the state. The goal was to listen to individuals and communities facing structural barriers and to put forth policy solutions aimed at better addressing racial disparities in the short-term and ultimately eliminating them in the future. The work resulted in a Feasibility Study, The Role of Health Care in Eliminating Health Inequities in Minnesota, and a Systems Transformation Framework. We urge institutions to utilize this tool to ensure all people — particularly those most underserved — can live the healthiest life possible. As physicians we must ask questions like what more can we all be doing to advocate for change in the systems where we serve? How can providers check our own biases to provide the highest level of care to all our patients?

Looking at Virtual Care in the Right Way From the moment the pandemic forced providers to reimagine the way they care for patients, and regulatory flexibilities were granted — COVID-19 unleashed a revolution in virtual care.

While there’s no denying that virtual care has filled a critical gap in the system left by the sudden restrictions on physical visits, serious questions remain surrounding the future of virtual care post-COVID. We recently launched a new initiative to explore how virtual care can best function as an innovative tool to help groups — disproportionately impacted by health inequities — access care in a whole new way.

enormous anxiety, uncertainty, and frustration. Although we do not know when the pandemic will end, for many, the psychological, physical, and mental scars may never go away. Our nation finds itself at a crossroads. The lessons we choose to learn from COVID-19 will shape policy and decision-making for generations to come. While the pandemic has highlighted so much of what’s wrong with our national health care system, it’s also highlighted what’s right – the people. Americans are finding hope amid the crisis – in religion, their families, and stories of people helping others. They are forever grateful and inspired by the extraordinary efforts of our nation’s physicians, nurses, and other medical workers on the front lines. We are faced with a unique opportunity to build a stronger health care system for the future — one that truly serves all – and we must do everything we can to that end.

We are starting our work with a listening tour to connect with people throughout the US and better understand their experience with virtual care. We’ll be pairing what we hear with research, evidence, and We must rethink our input from experts on how virtual care has helped 75-year-old system of jobto break down barriers to accessing care - or in some connected health insurance instances, create new ones. We’ll use this information to produce tools and resources policymakers and health systems can use to create a virtual care system that works for all of us. We then plan to bring together expert leaders to support the implementation of these resources and evaluate their impact over time. We also especially want to hear the perspective of physicians. Our questions include: Emily Barson is the Executive Director of United States of Care. How have you embraced virtual care since COVID-19 started to take hold in Penny Wheeler, M.D., is the CEO of Allina Health and a Founder’s the US? How can we think about virtual care as a tool towards achieving more Council Member of United States of Care. equitable access?

Investing in Communities to Improve Health The interlocking economic and public health crises have created the imperative to reframe what constitutes health as more inclusive of mind, body, spirit, and community. Providers are increasingly partnering with patients to gain a better understanding of their comprehensive healthrelated social needs. As one example, Allina Health is part of the Accountable Health Communities cooperative agreement with the Centers for Medicare and Medicaid (CMS). It has been screening its patients for basic needs such as food, housing, transportation, and interpersonal safety, then supporting patients with unmet needs to connect to community resources. We need to continue to accelerate approaches that support this type of multidimensional health care delivery.

Rethinking Job-Connected Health Insurance During the past seven months, the pandemic has magnified the risks to the more than 160 million people who have their health security connected to their jobs. In fact, it’s estimated that as many as 14.6 million people may have lost their job-connected health insurance benefits. These compounding effects of the pandemic have helped people see that one individual’s health is linked to the health of all, and we need to re-examine the precarious state of job-connected health insurance for people, employers, and our economy. We must rethink our 75-year-old system of job-connected health insurance, which can leave half the US population vulnerable to losing both their job and health security at the same time. Here again the voice of physicians is crucial. How does the system of job-connected health insurance help or hinder your patients’ ability to access the care they need?

Reflections on 2020 and Looking Ahead For the overwhelming majority of Americans, 2020 has been a year filled with

Please visit us online, we’d love to hear for you. (https://unitedstatesofcare.org/) for updates and the latest resources.

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3What’s 20% Over the National Norm? from cover

issues report that improvements in access/options are almost impossible to obtain once a critical mass of consolidation has occurred. Hence, our efforts now to protect our community and the patients we serve.

some troubling trends regarding the region’s health care infrastructure. Our region is not unique in struggling with these issues and our findings Because of CentraCare’s size and many contributions to the community, may be of interest to health care providers in identifying solutions that are acceptable to all other areas with similar demographics. In order health care providers as well as to employers and to promote continuous quality improvement and policy makers has been challenging. other innovation through competition – which However, with the recent closure of the maintain and foster a strong, community-based The cost of healthcare in HealthPartners clinic in St. Cloud this fall, and the health care infrastructure -- Minnesotans in the St. Cloud market, for pending closing of Physicians Neck and Back Clinic at St. Cloud and beyond should be able to choose 2019, was 19.6% higher the end of 2020, the concerns have been heightened, their physician and have options for choosing the than the national average. not only by CMHI, but also by employers and public location of their care. This is important for many officials concerned about health care costs and the reasons, including: privacy concerns, to assure necessity to be focused on continuous excellence in continuity of care, and preserve trust between all health care services provided. physician and patient to ensure quality care. The HealthPartners clinic in Sartell, which was closed by its parent Further, many patients are uncomfortable navigating a large health network company in Bloomington, provided a critical alternative option for primary and specifically seek out smaller clinics. care -- including prenatal care -- and was a clinic that received high marks Rapidly expanding healthcare systems across the country are increasingly in several quality surveys over the years, challenging other local physicians using their immense and expanding market power to limit healthcare choices. to compete with their exceptional standards. This is not in the best interests of communities over the long term. An example of such a rapidly expanding system is that of CentraCare in Central Minnesota. As a result of their expansion and consolidation of the local and regional market, our region is experiencing higher health care costs and the erosion of patient choice and access. Studies of such health care marketplace

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Across America, studies have shown that consolidation of health care is contributing to costs in general. According to information shared earlier this year by the St. Cloud Area Chamber of Commerce, Central Minnesota is experiencing higher health care costs when compared to other areas. The Cost of Living Index compiled by The Council for Community and Economic Research shows that the cost of healthcare in the St. Cloud market, for 2019, was 19.6% higher than the national average. Comparatively, healthcare costs are just 5.5% above the national average in Minneapolis and 6.1% above the national average in St. Paul. (Report published February 2020 for calendar year 2019, comparative data for 266 cities). According to the Chamber, “The index measures regional differences in the cost of consumer goods and services, excluding taxes and nonconsumer expenditures, for professional and managerial households in the top income quintile. It is based on more than 50,000 prices covering almost 60 different items for which prices are collected three times a year by the St. Cloud Area Chamber of Commerce. The composite index is based on six components - housing, utilities, grocery items, transportation, health care and miscellaneous goods and services.” Legislative and employer-funded research from across the nation indicate that health care costs increase as a geographic area’s health care services/ providers consolidate. Consolidation, especially with the sale of the St. Cloud Medical Group a few years ago and now the closure of the HealthPartners Clinic, is one of the troubling trends which the CMHI providers believe needs to be addressed by the community. The group has looked at some of the laws enacted in other states in hopes of curbing the escalating sales of physician practices to large hospital systems. In September of this year, the Rand Corporation released “Rand 3.0” which finds that consolidation is “a key contributor” to increased prices and price variability, recommending that “...employers can support efforts to promote competition in health care markets by opposing consolidation among existing providers and by promoting entry of new, lower-priced providers.”

Additionally, the experience of healthcare providers during the COVID19 pandemic has reinforced our belief that independent, smaller, and more nimble providers are an important part of the healthcare system that must be protected. At a recent, virtual meeting of the St. Cloud Area Chamber, independent providers gave examples of their flexibility – due in large part to their smaller size – to adapt to the safety needs created by state mandates and patient concerns.

Simplicity Health clinic remained open during the entire pandemic closures during the Spring of 2020.

Because of CentraCare’s size and many contributions to the community, identifying solutions that are acceptable to all health care providers as well as to employers and policy makers has been challenging. Certainly, the community deserves a vibrant hospital system that can serve as a critical regional center for our surrounding towns. However, innovation flourishes and quality is Health care costs increase as a enhanced when patients have access to alternative geographic area’s health care healthcare choices and we believe that competition services/providers consolidate. leads to greater effort.

