Minnesota Physician • December 2021 by Minnesota Physician Publishing

MINNESOTA

DECEMBER 2021

THE INDEPENDENT MEDICAL BUSINESS JOURNAL

Volume XXXV, No. 08

PHYSICIAN From the Trenches Covid is not a hoax BY CAROLYN MCLAIN, MD

Understanding Ageism Prejudice against our future self BY DAWN SIMONSON, MPA

mericans are conflicted about aging. We seek longevity but fear growing older. And no wonder. According to California State University psychology professor Todd Nelson, “Old age is stereotypically perceived as a negative time–the older person suffers declines in physical attributes, mental acuity, loss of identity (retirement from job), loss of respect from society and increasing dependence on others.” Much of the negativity associated with aging is based on myths and is rooted in ageism. Understanding Ageism to page 84

e’re heartbroken. We’re overwhelmed.” These words ran in bold print as an advertisement in the Star Tribune and pleaded for Minnesotans to get vaccinated to end this pandemic. It was signed by nine CEOs of Minnesota health systems. As an ER physician I want to tell you why we are feeling this way. I have seen more people die this year than in my past 21 years in medicine. The deaths are excruciating to watch as patients literally suffocate. The illness is nothing like the flu. The flu is predictable and short in comparison. Covid hits some people hard, causing illness that feels more like a marathon with day after day of new symptoms. Others are hardly sick at all. The unpredictability and randomness of this disease in combination with the fact that it targets the most vulnerable members of our society, the elderly and minorities, have made it uniquely able to tear us apart as a society. From the Trenches to page 144

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Volume XXXV, Number 08

COVER FEATURES Understanding Ageism Prejudice against our future self

From the Trenches Covid s not a hoax

By Dawn Simonson, MPA

By Carolyn McLain,MD

DEPARTMENTS CAPSULES .................................................................................. 4 BEHAVIORAL HEALTH.................................................................. 10 Sober Housing A thriving industry in need of regulation

By Sen. Karin Housley MINNESOTA HEALTH CARE ROUNDTABLE..................................... 18 Clinical and Non-clinical Care Teams Improving interoperability

PHARMACY................................................................................ 26 The Primary Care Team Pharmacist

CARE TRANSITIONS Improving the safety net

A Vital Tool to Prevent Hospital Readmissions

By Sandra Leo, PharmD

BACKGROUND AND OBJECTIVES: When a patient leaves the hospital and returns to an assisted living facility, or home, they experience a care transition. This term is also used when a patient goes from one physician to another. It can also refer to entering rehabilitation programs or treatment of a condition diagnosed by a physician and then transferred to another type of health care provider. As the spectrum of care teams expands, the number and type of care transitions also expands. Cumulatively these transitions are a leading cause of medical malpractice claims, most of which are easily preventable. Our expert panel will define and explain the most common problems in care transitions. We will examine the negative outcomes that arise from these issues and propose simplesystemic solutions. We will discuss best practice standards that have already been established around these concerns, why they are not more widely followed, and how they can be implemented. We will review technology, which in some cases creates problems, that can be used to reduce them.

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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.

As we transition to a post-pandemic business world, health care will lead the way in terms of new policies, procedures and readiness. The Minnesota Health Care Roundtable has adjusted to these dynamics. We now invite our readers to participate in this now remote conference process. If you have questions you would like to pose to the panel, or have topics you would like the panel to address, we welcome your input. Please email: Comments@mppub.com and put “Roundtable Question” in the subject line.

MINNESOTA PHYSICIAN DECEMBER 2021

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State Medical Cannabis Program Expands Delivery Options The Minnesota Department of Health (MDH) recently announced that it has approved infused edibles in the form of gummies and chews as a new medical cannabis delivery method in the state’s medical cannabis program. The new delivery method will become effective Aug. 1, 2022. A rulemaking process that will outline requirements for labeling, safety messaging, packaging, and testing will launch this month. Current permitted delivery forms include pills, vapor oil, liquids, topicals, powdered mixtures, and orally dissolvable products, like lozenges “Expanding delivery methods to gummies and chews will mean more options for patients who cannot tolerate current available forms of medical cannabis,” said Minnesota Commissioner of Health Jan Malcolm.

Coming in March 2022, registered medical cannabis patients will also be eligible for dried raw, smokable cannabis, which was approved by the 2021 Minnesota Legislature. Rulemaking for dried raw cannabis is also currently in process. No new conditions were added this year. As in past years, MDH conducted a formal petition and comment process to solicit public input on potential qualifying medical conditions and delivery methods for medicine. Since 2016, petitioners have requested anxiety disorder or panic disorder as a qualifying medical condition. Each year it was denied due to lack of clinical evidence and the desire to avoid any unintended consequences. This year at the request of Commissioner Malcolm, the MDH Office of Medical Cannabis conducted an in-depth review, which included a research review of anxiety disorder as a qualifying medical condition. Ultimately the addition was not approved

due to a lack of scientific evidence to support effectiveness as well as concerns expressed by health care practitioners. “We received many comments from health care practitioners treating patients with anxiety disorder, and they urged us to not approve it as a qualifying medical condition,” said Commissioner Malcolm. “We recognize that not everyone has equal access to therapy – which is considered the front-line treatment – but ultimately we concluded that the risk of additional harms to patients outweighed perceived benefits.”

Hennepin Healthcare Hosts Black Men with Stethoscopes Youth Summit As part of a series of initiatives and events organized by Hennepin Healthcare to expose youth to careers in medicine, while connecting them to high quality work-based learning opportunities and creating access to a network

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.

DECEMBER 2021 MINNESOTA PHYSICIAN

of BIPOC healthcare professionals, Hennepin Health recently hosted the first Black Men with Stethoscopes Youth Summit. The event took place at Hennepin Healthcare’s Clinic & Specialty Center in downtown Minneapolis, where participants, aged 12-18, had the opportunity to experience real-life medical simulations, tour the Hennepin Healthcare campus, learn about the path to medical and dental schools, and discover helpful tools for goal-setting and time management all while interacting with Black medical professionals. “We couldn’t be more excited to host this inaugural event for our community as part of a bigger plan to address inequalities and support our talented youth through further job shadowing, paid internships and mentoring opportunities,” explains Dr. Nneka Sederstrom, Chief Health Equity Officer at Hennepin Healthcare. “Knowing that this exposure may play a role in helping these young men consider applying their potential to a

CAPSULES

medical career is extremely rewarding – and a tremendous benefit to the medical profession, as well as the community.” Over the past few years, the Association of American Medical Colleges found that only 3% of total U.S. Medical School applicants self-identified as Black men. In the 2020-2021 applicant pool, only 8% of those who accepted and enrolled identified as Black. Hoping those numbers change, pediatric critical care physician Dr. Andrew Kiragu, said “Everyone deserves the opportunity to pursue a rewarding career – one that involves caring for others by applying medical skills certainly falls in this category. It is important that Black children are exposed to the multitude of STEMbased careers that are available and how to pursue them. That’s exactly why we want young Black men to see the possibilities of a career in Medicine. It is crucial that they see physicians who look like them and can provide mentorship so that they can see themselves in a fulfilling medical career.”

Mayo Report Cites Lack of Diversity in Cancer Research Funding A commentary recently published in Nature Magazine by researchers from Mayo Clinic and the University of Southern California suggests that agencies funding biomedical research must strive for diversity, equity and inclusion in research decisions, and that these agencies will only be successful if they address bias in the research funding process. “The lack of diversity in science and medicine exacerbates and compounds the problem of health disparities,” says Folakemi Odedina, Ph.D., a Mayo Clinic cancer researcher. Dr. Odedina’s education, training and community outreach activities have focused on addressing health disparities in racial, ethnic minority and underserved communities. Dr. Odedina and co-author Mariana Stern, Ph.D.,

of the University of Southern California write that the relatively small number of minority clinicians and researchers in biomedical research in the U.S., and the lack of minority participants in clinical trials, poses significant barriers to addressing health disparities. For example, “Black investigators continue to be under funded in science and medicine due to bias in the scientific review process,” says Dr. Odedina. She says multiple reasons have been associated with this bias, including a perception that Black investigators are less capable or less accomplished than White or Asian candidates. The authors say another factor limiting diversity in biomedical research is a misalignment between the priorities of funding agencies and the research focus of scientists from underrepresented groups. “Funding decisions that do not appropriately weigh the potential impact of awards on minority communities or the importance of promoting the careers of diverse scientists Black, Latinx and Indigenous miss the opportunity to improve diversity, equity and inclusion in science and medicine, and improve the health of minority communities,” says Dr. Odedina. She noted that bias toward Black scientists in academic funding has led many to switch to academic administrative positions or to leave academia altogether, as it is very difficult to be successful without extramural funding; “In the U.S., there is a nationwide problem retaining Black scientists in academia,”