For example, the physicians at St. Cloud Orthopedics met daily during the beginning of the crisis to make decisions without delay for patients that needed care. While the situation was urgent for some individual patients, the urgency regarding the shortage of personal protective equipment (PPE) and the lack of definitive knowledge on how exactly the coronavirus was spreading, required decisive and timely action to respond to each patient’s situation.

St. Cloud Surgical Center expanded its safety and cleaning protocols and then continued to adjust them, without delay, as more scientific information was made available. Because the physicians who use the Surgical Center offer a variety of services, it was critical that each procedure and each patient could receive customized care at truly a time of crisis. Another example of highly valuable nimbleness by a small provider was Simplicity Health. The primary care clinic was first in the community to provide electronic (telehealth) office visits and car visits to ill patients.

As leaders of CMHI, we hope to initiate further discussion on several problematic trends which, if reversed in a collaborative manner, can lead to the vibrant, high quality health care delivery system which will benefit our community is so many ways. The following are areas we have identified as needing improvement to help redirect the troubling trends we discussed earlier, both in Central Minnesota and nationwide; Issues of concern: • Encouragement of patient choice and privacy - Example: Ending the practice of financially penalizing employees and families for seeing independent practitioners What’s 20% Over the National Norm? to page 344

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BEHAVIORAL HEALTH

Improving Patient Outcomes Tools for promoting healthy behavior STEPHANIE A. HOOKER, PHD, MPH, MICHELLE D. SHERMAN, PHD, ABPP AND ANDREW H. SLATTENGREN, DO, FAAFP

vidence suggests that approximately 40% of the variance in health outcomes can be attributed to modifiable health behaviors, such as physical activity, dietary habits, smoking, alcohol use, and insufficient sleep. One of the ways to improve health outcomes is to address these modifiable risks and encourage patients to engage in healthier behaviors. Primary care is an ideal setting in which to address health behaviors. Many of the top reasons patients are seen in primary care have contributing behavioral components, including hypertension, chronic pain, and diabetes. Further, primary care offers easy access to care, continuity across time and stages of health and illness, and a comprehensive approach to health, which can enhance the development of trusting, collaborative relationships between clinicians and patients. Moreover, patients whose primary care clinicians ask about health behaviors (e.g., smoking) are more satisfied with their healthcare than patients whose clinicians do not. Thus, primary care clinicians need to be able to effectively discuss behavioral risks and encourage patients to make behavioral changes.

Several brief behavioral interventions have been found to be effective in primary care settings. For example, when primary care providers help patients set small, realistic goals for engaging in physical activity, patients increase their activity levels. However, despite many practice recommendations urging clinicians to address health behaviors with patients, primary care clinicians spend, on average, less than 1% of their time doing so. This discrepancy is likely due to many factors, including perceived insufficient time and low levels of confidence in delivering effective interventions. Perhaps further contributing to these problems is that little time is devoted to training physicians in medical school or residency on how to effectively encourage behavior change and to integrate these skills within their practices. Thus, there is a significant need for comprehensive curricula to train clinicians to use brief, behavioral interventions to address modifiable health risks.

Change that Matters: Promoting Healthy Behaviors To address the gap in comprehensive curricula, our multidisciplinary team at the University of Minnesota’s North Memorial Family Medicine Residency program and Broadway Family Medicine clinic created Change that Matters: Promoting Healthy Behaviors, a 10-module curriculum. This program teaches primary care clinicians brief, evidence-based interventions for common behavioral health topics, including alcohol use, chronic pain, depression, healthy eating, medication adherence, physical activity, sleep, social isolation, and stress. The development of the curriculum was co-led by two psychologists (Dr. Hooker and Dr. Sherman), and included input from professionals from multiple disciplines, including family medicine (faculty and residents), public health, nutrition, and pharmacy. Each module includes three components: • Didactic training, including slides that outline the importance of the behavior, assessment questions, evidence-based interventions, and practice of key skills • Electronic health record templates, including a documentation template to guide clinicians through how to deliver the intervention (assessment and goal-setting guide) and an after visit summary • Interactive patient handouts, available in English and Spanish, that guide the clinician and patient through a discussion about the topic, encourage goal setting, and problem solve potential barriers A key theme that runs through all modules is the idea that patients are encouraged to draw upon their values and sense of meaning in life to find motivation to make changes. Research suggests that when patients connect their reasons to change to the deeper “why” (e.g., to be able to spend more quality time with family), they are more likely to maintain those changes. The entire curriculum is available for free to download from the website, https://changethatmatters.umn.edu. On the website, there is also a detailed Implementation Guide and printable posters for exam rooms.

OCTOBER 2020 MINNESOTA PHYSICIAN

Interested clinicians can download one module at a time or use a convenient link to download the entire curriculum at once.

5 Tips for Addressing Health Behavior Change in Your Practice Making and sustaining changes in health-related behaviors is difficult! Approaching patients with a hopeful, encouraging attitude and a lot of patience can be useful. Here are a few tips on how to talk with patients about health behavior change:

In the initial evaluation of the curriculum, feedback from family medicine experts, resident physicians, and patients was all very positive. Eleven family medicine experts (physician and behavioral health faculty from family medicine residency programs) reviewed the patient handouts and rated them as highly understandable and actionable. In open-ended feedback, they stated that they liked the interactive nature of the patient Behavior change is a marathon, not a sprint. materials, the use of evidence-based principles (such as motivational interviewing and cognitive behavioral therapy), diversity in pictures and recommendations, the visual appeal of the patient handouts, and the concrete recommendations. Individual interviews at Broadway Family Medicine Clinic with 20 residents and 20 patients yielded similarly positive themes. Resident physicians felt more self-confident in their ability to discuss behavioral issues with their patients. One resident stated, “I feel more like I’m going to be able to plant a seed or make a difference in empowering somebody...it makes me feel more confident and sort of less tied to outcomes, more like seeing it as an on-going long process.” Similarly, patients felt more empowered to make changes and take ownership of their health. One patient noted, “There’s things I can do before we jump to like medication [for sleep]….kind of refreshing to know that, you know, there’s things I can do.”

Take a long-term perspective. Behavior change is a marathon, not a sprint. Most people take time to change old habits. Often, people try to make changes to their habits after years of engaging in the old behaviors that they want to change. The strength of those habits is very strong; thus, relapses are very common. For example, most patients who successfully quit smoking have tried to quit at least 8 times before! It is good not to expect overnight transformations and recognize that it may take a long time for patients to reach

their goals. Focus on and celebrate small changes. Setting small goals is a great way to build patients’ confidence that they can change. It is not uncommon for people to choose an initial goal that is actually their long-term goal. For example, when some people join a gym to increase their physical activity, they set a goal of going to the gym 5 days a week. If they were not exercising at all prior to making that change, the goal of 5 days a week may become Improving Patient Outcomes to page 164

Do you have patients with trouble using their phone due to a hearing loss, speech or physical disability? Contact the Telephone Equipment Distribution Program for easier ways to use the phone. Phone: 800-657-3663 Email: dhs.dhhsd@state.mn.us Website: mn.gov/deaf-hard-of-hearing The Telephone Equipment Distribution Program is funded through the Department of Commerce – Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services.

MINNESOTA PHYSICIAN OCTOBER 2020

3Improving Patient Outcomes from page 15 matter; encourage patients to use whatever method works best for them. Then, review the logs with patients at subsequent visits. Physicians can look for patterns in behavior: What was happening when things were going well? When the patient was struggling? This discussion and shared reflection can provide a helpful opportunity to learn what is working and what is not. These data are vital for helping patients set new small goals and continue to work on making changes. Maintain a spirit of hope. Sometimes patients Primary care is an ideal setting in and clinicians can get frustrated when progress which to address health behaviors. Encourage patients to reflect on their values to seems slow or nonexistent, especially when there enhance motivation for making behavior change. are lapses in behavior. Look for and celebrate Learn about what is really important to your changes that may not be initially observable patients – for some, this may be family, intimate or measurable, such as an improved ability to relationships, or friendships, and for others, it could problem solve or increased motivation to change. be work, spirituality, or community involvement. Reframe any setbacks as temporary and opportunities to learn how to Whatever their values, encourage patients to make a connection to those improve going forward. If you believe in your patients, they may believe a deeper values and why they want to make the changes for their health. Perhaps little more in themselves, too. a patient wants to better manage her chronic pain so she can volunteer at an organization that is important to her. Another patient may want to quit Continue the discussion across visits. Keeping in line with the first smoking because he wants to limit his child’s exposure to tobacco. Keeping in tip, the discussion about behavior change should continue across visits. mind the bigger reason for making those changes can motivate people when At the initial visit, encourage patients to keep track of their progress, the day-to-day task of making the changes gets difficult. such as on paper, a calendar, or a specific tracking log (e.g., sleep diary). Technological methods also exist, such as smartphone apps or wearable devices that can track some behaviors. The mode of tracking does not an almost insurmountable challenge. However, if that person was to set an initial goal of going 2 times a week, and they master that small goal, they can consider increasing the number of times per week over time. Further, even small changes can have a big impact. Exercising 2 times a week compared to 0 times per week is associated with improved fitness and ultimately increased longevity.