Office of Rural Health Announces 2021 Awards

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Every year the Minnesota Office of Rural Health and Primary Care announces awards given to groups and individuals who have made a significant contribution to improving rural health in our state. Traditionally announced at the annual summertime rural health conference in Duluth,

MINNESOTA PHYSICIAN DECEMBER 2021

CAPSULES

COVID-19 considerations rescheduled the announcement to coincide with Gov. Walz’s newly proclaimed Rural Health Day (November 18). The MN Rural Health Hero Award was given to Laurissa L. Stigen, MS, RN, System Campus Partnership and Project Coordinator at the University of Minnesota School of Nursing, and Registered Nurse at the Lake Region Healthcare in Fergus Falls. Laura worked to expand education for undergraduate nursing students in rural schools and towns. She also coordinated a project to increase and support Psychiatric Mental Health Advanced Practice Registered Nurses in rural communities and served as President of the Minnesota Rural Health Association. The MN Rural Health Team Award was given to the Cass Lake Indian Health Service and Leech Lake Band of Ojibwe Health Division, Cass Lake. They collaborated to develop and implement a mass

immunization model increasing access to COVID-19 vaccines for rural Minnesotans. While these organizations traditionally provide health care services for eligible Native Americans, the multi-disciplinary team conveyed the importance of taking a public health approach to protect the community at large. The team’s plan to provide vaccinations to all regardless of demographics was approved by the Indian Health Service and Tribal leadership. It became one of the best and fastest vaccine administration teams in the state and their vaccination model is now considered a best practice. It has garnered the attention of federal, state and private sector partners across the nation. The 2021 MN Rural Health Lifetime Achievement Award has been given to Raymond G. Christensen MD, an Associate Professor at the University of Minnesota Medical School, Duluth Campus, where he also serves as Associate Dean for Rural

Health, and Associate Director of the Rural Physicians Associate Program (RPAP). His supervision and faculty leadership contribute to the supply of family physicians and rural physicians for Minnesota. Over the years, numerous practicing physicians have had the pleasure of calling him mentor, role model, and advocate. Dr. Christensen’s commitment to and impact on rural health in Minnesota spans five decades and includes an extraordinary lifetime of achievements.

North Memorial Begins Construction on New Blaine Clinic North Memorial Health recently broke ground on an undeveloped lot located on the southwest corner lot of Lexington Ave and 109th Street in Blaine. The new building will include North Memorial Health primary care clinics, specialty care clinics

and hospice. The new state-of-the-art facility will encompass nearly 50,000 square feet and provide expanded primary, specialty and urgent care services to the northern suburban communities. It will also house some administrative and support services. Once completed, this clinic will be replacing North Memorial Health’s nearby clinics, currently housed in a multi-tenant medical office on Ulysses Street NE. “This new clinic will help us meet the growing need for primary, specialty and urgent care services for customers in the Blaine community,” said J. Kevin Croston, MD, and CEO of North Memorial Health. “We are excited to be creating a new, state-of -the-art space that will provide an even better customer experience and a wonderful environment for our team members.” The location was chosen by North Memorial Health’s leadership team with help from Forte Real Estate (formerly The Excelsior Group),

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a local advisory firm. The project team includes Gardner Builders as the General Contractor and HGA Architects & Engineers as the base building architect. MSP Commercial is the developer of the project and will also be managing it after completion. Construction will continue throughout the next three seasons, with a scheduled opening in fall, 2022.

HealthPartners Receives $1 Million Telemedicine Grant

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The Federal Communications Commission recently awarded $1 Million to HealthPartners for advancement of its telemedicine capabilities. The money will help Regions Hospital in St. Paul and HealthPartners’ critical-access hospitals in western Wisconsin purchase virtual patient care equipment and expand access to telehealth services. “We’re grateful for this grant that allows us to purchase software and cellular-enabled smart devices for acute care and chronic-disease management that are simple for patients to use with the push of a button,” said Jerome Siy, MD, HealthPartners medical director of value-based care. The grant is part of the FCC’s COVID19 Telehealth Program, which has had $150 million approved and another $100 million to be allocated in the future to 75 health care providers across the U.S. The program provides reimbursement for telecommunications services, information services and connected devices needed for telemedicine visits during the pandemic.

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A new clinical trial led by the University of Minnesota Medical School seeks to understand how psilocybin alters brain function with the hope of informing improvements in current treatment options for certain mental illnesses. It’s the first-ever study to measure how this compound alters the brain’s use of contextual cues during visual tasks. The study also hopes to identify how long these brain changes last, which could help therapists identify the therapeutic window of opportunity for psychotherapy interventions. “One arm of the study looks at visual perception and how it is affected by psilocybin,” said predoctoral researcher and study leader Link Nielson. “Another arm of the study is looking at the timecourse of brain changes produced by psilocybin, using diffusion tensor imaging (DTI), a type of MRI scan that can visualize dendritic spines, which until now, has only been shown in animal models.” The study is currently enrolling up to 46 carefully vetted participants who have good physical health and experience taking psilocybin but do not have a current or previously-diagnosed major mental illness or substance use disorder. “The point is to enroll people who are comfortable with psilocybin and are able to navigate their own mind very well because they will be asked to do visual performance tasks while in an altered state of consciousness,” Nielson said. After enrollment, participants will undergo

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a series of baseline tests to measure blood and brain biomarkers of neuroplasticity prior to taking psilocybin, which include blood draws and MRI and EEG scans. Then under the supervision of clinicians within a medical facility, participants will undergo the first of two dosing sessions — one with psilocybin and one with a placebo (niacin). Investigating the visual effects of psilocybin will illuminate general principles by which psilocybin might act on other circuits in the brain, including cognition, emotion and therapeutic outcomes, potentially yielding new scientific insights on the relationship between psilocybin and mental health.

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MINNESOTA PHYSICIAN DECEMBER 2021

3Understanding Ageism from cover

A recent study by Becca Levy at Yale University found that ageism is a major contributor to the eight most expensive health conditions, including cardiovascular disease, chronic respiratory disease and diabetes. The report estimates an excess annual cost from the effects of ageism at $63 billion.

In its “Global Report on Ageism” issued earlier this year, the World Health Organization (WHO) defines ageism as “how we think (stereotypes), feel (prejudice) and act (discrimination) towards others or ourselves based on age.” Ageism is based in stereotypes, biases and misconceptions learned in childhood and reinforced throughout life. It can impact both young and old, but the most detrimental impacts on health and well-being have been documented in older people. You should assume that The WHO report notes that “ageism is prevalent, you are ageist and educate ubiquitous and insidious because it goes largely yourself about the impacts. unrecognised and unchallenged.” As a society, we are seeing some momentum in creating age-friendly environments and attitudes; one example is the “AARP Age-Friendly Communities” movement. Nonetheless, ageism continues to be a significant social determinant that impacts health.

Impacts of ageism on older adults WHO reports that: “Ageism shortens lives, leads to poorer physical health and worse health behaviours, impedes recovery from disability, results in poorer mental health, exacerbates social isolation and loneliness and reduces quality of life. Ageism takes a heavy economic toll on individuals and society, contributing to financial insecurity and poverty and costing society billions of dollars.

Intersectionality with other “isms”

The effects of ageism are compounded for people who face other types of discrimination, particularly people of color, women, LGBTQ and people with physical or mental disabilities. A lifetime of inequities exacerbated by historical trauma puts older BIPOC (Black, Indigenous and People of Color) at greater risk of negative outcomes in all aspects of their lives. A lack of trust in systems that have often betrayed them means older BIPOC individuals are less likely to seek medical care and less likely to reap the full benefit from the treatments they receive. Elders in immigrant communities—many of whom are non-English speakers—face additional challenges. Being old is one more factor that sets them apart. LGBTQ elders face discrimination in housing, long-term care settings and in-home care. Many choose to bypass care for fear of not being treated well. Some feel going back into the closet at the end of their lives is their only option. A recent PBS report noted LGBTQ seniors are also at greater risk for social isolation “because they are less likely to have children and are more likely to live alone or estranged from their families.” People with disabilities and those with low incomes are likely to feel the impacts of ageism to a greater extent. A person who is in a wheelchair or uses a walker is easily discounted as someone who has no capacity at all.

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People who have financial means can often work around obstacles presented by prejudices. Those without means are often forced to make trade-offs, such as choosing between purchasing food or medications or retaining their housing. About one-third of older adults live on social security alone, and on average, the monthly benefit is $1,543, an inadequate level for maintaining health and well-being.

Self-directed ageism Nelson, the Cal State psychology professor who researches cognitive neuroscience as it impacts stereotyping and prejudice, calls ageism prejudice against our future self. Fear and loathing of a less vital self become actions that discount and harm older persons. His findings are in keeping with the extensive research done by Levy on how negative self-perceptions about our own aging contribute to poor health outcomes including shorter lifespans— on average 7 1/2 years shorter. Older adults themselves can be some of the greatest offenders of ageist behavior. Comments like having a “senior moment”, or being too old become self-defeating prophecies. Far from harmless, these comments and the thoughts that accompany the comments can cause real damage.

Ageism and COVID As of December 1, 2021, more than a half a million people aged 65 and over have died from COVID-19—75% of all deaths. The prevalence of deaths among older people has fueled negative stereotypes about older adults,

sometimes surfacing deeply embedded ageism such as a belief that an old life is not as valuable as a young life or “that they’re going to die anyway.” In recognition of the danger of being left behind due to bias about age and ability, the U.S. Department of Health’s Civil Rights Office issued a special bulletin in the early days of COVID-19, explicitly stating: “[P]ersons with disabilities should not be denied medical care on the basis of stereotypes, assessments of quality of life, or judgments about a person’s relative ‘worth’ based on the presence or absence of disabilities or age.” COVID-19 has had the greatest impact on people of color, those with low incomes and others who face health disparities, including people experiencing homelessness. BIPOC elders are both at higher risk of contracting COVID and of having more serious consequences of the disease, due in large part to lifelong disparities in social and medical care.

unifier across the usual divides of class, race, geography and even age.” She shares an example of a physician lamenting that he had only allocated 15 minutes for admitting a dying woman, assuming it was “yet another dying old woman.” Once he got to the patient, he realized the woman was 40 years old, and he said he should have allocated more time. He identified the problem as not knowing the age of the dying person, rather than devaluing the life of an older person.

Assuming a person lacks agency The ability of Ageism continues to be a significant social determinant that impacts health.

Ageism in medicine Ageism is found in medicine at both the systemic/institutional level and at the individual level. One in five people have reported encountering ageism in the health care system.

At the institutional level

a person to contribute to decisions and choices in their life differs for each person, independent of age. When you assume that a person does not have capacity based simply upon age, you take away their dignity. One way this displays itself is when a health care provider addresses the caregiver rather than the older adult patient. Throughout life, people need others. We constantly balance independence and dependence, and the balance between the two moves back and forth at different points in our lives. It is no different as people age.

Treating people in a patronizing or condescending manner This has been called “poor dear” syndrome or “elderspeak.” On the surface, it may seem to be kind and caring. But when the underlying belief is

• Older adults are rarely included in clinical trials, though older adults often react differently to treatments and inadequate testing can be harmful to them.

Understanding Ageism to page 124

• Professionals who focus on older adult care are not treated with the same respect or rewards as other specialties. • There is a lack of investment in the supports that are necessary for care of older adults. For example, there is minimal infrastructure for people receiving home-based services and therefore avoiding costly institutional care.

At the practice level • Older people often receive less aggressive treatment for ailments, many of which are dismissed as a natural part of aging. • Changes that are a natural part of the continuous process of aging are often treated as though they are diseases. • Older adults are commonly over-treated with excess prescriptions and other therapies that are not in keeping with the patient’s goals. • Older adults are prescribed treatments that put them at risk for other issues. The Washington Post reports that 94% of older adults have been prescribed a drug that increased their risk of falling at a time when the rate of death from falling is skyrocketing. The provider/patient relationship is fertile ground for supportive reinforcement of positive behaviors and attitudes. It can also be a minefield of damaging biases and prejudices. Here are some ways in which ageism towards older adults can enter these relationships.

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Devaluing older adults Louise Aronson, in her book, Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life, notes, “The devaluing of old people is ubiquitous and unquestioned, a great

MINNESOTA PHYSICIAN DECEMBER 2021

BEHAVIORAL HEALTH

Sober Housing A thriving industry in need of regulation BY SEN. KARIN HOUSLEY

ubstance use disorder is a recognized medical condition which affects a large number of individuals. Minnesota was a pioneer in developing in patient treatment options for these individuals and is nationally recognized for its work in this field. In fact, Minnesota is euphemistically known as the land of 10,000 treatment centers. As a national leader in providing care for individuals with substance use disorder, whether by personal choice, intervention, family intervention or court order, the road to recovery often starts at an inpatient facility. There are a variety of options and established oversight for these facilities. After between four and 12 weeks of extensive inpatient supervision, clients frequently require an additional level of supervision and assistance to guide them on the path to recovery. This structure is regularly provided through sober housing.

A Lack of Oversight Nationwide, and Minnesota is no exception, there is a serious lack of oversight in the sober housing industry, which has created large systemic issues for both patients and recovery facilities. In a world where we are facing

an opioid epidemic that fosters a breeding ground for addictions, sober homes have historically provided safe and nurturing environments in which recovering residents can live and coexist while embarking down the road to recovery. Sober housing at its peak is known to offer a form of housing where people in recovery live together in a supervised, substance-free setting. Unfortunately, with a lack of oversight in this sprawling and unregulated industry, many sober homes are falling short of these expectations and are in turn also failing their residents and their recovery efforts. Due to these concerns, the Minnesota Legislature recently passed language in the Health and Human Services omnibus bill that directs the Department of Health Services to develop industry recommendations for sober homes. These recommendations would focus on increasing access to sober housing programs, promoting person-centered practices and cultural responsiveness in the programs, considering potential areas of oversight, and providing consumer protections for individuals in these homes The language states the recommendations must be developed alongside stakeholders, so that proper input from all parties involved is considered when examining specific areas in need of oversight.

The need for support Recovering addicts need a support system. This article provides a legislator’s perspective on the magnitude of this problem and how it is affecting a highrisk population. To understand the numerous issues surrounding the sober housing industry, it is important to understand a few important things: the scope and depth of the issues, what should be regulated and how any changes would benefit a particularly vulnerable group of citizens. In discussing this issue, we must first break down the structure of the sober housing industry. Minnesota’s current leading authority in this area is the Minnesota Association of Sober Homes, also known as MASH, a membership-based organization that certifies homes, conducts inspections and responds to complaints. MASH currently has a membership of just under 50 sober homes throughout the state. Unfortunately, that is not an allencompassing number. In Minnesota, membership in MASH is not required of sober homes, which means many homes exist outside of the association. Because it’s borderline impossible to find a list of all sober homes in the state, and even harder to find resident numbers, it’s impossible to know how many lives are being hurt and negatively impacted by a lack of oversight.

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It’s also important to note the cost of these homes aren’t inexpensive. Member fees fall across a large range, but $550 per month for rent seems to be the most affordable; many homes also request that you call their facility to get more information on their additional specific fees. The combined cost and lack of accessibility form crippling barriers for those trying to work their way through recovery.

Lack of regulation The only formal regulation for sober homes is implemented at the local level through zoning and fire marshall occupancy codes. These codes are

DECEMBER 2021 MINNESOTA PHYSICIAN

supported and loosely enforced by MASH members, this is the absolute bare minimum in terms of regulation. There are only about 30 other organizations like MASH throughout the entire country that work to ensure the safety of their state’s homes. Unfortunately, as is the case in Minnesota, many recovery homes are not part of these associations and therefore are not forced to follow minimum standards. Many of the oversight agencies and organizations are partnered with state legislatures and addiction treatment agencies to ensure the safety of their homes.

treatment and are transitioning from being cared for to living on their own. They need guidance through an ongoing period of vulnerability and recovery. This issue is one of many where there should be a standard for the industry which would provide a safe baseline to help residents moving towards recovery. If some residents are less serious about recovery, it can hinder others around them. This difference in priorities can breed distrust and fear in the home and can lead to a decrease in the environment’s safety.