Improving Patient Outcomes to page 174

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3Improving Patient Outcomes from page 16

Michelle D. Sherman, PhD, ABPP, licensed clinical psychologist who is Board Certified in Couple and Family Psychology. She is a Professor at the University

Conclusions

of Minnesota in the Department of Family Medicine and Community Health

Nearly everyone can benefit from making some change to their behavior and Director of Behavioral Health at the North Memorial Family Medicine to improve their health. Change that Matters: Residency Program. She is editor of Couple and Promoting Healthy Behaviors is a comprehensive Family Psychology: Research and Practice. curriculum to help clinicians learn how to deliver brief behavioral interventions in practice Andrew H. Slattengren, DO, FAAFP, is an and is available for free on the website, https:// Assistant Professor at the University of Minnesota in 40% of the variance in health changethatmatters.umn.edu. If you have outcomes can be attributed to the Department of Family Medicine and Community suggestions for other topics or other questions modifiable health behaviors. Health and Associate Program Director of North about implementing the materials in your Memorial Family Medicine Residency. He is the practice, Dr. Hooker and Dr. Sherman are available for consultation. They can be reached current President of the Minnesota Academy of Family via email at stephanie.a.hooker@healthpartners. Physicians. com or sherman@umn.edu, respectively. Stephanie A. Hooker, PhD, MPH, is a licensed clinical health psychologist and Research Associate at HealthPartners Institute, Bloomington, MN. She is also an Adjunct Assistant Professor in the Department of Family Medicine and Community Health at the University of Minnesota. Her research examines behavioral influences on health and well-being, with an emphasis on developing and testing brief, theory-based interventions.

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INFECTIOUS DISEASE

Treating COVID-19 with corticosteroids Positive worldwide collaboration BY JAMES W. LEATHERMAN, MD, AND JOHN B. PFLUGI, DO

espiratory illness caused by the novel coronavirus SARS-CoV-2 (now known as COVID-19) was first identified in the Chinese city of Wuhan and surrounding Hubei Province in early December 2019. The first U.S. and Minnesota cases were identified on January 20 and March 6, respectively. On March 11 the World Health Organization (WHO) characterized COVID-19 as a global pandemic. From the outset, Chinese clinicians who were inundated with large numbers of seriously ill patients attempted a variety of therapies, including antibiotics, antivirals, antioxidants, N acetyl-L-cystine, and hydroxychloroquine. In addition, some of the most severely ill patients were given corticosteroids. An early report from Wuhan suggested that corticosteroids might decrease mortality of patients with COVID-related ARDS (acute respiratory distress syndrome), but interpretation of this finding was limited by the retrospective, non-randomized study design. Indeed, recommendations from the WHO, Centers for Disease Control and Prevention (CDC), German Intensive Care Society, American Thoracic Society, and the Infectious Diseases Society of

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North America recommended against steroid administration in patients with COVID-19 infection outside of a randomized clinical control trial. These recommendations were based on previous studies that had raised concerns about potential harm related to use of corticosteroids in the management of other respiratory viruses, including influenza and the coronaviruses responsible for SARS and MERS. Corticosteroid therapy appeared to decrease viral clearance in SARS and MERS and possibly increase mortality of influenza. In contrast, the Chinese Thoracic Society recommended steroids be given to critically ill patients with COVID-19 and the Society of Critical Care Medicine made a weak recommendation in favor of corticosteroids for COVID-19-related ARDS. These conflicting recommendations regarding use of corticosteroids created a dilemma for front-line clinicians responsible for managing patients with COVID-19. In the absence of evidence from randomized controlled trials, individual physicians were forced to use their own clinical judgement regarding the risk-benefit of treatment with steroids.

History The controversy regarding use of corticosteroids in patients with ARDS has been ongoing for decades. In a large multicenter trial, steroids given to patients with late (after day 5) ARDS did not affect outcome, and one metaanalysis of previous studies found no overall benefit to the use of steroids. Previous investigations varied widely with the specific type of steroid, dose, and duration of therapy. Earlier studies were also conducted without the application of lung-protective ventilation, an intervention associated with improved outcomes in ARDS. A subsequent meta-analysis that was limited to studies with low-to-moderate steroid dosing, a duration of 1â&#x20AC;&#x201C;4 weeks of administration, and lung protective ventilation concluded that steroid administration in ARDS increased ventilator-free days and decreased mortality. Recently, a multicenter randomized trial (DEXA ARDS) that assessed the impact of a 10-day course of dexamethasone (20 mg/day for 5 days, then 10 mg/day for 5 days) when given within 48 hours of onset of

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Severity of Illness

Viremia

Inflammatory response

Antiviral therapy

Time Course (Days)

Figure 1. COVID-19 disease phases and indicated therapy.

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Anti-infammatory therapy

NHS hospitals who were randomized to various treatment arms, with preliminary results announced 98 days after protocols were drafted. A total of 2,104 patients hospitalized with COVID-19 were randomized to receive 10 days of dexamethasone (6 mg/day) for 10 days. As compared to placebo, dexamethasone resulted in a highly significant reduction in mortality (29% vs. 41%) for those patients who required mechanical ventilation. For non-intubated patients who required supplemental oxygen, the reduction in mortality (23% vs. 26 %) was less pronounced but still statistically significant. We began to use corticosteroids

ARDS, also found that dexamethasone was associated with an increase in ventilator free-days and decreased 60-day mortality (Villar, March 2020 Lancet Respiratory Medicine).

Our approach

At Hennepin Healthcare, rather than take an allor-nothing approach, we made the initial decision to give corticosteroids only to COVID-19 patients with severe ARDS. Over time, as we observed what appeared to be a favorable response in some cases, we began to use corticosteroids routinely in nearly routinely in nearly all mechanically ventilated patients with ARDS and ventilated for those patients on the ward who were requiring at least 6 liters/minute of oxygen. The latter approach was prompted by an observational study from Henry Ford Health System that suggested use of steroids earlier in the course of COVID-related respiratory illness might decrease the risk of progression to overt respiratory failure. At this point in time, however, reliable data regarding the risk vs. benefit of steroids in COVID 19 was lacking and it was uncertain if this approach was justified. Fortunately, researchers in the United Kingdom were able to rapidly organize and complete a large randomized trial of the use of steroids for COVID-19. Preliminary results were published in mid-June, only a few months after the pandemic had reached the United States and Europe (RECOVERY Collaborative Group, July 2020 New England Journal of Medicine). This impressive study recruited 11,500 patients from 175

all mechanically patients

In contrast, among patients who did not require supplemental oxygen, dexamethasone did not provide benefit and there was a trend toward worse outcomes. With publication of this landmark study, other placebo-controlled trials of steroids for critically ill patients with COVID19 suspended enrollment, because it was deemed unethical to withhold steroids. A recent meta-analysis by a WHO committee of experts examined available data from six of the latter studies and the subset of RECOVERY patients who had required mechanical ventilation (Sterne, September 2020 JAMA). They concluded there was unequivocal evidence in favor of steroids for critically ill patients with COVID-19, but did not make a recommendation as to the type of steroid, dose, or duration of treatment that should be used. Importantly, they found that corticosteroids did not Treating COVID-19 with corticosteroids to page 204

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3Treating COVID-19 with corticosteroids from page 19 evidence of hypercoagulability and elevated inflammatory markers believed increase risk of infections or other serious adverse events. For mechanically to be related to various proinflammatory cytokines. Therapies that target viral ventilated patients with COVID-related ARDS, our current practice is replication, such as remdesivir—and possibly convalescent plasma—are of to give 20 mg dexamethasone a day for 5 days most benefit when given early in the clinical course followed by 10 mg a day for another 5 days. For of COVID, but are likely of little value when patients non-intubated patients who require at least 2 liters have developed a hyper-immune inflammatory of supplemental oxygen, we use a somewhat lower response with severe respiratory failure. In contrast, dose of 10 mg a day for 5 days followed by 6 mg corticosteroids appear to be of greatest benefit when Corticosteroids have been shown a day for 5 days. COVID-19 patients who do not excessive inflammation has resulted in respiratory to significantly reduce the mortality require oxygen are not given corticosteroids. failure, but not earlier in the disease when viral

of critically ill patients

Commenting on the results

The fact that corticosteroids appear to have their greatest benefit for the most severely ill COVID19 patients, but not for those with milder illness, is consistent with what is known about the evolution of COVID-19 respiratory illness. The clinical course of COVID can be divided into two phases: the viral replicative phase and a subsequent hyper-inflammatory immune response phase (see Figure 1). Many patients with COVID-19 remain asymptomatic or have very mild illness and presumably never progress beyond the viral replicative phase. When there is progressive and clinically significant respiratory involvement, patients often present to the hospital within 5–10 days after the onset of symptoms. Respiratory failure may be present at the time of admission, or may develop after hospitalization. Critically ill patients with COVID-19 usually have

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replication is dominant.

Summary Corticosteroids have been shown to significantly reduce the mortality of critically ill patients with COVID-19-related ARDS who require mechanical ventilation. For non-intubated patients with COVID 19, corticosteroids should also be given to those who need supplemental oxygen but not to those who have adequate oxygen saturation. James W. Leatherman, MD, is a member of the Division of Pulmonary and Critical Medicine at Hennepin County Medical Center.

John B. Pflugi, DO, is a current critical care fellow at Hennepin County Medical Center.

MINNESOTA PHYSICIAN OCTOBER 2020

RURAL HEALTH

COVID on the North Shore Establishing trust to meet the challenge KURT FARCHMIN, MD

s we in medicine face this pandemic of COVID-19, we face a reality where therapeutic medical approaches and public health measures start to become one and the same. In a disease where treatment is largely supportive even in the most advanced tertiary care hospitals, we have been repeatedly humbled and brought to the realization that what answers we have, lay largely outside clinic and hospital walls. I practice family medicine in the far reaches of the Arrowhead in Grand Marais, MN. Many readers will associate this area as a popular outdoor tourist area and have likely visited themselves. The Sawtooth Mountain Clinic where I work is a Federally Funded Qualified Health Center and the only outpatient clinic in our county of 5000 people. Likewise, the attached county hospital, North Shore Health, is the only hospital in the county where we as family medicine providers also staff the inpatient service. We have 16 beds, no ICU capacity, and no specialty physician presence other than infrequent orthopedic follow up. The nearest ICU is over 100 miles away in Duluth, Minnesota. When the COVID-19 pandemic became a stark reality, our local public health department had a sum total of one

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staff person covering the entire county. Our remote location and small scale immediately pose significant obstacles when it comes to providing care for an illness that causes rapid deterioration and too often requires highly specialized care, not to mention that our age demographic is heavily weighted to those most at risk of complications. Those same obstacles, however, also have proven to be assets. At the time of this writing, our county has the lowest case count both in absolute numbers and per capita across the state. I readily admit that much of our success can be attributed to factors out of our hands. We have a low population density, only one longterm care facility, no meat packing plants, a nearly nonexistent homeless population, and nearly everyone speaks English as a primary language. I also readily admit that our situation can change in an instant. That being said, we have clear examples of the success of our local efforts and I hope that it can be of help to others. If I could name the most important strategies that have had the biggest effect in keeping our numbers down, it would be the collaboration across public entities and our investment in public health. Early on in the pandemic, it was clear that we could not place our hope in a readily accessible cure for this disease. COVID-19 was humbling advanced hospital systems across the world. Our clinic and hospital recognized that our best chance to avoid becoming overwhelmed was to do our part to promote the public health measures shown to reduce the burden of this disease on healthcare. Already some of our staff was funded in part by public health funds through the County. These team members quickly shifted gears to support public health messaging and outreach to local businesses. We also immediately brought our local public health coordinator into the incident command meetings at the hospital so that she was aware of the capabilities and challenges of our remote healthcare system and vice versa. From those regular communications we coordinated with the popular local radio station that graciously offered regular airtime three times per week where representatives from public health, the clinic, and the hospital could keep the public informed on the latest COVID-19 information. A lot of time was spent making sure that our messaging was consistent and accurate. I don’t think I can emphasize how important that consistent messaging has been in establishing trust with our community. From a foundation of trust with the community, we have been able have some impact on how this virus spreads. One of the most immediate obstacles we faced was the fact that over 80% of our economy is tourist based. This seemed to be a major liability realizing that with tourism would inevitably come the virus. We made statewide headlines highlighting tensions between locals and visitors, most notably when a large tree was cut over the highway in an effort to keep tourists and COVID-19 out. Despite objection from some locals, however, it was readily apparent that tourism was coming whether we wanted it or not, and that the implications of trying to shut down 80% of our economy would have far reaching effects on the overall health of our communities. Our response was to bring together representatives from the local Chamber of Commerce, the clinic, hospital, and not least public health. National

us to isolate an asymptomatic adolescent contact at high risk of spreading headlines were pitting public health and the economy against each other, but our local group managed to make headway with a best practice guide COVID-19, and in another prevented over 20 high risk contacts from going for local businesses, support for creating business preparedness plans, and back to the local school for what could have been days prior to the initiation on-site visits by public health to help businesses address concerns and of contact tracing. strengthen their implementation of best practices As with every other health system, we have like physical distancing and masking. The key to put in an enormous amount of work preparing this business-public health partnership was that to safely care for patients with COVID-19 both it was not a punitive process, the businesses were at the clinic and hospital, but I cannot yet speak requesting the visits. The work of the Chamber of to rural care of a hospitalized COVID-19 patient. Our age demographic is Commerce was critical to establishing that trust As of the writing of this article, no local residents heavily weighted to those and businesses rose to the challenge. The clinic have needed hospitalization for COVID-19. most at risk of complications. and hospitalâ&#x20AC;&#x2122;s role was to consistently emphasize And that is my point. There are ways to slow the the importance of these interventions to those in spread of this virus. At their core they are not the business community. The summer of 2020 complicated. The essence of what we have done ultimately proved to be busier than ever with here can be done elsewhere. My sincere hope is more visitors to our area than most other years. A that our small community can be an example of recent poll showed that around 40% of businesses how we can come together and make a difference in this pandemic. reported revenues at or above an average year. Most notable is that at the end of this summer tourist season, there was no evidence of transmission Kurt Farchmin, MD, is a board-certified family physician practicing in from a tourist to a local resident. The largest initiative, and potentially the most important has been establishing our own local contact tracing. Our clinic triage nurses have been inundated throughout the last six months with questions regarding what to do when local businesses and community members were told that they were in contact with COVID-19. Our nurses did not have the training, nor the time to adequately address these concerns. It was also apparent that local residents and businesses that were involved with the statewide contact tracing process continued to have questions. We coordinated with public health to directly route those calls to their newly formed public health team who has the training and resources to clarify community questions. Additionally, in collaboration with the clinic, and hospital, and nearby Grand Portage Band of Lake Superior, our local public health coordinator realized that our local resources have innate advantages over the statewide contact tracing system. Through CARES Act funding that was graciously offered by the local County system, public health expanded their workforce and is assuming contact tracing for our region in collaboration with the Minnesota Department of Health, Grand Portage Band of Lake Superior, and the neighboring Lake County public health. By creating a local contact tracing program, we now have people who live and work in this community providing our contact tracing. This allows them to avoid some of the mistrust that limits the effectiveness of other programs. Our local tracers know the connections within the community, they are often familiar voices to those they are calling, and are highly motivated in their work, because it directly impacts the community in which they live. The local contact tracing program also addressed the inherent delays in the statewide system. It was immediately clear with our first cases that there could be a delay of several days between our lab getting a positive result and the initiation of contact tracing in the statewide contact tracing system. In the case of a virus that transmits up to two days before symptom onset, this delay risked any benefit that contact tracing could have. We now have direct communication from the lab to our local public health team. Almost as soon as the patientâ&#x20AC;&#x2122;s provider knows of a positive case, a contact tracer is notified and ready to begin that process. In one case this allowed

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MINNESOTA PHYSICIAN OCTOBER 2020

SENIOR CARE

Treating Underserved Aging Patients Never make presumptions LAURA PATTISON, MD AND MORGAN WEINERT, RN, MSN, AGPCNP

t’s a well-known fact that Americans are living longer than they were just a few decades ago. As our ability to identify and manage chronic and acute illnesses has improved, patients might live for many years with common conditions like congestive heart failure, COPD, and diabetes. Even HIV infection, once considered terminal, can now be managed in such a way that people living with the virus can expect to live a full life. Healthcare providers now need to support patients as they face the symptoms and sometimes complex treatments of chronic conditions as they overlap and interact with aging bodies. The work is rewarding but increasingly complex. The two of us have cared for geriatric patients of a multitude of socioeconomic backgrounds in various settings, from those who are unhoused to those living in upscale assisted living facilities. No matter the circumstance, we see that the social determinants of health (such as family and community support, financial resources, and access to transportation) have an outsized impact on our senior patients, on top of the multiple medical issues they face.