Minnesota is one of a handful of states working to provide greater oversight guidelines for the industry, with a goal of improved consumer protection. If we focus on these issues, we can ensure access to safe and dependable homes for recovery. Recently, Minnesota’s Office of Ombudsman for Mental Health and Developmental Disabilities expressed concerns, stating, “[the office] had concerns about the vulnerability of our clients in unregulated sober home settings after receiving complaints alleging rights violations, treatment promised but not provided, abrupt discharge without cause or due process, lack of any meaningful grievance process, and substandard living conditions.” As a result, the Substance Abuse and Mental Health Services Administration issued informal guidelines of best practices for sober homes. Many of these issues do not fall under jurisdiction of the Office of Ombudsman for Mental Health and Developmental Disabilities, yet the office still supports the study’s implementation through the Minnesota Legislature. Proper regulation will create positive living environments that offer support recovery, while also providing much-needed consumer protections. Sober homes can offer many benefits for residents, but they cannot operate at their best without proper guidance. In terms of regulation, there are a number of factors for consideration: management, physical conditions, results of the study put forward by the legislature and violation enforcement.

holding a job or are searching for a job and actively attending meetings dedicated to recovery efforts. The standards should require homes to have a game plan for working through any type of relapse for residents.

Where there should be a standard Another unfortunate note is that housing Addressing that point, there should also be for the industry which would participants in sober homes are not considered a logical cap on how many residents can live provide a safe baseline. renters or patients, so any laws pertaining to in the home safely and securely, depending on either of these two groups do not apply to the adequate space and facilities. Homes should also sober homes residents. To further compound the further facilitate recovery efforts by implementing problem, residents often also suffer from mental milestone requirements for tenants because illnesses; 50% of people with mental illnesses recovery is an ongoing process. Although relapses also have substance abuse disorders. A lack of oversight contributes to poor happen, they should not be such a common occurrence as they are in many of recovery outcomes, leading to adverse consequences. Implementing adequate these homes. If behaviors arising as part of relapse are consistently tolerated oversight is step one, and it is the only way to overhaul this industry and and sometimes even welcomed, it can be detrimental to multiple residents. provide residents the care and recovery they rightly deserve. Milestones that should be considered include ensuring residents are either

For example, there is currently no real training offered or required for sober housing managers. Many times, sober housing managers choose this employment option for reasons other than to help residents’ success in their path to recovery and often lack adequate knowledge and background on the connections between mental health and addiction. This need for training fails the residents on many fronts. Without a singular body to provide industry-wide standards, it’s impossible to regulate who is employed as a sober housing manager.

Setting the stage Ensuring proper physical conditions for sober homes is vitally important, When someone is seeking out a sober home, they are almost always looking for a safe and stable environment, two things that are key to recovery. Most of these patients are coming to a sober house after graduating from inpatient

Sober Housing to page 134

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3Understanding Ageism from page 9 that an older person needs to be taken care of or cannot make their own decisions, it can be hurtful and diminishing. This can also include over-accommodating speech (talking slowly or loudly), condescending comments (“It’s so nice to see you using an iPad”) and projections of lack of ability.

Fight implicit bias Eliminating bias is an everyday task. Being aware of your biases and counteracting them is a practice that can be learned and incorporated into actions to reduce the harms of ageism. Use a whole person approach Rather than seeing an older adult through

Using backhanded compliments A comment such as, “How are you doing today, young lady?” to an old women might appear to be a compliment, but it masks a belief that aging/old is not desirable. Other examples of backhanded compliments include “You’re young at heart” and “You look great for your age.”

Ageism is found in medicine at both the systemic/institutional level.

Addressing ageism Here is a three-step process you can use to help to reduce ageism in medical institutions and in individual practice.

Educate yourself Ageist attitudes are pervasive and unavoidable in our youth-oriented society. You should assume that you are ageist and educate yourself about the impacts of ageism and how you can use your authority to act and lessen its effects. If you have authority at an institutional level, ensure age discrimination is a part of your overall diversity, equity and inclusion efforts and everyone in your organization is trained on ageism.

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eyes that are colored by stereotypes, see the individual who is in front of you. Remember that older adults are extremely diverse. They are not a large and impersonal political, corporate, or social structure to be regarded as intractably indivisible and uniform. Each has been informed by different experiences over a lifetime and has unique characteristics, abilities and desires. Adopting Louise Aronson’s three stages of life—childhood, adulthood, and elderhood—could be a start in honoring the range of attributes of elders.

Conclusion Use your power to make change at the individual level and the institutional level. Physicians and other health care professionals have tremendous power to influence a patient’s sense of themselves and their willingness to take action to care for themselves. Studies have shown that patients are more likely to sign up for an evidence-based health promotion class if their physician recommends it. Getting your attitude right about aging and the challenges and opportunities of aging can make a major difference in older people’s health and well-being. At an institutional level, change comes when individuals recognize the need and make it happen. If you are looking for a way to get started, look to the John A. Hartford Foundations’s Age-Friendly Health Systems initiative. The foundation is doing pioneering work in helping organizations use evidence-based models and practice to better serve older adults while achieving the triple aim of health care.

Resources for further information • Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life. Louise Aronson. https://louisearonson.com/ books/elderhood/ • “They Treat Me Like I’m Old and Stupid’: Seniors Decry Health Providers’ Age Bias.” https://khn.org/news/article/ ageism-health-care-seniors-decry-bias-inappropriate-treatment/ • Age Friendly Minnesota MN Dept of HS. • Minnesota Elder Justice Center.

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Dawn Simonson, MPA is President and CEO of Trellis, a Minnesota nonprofit organization providing services, information and connections that help people optimize well-being as they age. Trellis provides backbone support for the Juniper network, a provider of evidence-based disease self-management and fall prevention classes for older adults. Trellis is committed to serving our aging communities with equity and inclusivity.

3Sober Housing from page 11 Further factors for oversight

important connections between substance use disorders and other disorders. This understanding will naturally lead to better-informed treatment from the doctor and a better outcome for the patient. All these resources together will help patients heal in the way they’re meant to. We cannot accomplish these changes without the support of physicians and the medical field.

The above factors should be considered for regulation and oversight, purely for the safety and well-being of those working towards recovery. That is why the Legislature passed language that allows the Department of Health to develop recommendations promoting Overall, I am optimistic about the study and better-quality practices in the sober home industry. its potential findings. If we look to physicians and The language we passed was a good step forward, All signs point to the need their contributions to recovery efforts, we work but there is still important work to be done, for better regulation. to solve the problems of the unregulated sober specifically in developing an authority that can housing industry. Though there is still much work exercise direct oversight for recovery homes. We to be done, we’ve taken an important step forward. should also examine the best ways to harness the In seeking to reform a broken system, in tandem medical community as tertiary support. If we had with looking to physicians for guidance, we will better oversight on the regulation and accreditation be able to make admirable and necessary gains. of sober homes and an authority responsible for rating homes based on stringent guidelines, it would not only benefit the industry as a whole, but Senator Karin Housley is the Assistant Majority Leader of the Minnesota the patients as well. Ideally and under specific guidance, if any home was to Senate. She is from District 39, is also the chair of the Aging and Long-Term break the rules set by a presiding authority, that home’s accreditation could Care Policy Committee. She was elected in 2012 and has been the chief author be lost. If we have a centralized authority with jurisdiction over sober homes, and co-author of numerous important pieces of legislation. only then could we fully enforce standards and consequences, therefore keeping these homes safe and beneficial. All signs point to the need for better regulation to reach improved outcomes. There are so many residents in these facilities who stand to gain from improved regulation. This is especially important because many individuals who develop substance use disorders are also diagnosed with mental disorders. This naturally broadens the sphere of those affected by the sober housing industry, further supporting the idea that consistent regulation would be beneficial across the board. In recent years, Minnesota has developed better oversight in the assisted living housing industry, in part due to the Legislature’s work. Now, people interested in assisted living facilities can easily research homes, view services offered and find ratings. The sober housing industry and those in it could benefit from a similar transparency.