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OCTOBER 2020 MINNESOTA PHYSICIAN

As we age, we tend to collect more than one or two chronic conditions, with symptoms or treatment side effects that can mimic or overlap with common symptoms of normal aging. A patient with COPD may also have chronic kidney disease, and severe arthritis that affects their mobility. Someone with congestive heart failure might also have memory loss, impacting adherence to medication and dietary recommendations. Visual impairment or loss of dexterity can prevent a patient with diabetes from being able to administer their own insulin. Chronic pain conditions can be difficult to manage, as we attempt to balance minimization of medication side effects (especially on balance and cognition) with sufficient pain control to enhance functioning and quality of life. Dementia, depression, and hearing loss can have overlapping symptoms as well. The COVID-19 pandemic has exacerbated the hardships that older patients face. Fear of contracting the virus has led to a reluctance, for some, to come to clinic appointments, or to seek care at all even for severe acute symptoms. Decreased contact with others can contribute to social isolation and increased depression, and some seniors also face decreased access to food and other necessities. Telehealth, unfortunately, has been an inadequate alternative for many seniors and other people living in poverty. Video or phone visits can be difficult or impossible due to sensory impairments, fine motor and dexterity issues, or a lack of technology training or equipment. Many of our homeless seniors lack consistent access to a phone, never mind a smart phone capable of video visits. Older adults often struggle with the practical and emotional ramifications of decreased independence, and the complicated family dynamics that can come with that. This can sometimes lead them to minimize symptoms and delay needed care. Even those with significant resources are often faced with financial issues as they reach retirement and must adjust to a fixed income. Multiple co-pays may mean that patients will split or ration pills, or stop taking their medications altogether to save money. Others may choose to switch to a cheaper but much less comprehensive health insurance plan because they need to increase their monthly income. For patients who have stopped driving, getting to and from the grocery store or their medical appointment can be financially and physically burdensome, even if they have access to a senior ride service or public transportation. Some of our patients are forced into homelessness at an advanced age, for the first time in their lives, due to a home foreclosure. The homeless population in the United States is aging rapidly due to many economic and social factors that have impacted the livelihoods of those born in the latter half of the post World War II baby boom. (https:// www.aisp.upenn.edu/wp-content/uploads/2019/01/Emerging-Crisis-ofAged-Homelessness-1.pdf) Research is showing that older adults who are homeless or marginally housed show the medical conditions of housed adults twenty years their senior. Homelessness is in itself an “aging” experience, and unhoused

adults struggle with nutrition, cognition, and mobility in ways their housed peers do not. While some older adults fall into homelessness due to unemployment or foreclosure, others come to homelessness due to mental illness or substance use. Regardless of the reason, homeless older adults often have unique barriers to medication adherence, accessing care, and taking care of their basic needs, which complicate our ability to manage their health. We do our best to keep in mind the context of a patient’s life circumstance as we provide care. All the follow up appointments and medication education in the world cannot overcome the economic and logistical barriers that keep our patients from many aspects of wellness.

As healthcare providers caring for an aging population we need to become more inquisitive and even more cautious about making presumptions about our patients, their lives, and their goals. The challenge of providing sensitive and effective care for seniors in today’s unusual world requires an attentive and communicative care team and, more than ever, a curious, compassionate, and holistic approach.

Make efforts to calmly broach subjects that patients might be embarrassed or uncomfortable mentioning.

For our patients who are homeless, we’ve learned not to make any assumptions about what resources they have, their health literacy, or their goals. We can’t assume that they have regular access to refrigeration for their insulin, for example, or even to food (healthy or not) or running water for basic hygiene. We ask many questions, and take care to speak with acceptance and respect, and to normalize issues that might make some feel shame or defensiveness. We make efforts to calmly broach subjects that patients might be embarrassed or uncomfortable mentioning to us. All patients, of course, deserve a provider who approaches them without preconceived ideas and with curiosity about their lives. It’s particularly necessary and useful for seniors, however, given the substantial impact these factors have on their health.

Laura Pattison, MD, is a family physician at Minnesota Community Care’s Healthcare for the Homeless clinic in downtown St. Paul. Her focus is on primary care for underserved populations, including those living in poverty, with homelessness, and with severe persistent mental illness. She has a particular interest in addressing inequities in health care.

Morgan Weinert, RN, MSN, AGPCNP, is an Adult/Gerontology Nurse Practitioner and the current Medical Director of the Healthcare for the Homeless program at Minnesota Community Care. They work with older adults who have HIV and HCV, use substances, are experiencing homelessness, and are living with mental illness.

Health care providers need to ask older patients questions about life outside the exam room. When possible, we involve family members in visits and communicate regularly if they’re not able to attend a visit. One patient with uncontrolled hypertension and pain ultimately revealed that he had not taken medication in over a week because he didn’t have the dexterity to get his pills out of their container - his wife usually did this for him, but she was hospitalized for a surgery. Another older patient minimized her own symptoms and often delayed visits because she was solely responsible for the care of her disabled adult child. Many of our homeless patients are particularly isolated, without any available caregivers at all. Older patients have often been to multiple providers over many years, and have “collected” a long list of medications. A thorough medication review is vital, as is an ongoing effort to avoid or limit polypharmacy. It’s especially important to consider the expense and complexity of medication regimens. Issues of mobility, level of functioning, and quality of life rise to the top of our priorities as we develop care plans for them. These and other important conversations (about depression, cognitive impairment, or changing goals of care towards the end of life, for example) take time, which is not in abundant supply in most clinical settings. We rely on the involvement of an expanded care team that includes nurses, social workers, behavioral health specialists, alcohol and drug counselors, care coordinators, housing specialists, and culturally sensitive interpreters.

MINNESOTA PHYSICIAN OCTOBER 2020

HOME HEALTH CARE

Private Duty An Essential Role During COVID-19 BY AARON STROMLEY

• Intravenous or nutrition therapy

he world has experienced huge disruptions in this time of COVID19, and in no arena more so than healthcare delivery. Parts of it, like hospitals, are under strain as they heroically act to meet the pandemic challenge. Others, like private duty home care, are stepping up to fill new needs created by the pandemic. Minnesota is one of the states with the highest number of private duty home care agencies, and these providers are a valuable part of responding to this challenge.

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What does private duty mean? There are significant differences between home health care and private duty care. Home health care visits are coordinated by a patient’s physician and typically covered by Medicare. Home health care provides a wide range of skilled health care services. Visits typically do not last long (under an hour) and treatment is typically complete within after 30-60 days. Examples of Home Health Care Services • Wound care for pressure sores or a surgical wound • Patient and caregiver education

• Monitoring serious illness and unstable health status Home health care services are typically offered just during 8-5 business hours, not early mornings, late evenings, overnight or on weekends. They also do not offer ‘same day starts’ in those crucial first 24 hours after a patient release. Once discharge orders are given to home health groups, it can take 72 hours just to get out and see the patient for a first-time visit. Private duty care is a service available for individuals of any age who require assistance with their day-to-day activities. Private duty aides can assist with tasks such as housekeeping; meal preparation and offering companionship to those who need additional assistance to remain safe and comfortable in their own home. Private duty care is not covered by Medicare and is typically paid for by the client. The goal of private duty care is to help maintain a client’s ability to stay in their home comfortably, offer a respite care to other caregivers or to provide an extra level of care in long-term care facilities or even in hospice. Examples of private duty care services • Personal care – bathing/dressing, hygiene, transfers, and ambulation. • Homemakers & Companions • Meal cooking and preparation • Medication reminders • Transportation for doctor’s visits, shopping, etc.