Next steps The industry is in desperate need of guidance, both for providing structure and stability for residents and also for offering resources to those looking to take the next step in their recovery. The study language we passed was not as encompassing as what the Senate originally envisioned—with the adopted House language, more stakeholders are involved. The increase in stakeholders can be positive when it comes to input, but can also be problematic when they have their own interests to serve. The language agreed upon will implement a study that is not as in-depth as I had hoped, but is a step in a generally positive direction. To help maximize the study’s output, it is critical we get physicians on board helping the sober housing industry. The next step would be to harness the aid of physicians—they have depths of knowledge that can be used to advocate for better oversight and can provide input regarding what constitutes a “safe” and “effective” sober home. Physicians have a better understanding of patients’ needs, and they are able to provide better care and treatment for patients if they are aware of what progress is occurring in a sober home. Physicians also understand the MINNESOTA PHYSICIAN DECEMBER 2021

3From the Trenches from cover

pilot a few tips on how to reach our destination faster from my online “research” prior to the flight. I have had patients refuse the Covid swab due to the danger of the chemicals in the swab itself. I have had a patient arrive In the line of fire wrapped head to toe in Saran Wrap, wearing swimming goggles, a shield and We are heartbroken and overwhelmed because for the past 2 years, we have multiple masks for fear of getting Covid in the ER. been working extra hours, managing the rise in I have had patients deny that their symptoms were overdoses and alcoholism, struggling to give caused by Covid and refuse oxygen and decadron patients who don’t have Covid the care they need because they believe I am offering these treatments while our hospitals have been overwhelmed with in order to make money. It’s hard not to take these Covid admissions, and telling devastated families comments as personal criticism. After all, I am the in a cold parking lot that their family member has Politics has made patients question one ordering the “toxic swab” and the one who is died. As the pandemic drags on, caregivers are in if they can trust physicians. getting paid for providing the service. the direct line of fire for people’s anger and despair at the government, the pandemic, masking, social injustice, school closures, and all of the confusing messaging about public health and Covid that began as soon as it was announced that the virus had been found in our country. The pandemic has put caregivers in the middle of a political maelstrom that our years of training did not prepare us for. Caregivers are not, nor should they be, politicians.

Early in the pandemic, I had a patient surreptitiously video record our interaction. He had wanted hydroxychloroquine and azithromycin. As these were not proven therapies and he was in a low risk group for serious disease I explained my rationale for not prescribing these. The next day as I arrived at work, a news crew was outside the ER. Our interaction had been edited and was shown on the evening news.

An erosion of trust

The erosion of trust in medicine has accelerated dramatically over the past two years. The pandemic has revealed the scientific process to the public and it hasn’t gone over well. Science is messy. We work with imperfect information and modify our protocols as we learn more, often completely abandoning what we did before. That is why medicine is a “practice,” not a performance. At the beginning of the pandemic, we knew virtually nothing

For the past 15 years, Dr. Google has been in competition for our jobs. But today, it is not just Dr. Google. It is Fox News, CNN, YouTube, Facebook and a myriad of other social media sites that seek to replace our expertise. It is becoming increasingly common for patients to tell me not only their self diagnosis but how to manage it. It is similar to me giving the airline

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about this virus. We didn’t even know how it was transmitted. Papers were published and given to the media without peer review. It was like the Wild West because it had to be. This was a brand new disease and it was affecting the entire world. We didn’t have time to do thorough reviews. But everything we did, every mistake we made, was reported and discussed extensively in the media.

To make matters worse, the hospitals are overwhelmed. It is not simply the number of Covid patients that present to the hospital it is the length of time they stay. Any patient admitted with Covid stays in the hospital for a long time. Some for up to two weeks versus the average patient stay of three days. With hospitals at capacity, ER’s back up and patients that are admitted sit in the ER for days. In rural hospitals, it is even worse, critical patients are unable to be transferred for the care they need because there Any patient admitted is no availability. Hence, other healthcare needs, with Covid stays in the like elective surgeries are cancelled.

Political polarization

Transforming Healthcare

In a world that was shut down, the public had nothing else to do but watch the media coverage of the Covid pandemic. It was Team Fauci vs. Team Scott Atlas and the Great Barrington hospital for a long time. We know that widespread vaccination will Declaration. This polarization into factions has take the pressure off our hospital systems. This unfortunately become a daily part of patient is why the CEOs pleaded with the public to get interactions. Patients will frequently start a visit vaccinated. This has, not surprisingly, been a by discussing how stressed they are about “the difficult task. Even before Andrew Wakefield stolen election” or how they are not celebrating published his now debunked study implying vaccines caused autism, the holidays with their family because their Uncle won’t get vaccinated, or vaccines have engendered public fear and resistance. In the UK, an 1885 how people who don’t get vaccinated are “idiots.” It feels like a test. Patients protest against the government’s requirement of the smallpox vaccine want to know if I am with them or against them before they decide if they garnered 100,000 participants. The Covid vaccine arrived in the setting of a can trust me. When a patient is sick, it shouldn’t matter what team they large anti-vaccine movement. The argument for vaccination is made harder side with. It shouldn’t be about politics. It should be about a relationship by the caprice of Covid. Many people don’t get really sick, so why take between a doctor and a patient and in order for healing to take place, there the risk? It is hard for the public to understand that every person who gets has to be trust. Today, politics has made patients question if they can trust physicians. For physicians who consider the field a calling and not a job, this is the heartbreak. From the Trenches to page 164

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MINNESOTA PHYSICIAN DECEMBER 2021

3From the Trenches from page 15

where I worked. After hearing I was an ER physician he expounded on all the reasons he was not going to get the vaccination. “Covid was a hoax.” He’d stored up all his horses’ heartworm medication and could take it if he started getting sick. The whole thing was engineered by the Chinese.

Covid, no matter how benign their individual illness is, increases the risk for a mutation that could be far more devastating to all of us. The vaccine may not be perfect, bit is much safer than Covid itself. Aside from the mortality risk, there’s also risk of hypercoagulability causing pulmonary embolisms, some patients develop long Covid, and any serious case will entail personal lost wages and decreased economic productivity. I I have seen more people get that the risk of any of these things happening die this year than in my to a specific individual is low but so is dying in a past 21 years in medicine. car accident, and I still put on my seatbelt.

Maintaining hope Yes we are heartbroken and overwhelmed but there is still hope. A month ago, I was working an overnight shift in a rural emergency department. On my way to work, my car had broken down and there was no way I was going to make it back to the Twin Cities without getting it fixed. After a long night of managing critical care patients that could not be transferred to other hospitals due to capacity issues in addition to the patients with noncritical but still emergent needs, I was tired. As I drove out of the parking lot, I passed the ever present elderly man who pushes a shopping cart back and forth in front of the hospital that is bedazzled with hand written signs stating “vaccines are bioterrorism.” My car, thankfully, made it the few blocks to the repair shop. Still dressed in my scrubs, the mechanic asked

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That morning, I was done with work. I just wanted my car fixed and didn’t have the energy to have the discussion. Two hours later, my car was fixed. I asked him how much I owed him. He said, “nothing, it’s on me. Thank you for everything you do.” It was just what I needed. A reminder, that despite the politics of this pandemic, we do still care about each other and our patients still care about us. Carolyn McLain, MD, an emergency physician with the Emergency Physicians Professional Association (EPPA) an association of physicians and advanced

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MINNESOTA HEALTH CARE ROUNDTABLE

Clinical and Non-clinical Care Teams Improving interoperability The 53rd session of the Minnesota Health Care Roundtable continued in the remote format. This provided panelists more time to reply to the questions and in some cases consult with colleagues for a response that represented consensus from within their organizations. In consideration of our focus, improving care team interoperability, allowing for this increased input was invaluable. While there were some issues where panelist responses bordered on repetitive, other responses helped define specifically unique areas where improvement is both clearly needed and a manageable challenge to address systemwide. We extend our special thanks to the participants and sponsors for their commitments of time and expertise in bringing you this report. In April we will publish the 54th session of the Minnesota Health Care Roundtable on the topic “Care Transitions, improving the safety net.” Consideration of issues around the pandemic dictate that we must continue with the remote format. We welcome comments and suggestions. Please define the term clinical care team. JENNIFER L: Our perspective is focused on strengthening the connection between health care and community. We are currently engaged in facilitating the processes for Minnesota stakeholders (health systems, community organizations and payers) to co-design a common approach to sharing social needs resource referrals between health care organizations and community organizations. So, for the purposes of our responses here, the care team is broadly inclusive of the clinical care team and extended care team members in the community who are offering services and supports which address social needs related to health. MANDY: A clinical care team is a group of health care professionals that operate on the front lines of patient care. For us, the clinical care team consists of physicians, pharmacists, physician assistants, advanced practice nurses, therapists, registered nurses, social workers, spiritual care coordinators, recreational therapists, occupational therapists, art therapists, psychiatric technicians and residential counselors. All work collaboratively to either direct, coordinate or assist in carrying out the patient’s plan of care. VIVI-ANN: A clinical care team is a group of multidisciplinary health care

professionals, working together to determine the most appropriate care plan for the patient, based on the family and patient’s needs and preferences. The