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OCTOBER 2020 MINNESOTA PHYSICIAN

• Care giving for specialized conditions such as Alzheimer’s disease, Hospice, or other comfort needs. Patients or their loved ones hire their own private duty provider and use the service for the short term or for long stretches. It is often a preferred choice when there is no immediate family to care for a recently released patient and it also fills the care gaps when home health care is available for only one or two visits per week. Private duty home care is being tapped more and more for medically complex cases including those that require overnight assistance. Private duty agencies can get an inquiry at noon and have a highly trained professional on site that evening.

Additional benefits This March, Governor Walz’s executive orders postponed non-elective surgeries to reserve hospital beds and staff for caretaking potential overflow COVID patients. A key concern now that those regular hospital procedures have resumed is re-hospitalization. Nationally, typical re-admission rates are more than 15%. When patients receive post-hospital home care, however, readmission rates can drop to 4-5%. With the aid of dedicated private duty agencies, this rate may be even less than 3%. Statistically, the first 48-72 hours after discharge are the most crucial to prevent complications. Private duty home care is especially valuable in the first 72 hours after a hospital discharge. Studies show that it more than pays for itself during this time period and many hospitals in the U.S. are willing to pay for it for 3-5 days.

Avoiding medication errors in the home after a hospital stay or surgery and preventing falls are two primary causes of re-hospitalizations and both are positively impacted by private duty home care.

Private duty in the home Once a patient is released from a medical facility, family members are typically not conversant with post-hospital care needs. Decisions about parent care during this pandemic are especially fraught with stress. Having a Certified Nursing Assistant (CNA) there to explain procedures and offer a constant, caring presence can make a world of difference. The patient recovers his/her strength faster while other family members can get their rest at night and not become worn down themselves. With the aid of private duty home care, breadwinners are able to maintain their regular schedule rather than take time off because a family member has compromised health. In response to the pandemic, assisted living sites and nursing homes have prohibited non-essential onsite contact with a resident. Many families are deciding to bring their parent home for care and support. A private duty caregiver can also offer a viable way to isolate a vulnerable patient or senior within the home, serving as a safety barrier against potentially high virus exposure from multi-generational family caregivers.

Long Term Care Support In long-term care facilities, the ratio of residents to caregiver aides can be 15-20 to 1. As a result, more and more families are hiring private duty aides to give supplemental attention to individuals living at these sites. It’s heartbreaking when loved ones are prohibited from contact with family members when in a senior community. Hiring a private duty home care agency to serve a loved one can be a way of addressing the lack of physical and emotional support from those with whom they may have shared a lifetime.

Keeping Safe Private duty home care agencies have adapted their business models to new CDC/MN Dept of Health COVID-19 guidelines. Staff members wear appropriate PPE and have daily health screenings before going on shift. Agencies screen new clients coming from a hospital stay and require a negative COVID test. Families are communicated with virtually and schedules/notes are posted on a family portal site. Hiring interviews are done by Zoom, as are staff meetings. Service packages for hospital discharges, transitional care and long term care are fine-tuned to meet the needs of the individual situation. Same-day starts are available and ‘wraparound care’ can bolster the nursing provided by existing care scenarios.

Closing thoughts COVID-19 has changed the equation in bringing to light how private duty home care agencies can be an important adjunct to nursing homes and in private residences. They care for patients with a wide spectrum of needs and stressors. Private duty care is an invaluable resource that is helping to meet the changing health systems needs demanded by the pandemic. When physicians integrate private duty home care into their range of recommendations to families, they ensure that a continuum of care is provided so that optimal patient outcomes are achieved. Aaron Stromley, is owner of Touching Hearts at Home, a Twin Cities private duty home care agency focusing on memory care, hospice care and transitional care: www.touchinghearts.com/southmetro.

These healthcare professionals can be brought in on a flexible basis short term or long term - to complement whatever schedules and capacities family members are managing. Whether it’s just a few hours per day or 24/7 care, the family knows that with private duty assistance they are safeguarding their parent from elevated virus exposure rates in senior living communities while also assuaging anxiety and concern about this indefinitely long period. Private duty caregivers are now acting in a new role in making adjunct social visits on behalf of families so residents are not left feeling so alone. Especially in memory care settings where Alzheimer’s and dementia patients don’t understand the reasoning for the new house rules about masks and social distancing, such supplemental caregiving can provide one-on-one companionship to decrease patient stress/depression and provide a sense of normalcy.

Supporting independence Private duty home care can play an important role in supporting seniors who live alone in their own homes and wholeheartedly want to continue to do so. Studies show that their lives are extended with high-touch quality care in familiar surroundings. Accidents in the home are significantly reduced and lessen the need for things such as hip replacements. This can be as simple as reviewing safety features, tossing out slippery throw rugs or maximizing lighting. Socialization is another key benefit for seniors. If they happen to need care in while COVID-19 protocols preclude family visits, a private duty CAN, with whom they already have a nurturing relationship, can provide much needed human interaction.

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THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXII, No. 05

CAR T-cell therapy Modifying cells to fight cancer BY VERONIKA BACHANOVA, MD, PHD

niversity of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma. Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells.

Physician/employer direct contracting

CAR T-cell therapy involves drawing blood from patients and separating out the T cells. Using a disarmed virus, the patient’s own T cells are genetically engineered to produce chimeric antigen receptors, or CARs, that allow them to recognize and attach to a specific protein, or antigen, on tumor cells. This process takes place in a laboratory and takes about 14 days. After receiving the modification, the engineered CAR-T cells are infused into the patient, where they recognize and attack cancer cells. Kymriah received initial FDA approval in 2017 for the treatment of pediatric acute lymphoblastic leukemia. CAR T-cell therapy to page 144

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ith the continuing escalation of health care costs, large and midsized selfinsured employers are once again looking for an edge to manage their medical plan costs and their bottom line. They understand that they are ultimately funding health care as they pay for their population’s claims.

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MINNESOTA PHYSICIAN OCTOBER 2020

PEDIATRICS

Autism Spectrum Disorder Advances in diagnosis and treatment RACHEL BIES, M.D., ANGELA HEITZMAN, PSYD, LP AND VANESSA SLIVKEN, MA, LMFT

arenthood is a time of great anxiety, with parents wondering and worrying if their children are healthy, if they are getting adequate nutrition and sleep, and if they are being provided with an environment that is appropriately stimulating. For some parents, their child’s behavior or development raises additional concerns: “My infant doesn’t make eye contact.” “My son only repeats what he hears.” “My four-year-old licks and smells everything he picks up.” “My toddler spins constantly and walks on her toes.” “My preschooler is shy.” Internet searches can deepen concerns, given the wealth of information and misinformation available. “Could my child have autism?” “Does my child need more evaluation?” “What will a diagnosis or ‘label’ mean for my child’s future?” Parental worries about development are often compounded by awareness of the statistical increase in the prevalence of autism or autismrelated disorders since researchers first began tracking them in 2000.

Autism Redefined Significant changes were made to the diagnostic criteria for Autism Spectrum

Disorder (ASD) when the American Psychiatric Association (APA) published the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, in 2013 (DSM-V). The DSM-V defines Autism Spectrum Disorder as “persistent deficits in social communication and social interaction” along with repetitive behaviors and restricted interests that cause impairment in multiple environments. Individuals previously diagnosed with Asperger’s Syndrome and Pervasive Developmental Disorder now typically meet criteria for Autism Spectrum Disorder.

Prevalence in 2016 The U.S. Centers for Disease Control (CDC) launched the Autism Developmental Disability Monitoring Network (ADDM) in 2000, and the Early ADDM Network in 2010. The ADDM reported an autism prevalence rate of 1:150 children in 2000, with an increase to 1:54 from the most recent data in 2016. There are several different thoughts on the increased prevalence of ASD in the United States: enhanced awareness, increased rate of screenings and evaluations, improved accessibility to early intervention and other services, changes in the diagnostic criteria in 2013, diagnostic clarity or diagnostic substitution in children previously diagnosed with intellectual disability, or a true increase in the incidence of the disorder

The Neurobiology of ASD

SUNFLOWER SPREAD

Our current understanding of the pathophysiology of ASD suggests that genetic, biologic, and environmental factors may all play a role. Early studies looking at family history showed that families with one child with ASD have an increased risk of having another child with ASD. Per the National Institute of Health (NIH), identical twin studies have shown that one twin has a 36-95% chance of having ASD if their twin is affected. ASD is associated with certain genetic diseases, including Fragile X and Tuberous Sclerosis Complex. Research has identified many genes involved with the development of autism, likely converging in specific biological pathways associated with changes in structural brain development and synaptic function. Many researchers are studying biomarkers that may allow clinicians to diagnose ASD earlier and to act as potential targets for therapeutic intervention. While environmental factors have been implicated in the pathogenesis of ASD, no specific environmental factors have been identified to date.