DECEMBER 2021 MINNESOTA PHYSICIAN

MANDY DAGEFORD MSN, RN-BC, CENP, is the Chief Nursing Officer at PrairieCare, a privately-owned clinician led organization providing a partial hospital program (PHP) and inpatient mental health services in several Minnesota locations. She joined PrairieCare in 2013 and is responsible for overseeing quality, patient safety, and adherence to regulatory standards. She leads the organizational patient experience initiative and is passionate about decreasing stigma associated with mental illness. Prior to joining PrairieCare, she had a long tenure in Hennepin County where she provided innovative leadership resulting in improved mental health care in departments system-wide. MAJ(R) JENIFER DETERT, PA-C, MPAS, DFAAPA, BA, BS CAQ: ER, has a solo rural emergency medicine practice that serves communities surrounding St. Joseph, Minnesota. She is President of the Minnesota Academy of PAs (MAPA) and is a retired combat veteran. MAPA’s mission is to promote the professional and personal development of Minnesota PAs, through representation at the local, state, and national levels, advocacy, educational opportunities, and public relations, with the goal to promote quality and cost-effective, accessible health care for every person.

SARAH DERR, PharmD, is the Executive Director of The Minnesota Pharmacists Association (MPhA). a professional association that serves Minnesota pharmacist providers. The association promotes inter-professional collaboration and cooperation between health care professionals from many different specialty areas. Additional work focuses on maintaining a strong economic environment for pharmacy practice and engagement in advocacy efforts to ensure that laws and regulations keep pace with the evolution of the profession. MPhA encourages and promotes networking among pharmacy professionals and partnership with other professional organizations to advance common goals and patient care through collaboration. VIVI-ANN FISCHER, D.C, is the chief clinical officer of Fulcrum Health, an organization dedicated to leveraging physical medicine to transform health care. ChiroCare, the nations first chiropractic network founded over 35 years ago is part of the Fulcrum Health network. Dr. Fischer oversees network credentialing, utilization services, and provider services. She has been with Fulcrum Health since 2012, is currently a Board of Trustees member at Northwestern Health Sciences University (NWHSU), and has served as a member on the Board of Directors for the Minnesota Chiropractic Association (MCA).

JENNIFER P. LUNDBLAD, PHD, MBA,

is the President and CEO of Stratis Health, an independent non-profit organization that leads collaboration and innovation in healthcare quality and safety. Stratis Health improves health care quality and patient safety – locally and nationally – at the clinician, organization, and community levels and across the full continuum of care. Established as the Foundation for Health Care Evaluation in 1971, this year Stratis marked its 50th anniversary, celebrating its mission to embrace new and emerging improvement methodologies and deepening its work to bridge health care and community.

team may include physicians, doctors of chiropractic, physical therapists, nurses, massage therapists and acupuncturists. The goal of a care team is to improve safety, outcomes, efficiency and affordability by delivering the right care at the right time and providing care coordination between team members. In high-functioning teams, patients are members of the health care team and assist with decision making. SARAH: A clinical care team is a team composed of health care professionals

who work collaboratively to provide the best care for the patient. This team may be composed of physicians, physician assistants, nurses, pharmacists, dentists, physical or occupational therapists, dietitians, nutritionists, social workers, respiratory therapists, behavioral health workers, technicians, etc. Each member of the clinical care team brings a unique perspective to patient care, which is why it is important to maintain a diverse clinical care team. Clinical care teams can span different practice sites. For example, a pharmacist may work in the community pharmacy, work closely with a clinic who employs a physician, nurse practitioner and physician assistant, and also a hospital. It is important to note that all members of a clinical care team do not have to be part of one health system or one location.

representing the behind-the-scenes essential work force: high-level executives, administrators and billing and coding specialists, along with financial, human resource, managerial, clerical, maintenance and environmental staff. Nonclinical team members ensure the clinical team has optimal support to allow safe, effective, efficient high-quality clinical care to every patient. During the initial stages of the COVID pandemic, medical information technologists were instrumental in pivoting patient care from bedside to virtual. Clinical and non-clinical care teams are incomplete without the supporting role of family, friends, significant others and caregivers who extend beyond clinical and non-clinical duties advocating for and supporting the personal, spiritual, emotional and best interests of the patient. JENNIFER L: The non-clinical care team broadly

includes the clinic staff and/or members from community organizations providing services and supports necessary for health care. Some health care organizations opt to employ social workers and community health workers (CHWs) so they are more closely connected to the clinical care team in supporting and transitioning patients, have the data available within the practice, and are known and trusted by the clinical care team. Interoperability is not only Alternatively, clinical care teams can rely on community organizations which embed such staff, JENIFER D: A clinical care team blends important within one individual enabling the social workers and CHWs from local multidisciplinary professionals, allowing several healthcare episode, but it is communities to do visits in the home that provide insights and perspectives to offer health care, important and imperative to a more comprehensive context of that person’s delivered in a holistic, high-value manner and provide continuity of care. and family’s life–the patient’s lived experience. completing various clinical tasks to serve the There are advantages to both approaches, and we needs of patients. The clinical care teams operate —Mandy Dageford in all clinical settings: inpatient, outpatient, are observing carefully as our approaches evolve skilled nursing care facilities and surgical and and are studied. Regardless of what approach clinical specialty care. Clinical care team members is taken, it is essential for clinical care teams to are called to fill the needs of a patient from all have the contextual information about their levels and specialties in nursing, laboratory and radiology technicians, speech, patient’s lives which helps determine interventions and care plans that really occupational and physical therapists, pharmacists, nutritionists/dietitians, work. An example of the benefit of a broad and inclusive care team is when a mental health psychologists and counselors, often by the referral or request patient presents in a clinic or hospital (including behavioral health services), from a primary care clinician/provider, such as a physician assistant, advanced the context of that person’s day-to-day health risks can be considered. One practice RN/NP, or physician. physician described a patient diagnosed with asthma. She had been prescribing various medications and therapies which were not as effectual as they should Please define the term non-clinical care team. have been. A social needs screening was done at the clinic, which triggered a community health worker to do a visit to the home and identified unhealthy JENIFER D: The non-clinical care team encompasses members, without direct air quality in the home as a potential contributor in getting the patient’s patient care responsibilities, vital in performing tasks and supporting the asthma under control. The community health worker was able to connect essential needs of a health care system. Non-clinical care teams represent a wide with a local housing organization to find more appropriate housing. The range of education, background, experience and competencies from personnel

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MINNESOTA HEALTH CARE ROUNDTABLE

referral and follow-up action were linked back to the clinic’s electronic health record for the clinical care team to incorporate into the care plan. SARAH: A non-clinical care team would include team members who do not

provide clinical care to a patient. These members are essential to coordinating patient care and making clinical care possible. Members on this team include the following personnel: administrators, schedulers, IT, front of store operations and call center staff, environmental services, etc. The non-clinical care team is essential to supporting the clinical care team to provide the best possible patient care.

for response to escalated patients. All members of the clinical care team have been trained in CPS, and all disciplines are now using a shared language, philosophy and techniques for de-escalation and management of patient behaviors. Consequently, we have experienced a 61% reduction in seclusion and restraint episodes over the past two years. SARAH: There are many ways care teams improve outcomes. In a retail

pharmacy, non-clinical staff availability to check out customers or direct them to a specific item assists in patient care by providing more time for the clinical staff to spend with patients. Pharmacists improve VIVI-ANN: The non-clinical care team refers to outcomes in the dispensing setting by ensuring the support team assisting the patient and health medications are safely dosed, with no major care professionals such as the office manager, drug-drug interactions, and financially accessible medical billers, care coordinator, coaches and for the patient. In a clinic (primary care or community health workers. Studies demonstrate specialty care) setting, pharmacists are able to many care and care-coordination activities have improve patient outcomes and free up provider been successful when provided by nonphysician time by engaging in their own patient visits and members of a care team. managing complex medication regimens. NonMANDY: I perceive the non-clinical care team as clinical team members are able to free up clinical comprised of every individual working where pharmacist time, in turn, by scheduling patients health care is provided, but who is not part and ensuring appropriate outreach. In a hospital, of a clinical care team. The non-clinical team pharmacists may work with respiratory therapists, essentially provides the pillars to support the speech-language pathologists and nurses to ensure delivery of safe, high-quality health care services Care teams improve outcomes patients are receiving the correct medication to patients. These positions consist of health unit type, dosage and frequency. These are only a few when utilizing team members coordinators, security, facilities and food service examples; there are so many others they can’t all at the top of license, experience, staff, receptionists, environmental services workers, be addressed in a short response. Additionally, competency, education, information management and utilization review. it is imperative that the clinical care team work This could be expanded further to include the collaboratively to provide the patient with the best and training. performance improvement team, administrative possible outcomes. For example, the pharmacist —Jenifer Detert support roles, business office and finance personnel in the community setting contacts the clinic or and the executive team. hospital if there is a question on a medication that the patient is taking. In turn, the clinic may What are some examples of how care contact a community pharmacist to discuss a teams improve outcomes? challenging medication regiment. In the clinic setting, often pharmacists will discuss medication regimens and disease state concerns and medications faceJENNIFER L: Team-based care has been shown to be effective in health care. to-face with physicians, physician assistants and nurse practitioners. Adding team members such as social workers and community health workers who can assess social needs and make referrals and connections to community organizations addresses essential elements that were previously missing but are beneficial for good clinical decision making and support. The value of identifying social needs and connecting patients to social services such as those provided by community-based organizations (CBOs) has existed and been a focus long before SDOH emerged locally and nationally as a priority in health care. The COVID-19 pandemic and its wide-ranging health and social impacts catapulted SDOH and e-referral solutions into daily health care conversations in literature, webinars, remote conference events and other forums. The term e-referral describes social needs electronic referrals. E-referrals are the approach to assessing a patient’s social needs by a health care organization, identifying services that can meet those needs, and conveying the referral electronically to CBOs that provide services and support to meet those needs.

VIVI-ANN: Care teams improve outcomes when utilizing a navigator who

MANDY: One example of how care teams have improved outcomes within

the top of license, experience, competency, education and training. Assigning a non-clinical team to health maintenance, prevention and care gaps improves the health of the patient population and allows the clinical team to focus on

our organization is through the adoption and implementation of the Collaborative Problem Solving (CPS) philosophy and associated techniques

DECEMBER 2021 MINNESOTA PHYSICIAN

assists with finding the right team member at the right time. Non-clinical care team members demonstrate improved care and care coordination by reducing the fragmentation of repetitive services and engage patients by focusing on the patient needs and preferences. The care team provides seamless communications and transitions among health care professionals. For example, a patient hurts their low back, and the navigator suggests to start care with a chiropractor. The chiropractor determines if this case can be treated conservatively and if x-rays are needed. If the patient is a conservative care candidate, care can begin with a non-pharma option. If the patient is not a conservative care candidate, the care team expands as needed with more specialists, each offering the patient options to achieve maximum quality of life goals. JENIFER D: Care teams improve outcomes when utilizing team members at

medical decisions required to treat acute and complex disease management. Utilizing teams in this manner may decrease the risk of illness, disease progression and hospitalization, thus improving outcomes. Multiple evidence-based studies have proven that including physical assistants (PAs) within the care team results in improved quality outcomes. The trauma surgeon-PA team model resulted in a 13% decrease in overall length of stay and a 33% decrease in neurotrauma intensive care length of stay. A primary care best practice study showed evidence that working with PAs and utilizing PAs to the full extent of education and experience ranked the highest in care delivery. A cohesive care team culture instills trust and reassures patient and family, emboldening them to ask questions, follow treatment recommendations and speak up about concerns. This culture thus reduces medical errors, increases patient safety and improves overall health care delivery and outcomes.

right reasons, PrairieCare felt compelled to go all in on this initiative. I am proud of how we embraced so many challenges, and our metrics reflect that our patients and staff are experiencing the benefits of a CPS culture. JENNIFER L: Key interests and considerations for improvement come from

multiple stakeholder groups. For CBOs, improvements include a system that is simple and generates reports and actionable information, to be fairly reimbursed for the value of their services, a better understanding of models and technology, and trust. In health care organizations, an example is a system that is integrated with EHRs, bidirectionality of information and accurate and continually undated directories of the CBO information. For payers, an example is a system that produces actionable data at the patient and population levels. Trust and trustworthiness, as well as cultural responsiveness, are factors that become obstacles if they are not addressed. Also, transparency about who has access to data and strong walls that What are the primary obstacles to creating prevent access by outside groups or agencies are this improvement? important for community organizations (e.g., no ICE access for immigration enforcement). There is JENIFER D: Obstacles arise when a clinical care an obstacle to improvement if it is not made clear to team is assigned non-clinically relevant work. patients and clients that they can consent to or refuse For example, administrative paperwork and referrals. When a referral is being made, it should burdensome documentation requirements limit Increasing community be communicated to the patient or client that the the care team’s time dedicated to patient care. information will be seen and may be followed up Obstacles arise when a health care system’s policies, pharmacist access to patient’s by other providers engaged in the person’s care bylaws, leadership and culture do not allow care health care records would and support. There should be an express approval team members to perform at the top of licensing improve patient care. process before entering a referral in the common and scope of practice afforded by state laws. These platform. This will also assist with HIPPA issues unnecessary restrictions create inefficiencies and —Sarah Derr and is an easy opt-out button for those who do not undermine the trust and culture of the care team. want to be followed. It is important to accurately When team members are granted more autonomy, match cultural needs with responsive service and respect and trust, it encourages opportunities for to recognize community organizations’ language them to seek out and speak up. This cultivates and cultural attributes so that people from one positive changes and initiatives that improve safety, culture are not referred to services from another culture, particularly where there decrease inefficiencies and creates a cohesive care team. are language differences. For example, the platform must be able to record and MANDY: One of the obstacles that needed to be overcome in implementing recognize patient or client names in ways that are different from dominant culture CPS and achieving a reduction in seclusion and restraint involved the large approaches, such as the use of two last names. amount of resources needed for engaging, educating and supporting staff VIVI-ANN: There are opportunities to improve team care. One obstacle is the through adoption of this philosophy and the resulting culture change. We were lack of a clear pathway where patient care should begin when they have spine able to sustain implementation of the initiative, despite also having to navigate or joint pain. This absence of clarity creates confusion for the patient and may the ever-changing and challenging environment of a global pandemic, and at involve many team members when only one or a few are necessary. Many times, civil unrest. The killing of George Floyd in May of 2020 challenged our physicians are holding on to outdated pathways rather than first following leadership team and our staff to be mindful of the physical and psychological non-pharmacological care for spine care. Another obstacle is the understanding effects of seclusion and restraint on the patients we serve and to find a way to by care team members of each other’s roles and responsibilities and appropriate do things differently. As a psychiatric health organization, and for so many

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hand-offs to other members. Care today is often siloed, and there is a lack of communication and transitions among health care professionals. Ease of communication among the care team members is a common obstacle. The EMRs were not created to communicate with other systems, and there is a need for platform changes. Standards are being developed via the Fast Healthcare Interoperability Resource (FHIR), which allows for the secure exchange of clinical, administrative and other healthcare information. SARAH: Communication is the first obstacle, especially in the community

pharmacy when you do not have direct face-to-face contact with prescribers or other team members at the clinic or hospital. Understanding of each person’s role on the team can also be confusing if it has not specifically laid out the skills, education and role of each person on the team. This can be improved by creating job descriptions for each team member. Another obstacle is when certain team members are out of sight and are often not thought to be included in clinical decisions. Health care outcomes can be improved when team members respect each other, recognize the role each plays and are comfortable asking for help or offering assistance when needed. What are some examples of care team interoperability? SARAH: Interoperability is the act of computer systems and software

applications exchanging information. This transfer of information needs to be diligently protected since it involves private patient information. One example may be the need to link information across health care systems if a patient is seen while on a vacation or only able to reach a specific health care system that is separate from the patient’s primary care facility. Another example is working closely with the community pharmacy to provide, at a minimum, read only or, better yet, the capability to add information to patients’ electronic health records. This collaboration allows the pharmacists to access the necessary labs, diagnostic information and other medical information to ensure that all medications are indicated, safe, effective and accessible to the patient. It is important to note that pharmacists are HIPAA trained and protect patient health information on a daily basis in their practice. Interoperability is essential for best practice of quality patient care by allowing access to all of a patient’s data to allow for the safest and most effective treatment plan. VIVI-ANN: Much of the discussion around health interoperability centers on the

need for progress on sharing data with the patient, health plans and healthcare professionals. Sharing of medical records among healthcare professionals allows for significant efficiency and cost savings while avoiding redundant testing, and sharing with patients increases their engagement and understanding. An ideal example is when a patient sees a chiropractor for back pain and is referred to an acupuncturist to address other health care concerns, and the acupuncturist can see the medical history along with prior exams and tests, which allows for a quicker diagnosis and care plan development. The records from the chiropractor and the acupuncturist would be visible to the patient’s primary care or other care team members which may impact their care plan development. The patient would receive treatment by both practitioners with alignment of the care plan. MANDY: Care team interoperability may look much different in a mental

health or substance abuse setting than it does in a medical one. We all know the saying ,“It takes a village,” and in child and adolescent mental health, that is so very true. Interoperability for those seeking our care starts with a 90-minute in-depth assessment by a master’s prepared intake staff, who then consults with a psychiatrist to determine an appropriate level of care. This starting point could be likened to an X-ray or other diagnostic procedure in a medical setting