Advancing the Diagnosis of ASD

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According to ADDM, the median age for formal ASD diagnosis ranged from 5.2 to 5.7 years of age. The American Academy of Pediatrics (AAP) suggests that ASD can reliably be diagnosed in children as young as 18 months of age. There are opportunities to bring down the median age of diagnosis, which will allow for earlier intervention. To achieve this, screening and surveillance for Autism Spectrum Disorders in the primary care setting is critical. A mission for universal screening has been set by the CDC and AAP. Screening determines at-risk children who should be referred for more formal evaluation. The AAP Clinical Guidelines

recommend that all children are assessed using a validated screening tool at 18 and 24 months of age. There are numerous screening measures in use and in development. General developmental screening measures are known to miss the social aspects of ASD; thus, it is recommended that primary care providers use an ASD-specific screener. The most studied screening measure is the M-CHAT-R/F (Modified Checklist for Autism in Toddlers, Revised, with Follow-Up, 2018), which is available online (https://mchatscreen.com/ wp-content/uploads/2015/09/M-CHAT-R_F_Rev_Aug2018.pdf). As stated in the AAP Clinical Guidelines, “the primary care provider has critical access to the child in the context of the medical home to identify symptoms of ASD early in childhood, support the family through the process of diagnosis and intervention, address etiologic evaluations, help the family understand how to interpret the evidence supporting different interventions so they can effectively engage in shared decision-making, and manage co-occurring medical conditions that may influence outcome and affect daily function.”

Research published in Pediatrics in 2015 suggests that more than 50% of children referred for a formal diagnostic assessment by their primary care provider do not follow through on the referral process. While there may be multiple reasons for this, the authors of the study noted several anecdotal possibilities from parents: lack of awareness regarding the importance of timely diagnosis and intervention; lack of understanding about what the process involves or what steps the parent needs to take; denial or difficulty accepting something may be wrong; and concern about having the child “labeled.” Primary care providers can lessen the chance of missed or late diagnosis by directly referring the child for the evaluation, ensuring the parents understand why the child is being referred, emphasizing the importance of early diagnosis and intervention, and following up with the family. Autism Spectrum Disorder to page 304

Addressing Barriers to Early Diagnosis There are multiple barriers to early ASD diagnosis in children that have been identified. One of these barriers includes racial and ethnic differences. The ADDM reports note that more white children are diagnosed with ASD than Black or Hispanic children, despite the incidence of the disease being similar among groups. Stigma, lack of access to healthcare, non-citizenship or low-income status, and lack of English as a primary language have all been implicated as potential barriers to diagnosis in non-white children through studies. Female gender has also been identified as a risk factor for diagnostic delay. The incidence of ASD is 4-5 times higher in males than females. Several studies have examined the varied presentation of symptoms in males versus females and have suggested that girls may exhibit less of the repetitive or restrictive behaviors that are often an early clue to diagnosis. The delay in diagnosis in females has led to a higher incidence of anxiety and depression in the adolescent years, as the social differences may become more apparent. One of the primary barriers to early diagnosis is the lack of access to clinicians trained in diagnosing ASD. Access limitation leads to long wait times and wait lists that delay diagnosis and prolong the time to intervention. If a child is identified as being at-risk by screening, there are steps the primary care physician can take while awaiting formal evaluation: • Refer for audiology/ENT if the child does not respond to name or seems to have a hearing impairment.

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THE SAINT PAUL HOTEL has a long-standing special pricing policy for guests with loved ones that require hospital stays. If you have patients from either out of state of suburbs that require hospitalization at any of the outstanding St. Paul area hospitals, please let them know that family members and loved ones are welcome to our discounted health care stay pricing.

• Refer for a pediatric occupational therapy evaluation if the child has any of the following: delayed motor development, sensory processing differences, clumsiness, feeding concerns. • Refer for a speech therapy evaluation if the child has issues with any of the following: speech development, social aspects of language, following verbal instructions, imitating sounds, expressing needs, or responding to other children. • Encourage parents to place their child on the wait lists for all providers in their area who perform ASD evaluation. Follow up with parents to encourage follow-through with diagnostic assessment.

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3Autism Spectrum Disorder from page 29 Approaches to Treating Autism Spectrum Disorders

that desired behaviors can be taught through a system of rewards and consequences. ABA can be thought of as applying behavioral principles to behavioral goals and carefully measuring the results. In existence since the early 1960s, there is substantial research on the effectiveness of ABA, resulting in a strong and vocal presence in the field.

Once diagnosed, young children with autism and their caregivers often find the myriad options for treatment a complex web to navigate, especially given the need for highly individualized, tailored approaches to the disorder. As Dr. Stephen Shore, professor and autism self-advocate, stated, “If you’ve met • Developmental Approach: The Screening and surveillance for one person with autism, you’ve met one person developmental approach to autism was Autism Spectrum Disorders in the with autism.” Likewise, there is likely not one established in the 1980 and evidence primary care setting is critical. singular treatment that will be effective for every based research is producing growing use. This approach uses typical developmental individual on the Autism Spectrum. In addition sequences as the framework for to considering different treatment intervention assessment and intervention and is options, providers also need to consider disparities relationship-based, child-centered, in access to diagnostic and intervention services, and play-based. Examples include the particularly among underserved communities, Greenspan Floortime® Model, the Developmental-Individual such as cultural and linguistic differences, financial and health insurance Differences-Relationship-Based model or DIR, and Relationshipbarriers, and comorbid diagnoses (70% of children with ASD have at least Based-Developmental-Individual Differences model or RDI. one co-occurring condition and 40% have two or more). • Hybrid Approach, Developmental-Behavioral: The most recent Following are the three primary approaches in the treatment of ASD: advancement in the treatment of autism is the development • Behavioral Approach: Many who are versed in autism of hybrid models that integrate developmental and behavioral intervention know that it has often been synonymous with Applied approaches, such as the Early Start Denver Model (ESDM) Behavior Analysis or ABA. ABA is a behavioral approach to autism intervention based on behaviorist theories which, simply put, state Autism Spectrum Disorder to page 324

With more than 35 specialties, Olmsted Medical Center is known for the delivery of exceptional patient care that focuses on caring, quality, safety, and service in a family-oriented atmosphere. Rochester is a fast-growing community and provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Opportunities available in the following specialties: • Active Aging Services - Geriatric Medicine/Palliative Care • Anesthesiology • Dermatology

• ENT - Otology • Family Medicine • Gastroenterology • Internal Medicine

• Non-Invasive Cardiology • Psychiatry - Adult • Psychology - Child • Rheumatology

Equal Opportunity Employer / Protected Veterans / Individuals with Disabilities

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 30

OCTOBER 2020 MINNESOTA PHYSICIAN

A Place To Be Your Best. Dr. Julie Benson, MN Academy Family Physician of the Year

POSITIONS AVAILABLE:

OB GYN & FAMILY MEDICINE – Full-scope practice available (ER, OB, C-Section, Hospitalist, Clinic) • Independent/growing system • Located in the heart of lakes country, Staples, MN • Critical access hospital with 5 primary clinics and a senior living facility • 15 family medicine physicians and 16 advanced practice clinicians • Competitive salary, benefits, and sign-on bonus available Contact Michael Paul at 218.894.8633, or michaelpaul@lakewoodhealthsystem.com

Family Medicine & Emergency Medicine Physicians • • • • •

Great Opportunities

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

with a Mankato Clinic Career Established in 1916, physician-owned and led Mankato Clinic is 100 years strong and seeking Family Physicians for outpatient-only practices. Over 50% of our physicians are involved in leadership positions and make decisions for our group. Full-time is 32 patient contact hours and 4 hours of administrative time per week. Four-day work week available. Clinic hours are Monday-Friday, 8 a.m.-5 p.m. OB is optional. Call is telephone triage, 1:17, supported by a 24/7 Nurse Health Line. Market-competitive guaranteed starting salary, followed by RVU production pay plan. Benefits include 35 vacation / CME Days annually + six holidays, $6,600 annual CME business allowance and a generous profit-sharing 401(k) plan. We’re just over an hour south of the Mall of America and MSP International Airport. If you would like to learn more about building a Thriving practice, contact:

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

Dennis Davito Director of Provider Services 1230 East Main Street Mankato, MN 56001 507-389-8654 dennisd@mankatoclinic.com

Apply online at www.mankatoclinic.com MINNESOTA PHYSICIAN OCTOBER 2020

3Autism Spectrum Disorder from page 30

of Minnesota Medical School in 2005 and completed residency and chiefresidency at the University of Minnesota in 2009. She is board certified in

developed by Drs. Sally Rogers and Geraldine Dawson at the University of California Davis MIND Institute. ESDM is a play-based early intervention for children with ASD who are very young (age 12-48 months) and focuses on imitation, nonverbal and verbal communication, social development, emotion sharing, and play.

Moving Forward

Pediatrics and is a current Fellow in the American Academy of Pediatrics. Dr. Bies has been a partner at Wayzata Children’s Clinic since 2009 and medical director of the clinic since 2011.

Angela M. Heitzman, PsyD, LP, Certified Rehabilitation Counselor is a Clinical Psychologist at

Follow up with parents to encourage follow-through with diagnostic assessment.

An awareness of the value of intervening as soon as possible is leading to important advances in early diagnosis. Through screening measures, physicians can play a vital role in helping parents understand the markers that might indicate a diagnosis of ADS and provide diagnostic and treatment resources to the family. There have also been important advances in therapeutic treatment options that allow providers to create more effective and individualized programs. The sooner we are able to identify where a child may be on the Spectrum, and the sooner we are able to begin treatment, the more able that child will be to live to the fullest potential.

St. David’s Center, focusing on evaluation, diagnosis, and intervention planning with children ages 18 months to 18 years of age for a variety of concerns, including autism. Dr. Heitzman also sees children, families, and adults for psychotherapy.

Vanessa Slivken, MA, LMFT, Senior Director of Autism Services, oversees the Autism Day Treatment and Autism Spectrum Disorder Support Services (ASDSS) programs at St. David’s Center. With more than fifteen years of professional experience in the behavioral health field, she has been leading autism services at St. David’s Center for several years.

Biographical Information on Co-Authors Rachel Bies, MD, FAAP, is the current medical director for St David’s Center for Child and Family Development. Dr. Bies graduated from the University

Carris Health

is the perfect match

Carris Health is a multi-specialty health network located in west central and southwest Minnesota and 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: • • • • • •

Anesthesiology Dermatology ENT Family Medicine Gastroenterology General Surgery

• • • • • •

Hospitalist Internal Medicine Nephrology Neurology OB/GYN Oncology

Loan repayment assistance available.

FOR MORE INFORMATION: Dr. Leah Schammel, Carris Health Physician

OCTOBER 2020 MINNESOTA PHYSICIAN

Shana Zahrbock, Physician Recruitment Shana.Zahrbock@carrishealth.com (320) 231-6353 | carrishealth.com

• • • •

Orthopedic Surgery Psychiatry Psychology Pulmonary/ Critical Care • Rheumatology • Urology

Unique Practice Opportunity Join an established independent internal medicine practice Be your own boss in a collaborative business model with a healthcare philosophy that puts patients first and allows physicians to have complete control of their practice.

SHARE YOUR INSPIRATION.

On the U.S. Army health care team, you will enjoy the satisfaction of providing quality care to Soldiers and their families, in a setting with innovative technologies, robust resources and a dedicated, supportive team.

The specialties we are looking for are: Internal Medicine, Family Practice, Preventive Medicine, Cardiology, Dermatology, Allergist, or any other office-based specialty. Preferred Credentials are MD, DO, PA, and NP. • Beautiful newly remodeled space in a convenient location • Competitive Wages and a great Professional Support Staff

Learn more at healthcare.goarmy.com/nz72 Contact Mitchell for more information | mitch@brandtmgmt.com 6565 France Ave S Ste 350 Edina

Practice Opportunities throughout Greater Minnesota: Our nation faces an unprecedented number of individuals who having served their country now receive health care benefits through the VA system. We offer an opportunity for you to serve those who have served their country providing community based health care in modern facilities with access to world-leading research and research opportunities. We provide outstanding benefits with less stress and burnout than many large system policies create. We allow you to do what you do, best – care for patients.

Minneapolis VA Health Care System Metro based opportunities include: • Chief of General Internal Medicine • Chief of Cardiology • Cardiologist • Internal Medicine/Family Practice • Gastroenterologist • Psychiatrist

Ely VA Clinic

Hibbing VA Clinic

• Tele-ICU (Las Vegas, NV)

Current opportunities include:

• Nephrologist

Internal Medicine/Family Practice

US citizenship or proper work authorization required. Candidates should be BE/BC. Must have a valid medical license anywhere in US. Background check required. EEO Employer.

Possible Education Loan Repayment • Competitive Salary • Excellent Benefits • Professional Liability Insurance with Tail Coverage

For more information on current opportunities, contact: Yolanda Young: Yolanda.Young2@va.gov • 612-467-4964 One Veterans Drive, Minneapolis, MN 55417

•

www.minneapolis.va.gov MINNESOTA PHYSICIAN OCTOBER 2020

3What’s 20% Over the National Norm? from page 13 • Implementation of a secure, electronic interface between providers - Example: allow for transfer of patient health records, images, and electronic orders to outside providers • Examination of a hospital’s practice of sending appointment requests to patients whose primary physician is established outside of a connected large health care system • Examination of electronic medical record design issues (i.e., “information blocking” and “white listing”) that provide a disincentive for large health care system providers to refer patients outside of their system • Providing information to patients when their current health care provider is being acquired/absorbed by the geographically dominant large health care system, with the result being a new facility fee or higher charges/copays

care providers has been mandated elsewhere, e.g., Connecticut, when legislators have become concerned and the higher health care costs accompanying consolidation of health care providers Our goal is to ensure that employers and patients understand the detrimental and long-term effects of consolidation and become engaged in preserving our region’s health care resources. We all have a goal to create better healthcare outcomes for everyone in our region. We believe our community will be best served when we achieve full and secure interoperability of health care records, as mandated by current legislation. We have seen these issues unfold over the past several years and believe it is necessary to work together to improve this situation, especially given the extraordinary demands on healthcare providers during the COVID-19 pandemic. Those who are part of CMHI have shown courage and deep dedication to our community.

• Disclosure of cost/charge ratio on patient bills

Central Minnesotans for Healthcare Independence will continue to have conversations with people in our region, with lawmakers, and with regulators in the best interest of our community. We look forward to having more people join in our effort.

• Stronger adherence of the state’s transparency mandate to eliminate facility fees

Julie Anderson, M.D., is the founder of Simplicity Health, a family medicine

• Public disclosure/transparency of large health care system referral volumes to itself vs. independent and/or non-related practitioners

• Community reinvestment commensurate with the unpaid property taxes due to non-profit status

clinic in St. Cloud.

• Disclosure of top-paid hospital employees’ compensation including benefits, fringe benefits, and expenses. This requirement on health

Derik Weldon, M.D., is the Central Minnesota Medical Director for Center for Diagnostic Imaging.

Three patients. Who is at risk for diabetes?

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

OCTOBER 2020 MINNESOTA PHYSICIAN

URGENT RESOURCES FOR URGENT TIMES. In a pandemic, speed and access to information and resources are vital. Knowledge saves time, and you need all the time you can get to save lives. Introducing the COVID-19 Resource Center. Right here, right now, for you. On our website, you’ll find the latest information and resources for important topics like: • Telemedicine: including best practices and plain language consent forms • Links to infectious disease prevention guidance • Education and resources for healthcare providers on the front lines

You can access Coverys’ industry-leading Risk Management & Patient Safety services, videos, and staff training at coverys.com. All in one place, for our policyholders as well as for all healthcare providers. Thank you. For all that you are doing. You are our heroes, and we are here if you need us.

Medical Liability Insurance • Business Analytics • Risk Management • Education COPYRIGHTED. Insurance products issued by ProSelect® Insurance Company and Preferred Professional Insurance Company®

MINNESOTA PHYSICIAN OCTOBER 2020

Holly Boyer, MD

TRANSFORMING HEALTH & MEDICINE Leaders • Educators • Innovators

mphysicians.org

Minnesota Physician • October 2020

Articles inside

RURAL HEALTH COVID on the North Shore

HOME HEALTH CARE Private Duty

BEHAVIORAL HEALTH Improving Patient Outcomes

INTERVIEW

SENIOR CARE Treating Underserved Aging Patients