DECEMBER 2021 MINNESOTA PHYSICIAN

that would set in motion a plan of care for a patient. Upon admit, the clinical care team is assigned, and interoperability begins to take shape. Each care team member has a unique set of skills and expertise they use to contribute to the patient’s overall care and outcomes. A typical inpatient plan of care consists of medication management and education, individual therapy, family therapy, psychosocial groups, safety assessments, illness education, development of coping skills, leisure and recreational activities, milieu management, discharge planning and collaboration with outside agencies. To achieve optimal outcomes, all care is provided based upon an underlying foundation of the principles of CPS, Trauma Informed Care, Patient and Family Centered Care and Relationship Based Care. JENNIFER L: There are three viable models for a common approach to electronically sharing social needs information between health care organizations and community-based organization: a single e-referral vendor, an integrated model; and an interoperable connectivity model (network of networks). There are a few examples of these models underway in other states and regions of the country that we are learning from. The social needs e-referral landscape continues to be a rapidly changing and dynamic one, accelerated by COVID-19 and its socioeconomic effects, which have elevated the intensity of social needs throughout the nation and Minnesota, including urban and rural environments. There are currently three predominant national vendors serving health care organizations in Minnesota in the social needs e-referral vendor marketplace: Aunt Bertha, NowPow, and UniteUs. This is an emerging and dynamic environment. For example, UniteUs recently purchased NowPow as well as Carrot Health, a social determinants of health predictive analytics company. Products are developing rapidly, and HER vendors are building this capacity within their tools (e.g., Epic). The market is guaranteed to be different by tomorrow. JENIFER D: EHR is a communication platform that can filter and relay patient information allowing care team visibility and accountability. For example, a primary care office visit is scheduled with a PA for preventative care. The patient offers no concerns or symptoms. However, during the clinical exam, an irregular heartbeat is identified. The Medical Assistant performs an EKG - ordered, supervised and read by the PA –who identifies an abnormal rhythm. The PA with supporting data requests clinic staff to contact the on-call cardiologist. The EHR allows for knowledge to be shared during clinical consultation and for plan of care to increase patient safety and decrease heart risk. The care coordinator uses EHR to facilitate a prompt appointment with the consulting cardiologist. Utilizing and focusing EHR with care team education, training, background and talents allows for increased interoperability.

What are some examples of how care team interoperability could be improved? MANDY: One thing that could improve care team interoperability would be an EHR where charting would occur by all disciplines in one continuous form that provides sequential details from admission to discharge. Most EHRs were designed for notes to be entered in a modular or segmented way, which means information is separated out by disciplines. Important information has the potential to get lost or buried in different places within numerous notes from multiple staff. In this case, the information is fragmented, and we lose the narrative that helps to tell the patient story. JENIFER D: Care team interoperability can be improved exponentially when well-intended but unnecessary barriers on team members are removed. This would involve seeking out and removing barriers in bylaws, policies, procedures

and accepted practice arrangements that impose restrictions on care team members’ ability to function autonomously and are not supported by state practice law. The Minnesota state legislature passed a bill that modernized PA practice that allows a PA’s clinical practice to be determined within the care team. It also removed the physician supervision agreement requirement for PAs and removed physician liability for PAs practice decisions. Ensuring health system bylaws and policies reflect the most up-to-date advancements in state practice laws in an expedited manner will improve care team interoperability. JENNIFER L: At the national level, there has

Having resources, such as consumer-facing apps, as part of the seamless patient experience would support team messaging and care plan decision making while alerting the team if the patient is experiencing positive or negative outcomes. Data collected from remote patient monitoring and patient records could be used for machine learning and artificial intelligence to predict good and bad outcomes and provide early intervention when indicated. SARAH: Within pharmacy practice, there are many times when access to

information is not available to pharmacists. The primary example is in regard to community pharmacies that have limited or no access to patient health care records that would otherwise be essential to assure the patient’s medications are indicated, effective, safe and accessible. This access can also eliminate duplicate questions to prescribers in regard to whether the patient has tried a medication in the past when we are looking at their drug therapy. Often, in different disease states, the patient may need to try and fail multiple medications before moving to another option. The access also eliminates the need for the pharmacist to reach out and ask why the patient is on a particular medication (for example an ARB) rather than another (for example an ACE inhibitor) because we can see they have had a previous adverse reaction (for example a dry cough). Increasing community pharmacist access to patient’s health care records would improve patient care.

been a long-term movement by stakeholders in government, vendor solutions, health care systems and other entities to promote interoperability and the use of standards-based data exchange. These standards and interoperability solutions are replicable and applicable to the emerging e-referral marketplace without reinvention of technical standards. Relevant strategies and standards for e-referral systems include the use of application programming interfaces (APIs) and the ability to query and request specific discrete sets of clinical information through the Fast Healthcare Interoperability Resources (FHIR) Race, ethnicity, and religion standard. E-referral vendors, their customers and stakeholders are coming together to build similar have become an increasingly networks of exchange at the community level– important factor in terms of known as community information exchanges patient care. (CIEs) and often collaborate with those entities. Just as Minnesota is building a network of —Vivi-Ann Fischer networks for health care data exchange, we What are some examples of how improved should also endeavor to create interoperable care team interoperability can address issues networks to assist and solve social needs and in health care that involve diversity, equity join the larger HIE network of networks. While and inclusion? Minnesota does not have a state-level HIE, many JENNIFER L: A racial equity focus is an essential states and regions with a varied EHR vendor landscape (like Minnesota) can component to our current effort to co-create a common statewide social effectively exchange patient data. Health care systems in this environment can needs referral approach supported by technology in Minnesota. Supporting cooperate in the context of patient health data exchange. social needs is an essential element in assuring equity and reducing health VIVI-ANN: One of the first steps is developing a patient-centered, best practice

pathway that teams can agree upon. Patients would be informed as to their options regarding provider types and be given recommendations and choices of where to initiate care. This will create clarity of how the patient should progress on the care pathway and when additional care team members should be added. The pathway creates efficiency of both number of services provided and number of members seen along with saving the patient’s time. Engaging the patient and supporting self-management instructions improves care.

disparities. It is widely recognized that 70%-80% of a person’s health is influenced or determined outside the traditional health care service delivery walls of clinics, hospitals, long-term care and other health care settings. By cataloging needs and connecting patients to CBOs in an automated fashion to address health-related social needs, we are helping streamline an often disconnected and cumbersome process. Collecting data about individuals and communities also helps identify social needs and gaps taken together to inform policy and decision making.

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SARAH Addressing diversity, equity and inclusion is an important aspect of

healthcare, especially as we have a very diverse population in Minnesota. Additional collaboration in access to the electronic record will improve patient care as pharmacists and the health care team address specific concerns that may impact certain populations more than others. Diversity, equity and inclusion is one of five areas that MPhA is addressing in their strategic plan this year (June 2021 to May 2022). Our exact plan is not fully formulated, but we are looking at this from both an association standpoint and ways in which we can support our member pharmacists, student pharmacists and pharmacy technicians in these efforts. MANDY: In order to address these issues, they first need to be identified. Inclusion

of various members on a care team who come from diverse backgrounds and have different life experiences contributes positively to an increased diversity, equity and inclusion care perspective. As each member brings a unique lens from which to view the patient’s story, there are opportunities to discover and explore possible underlying DEI issues and how to provide care that minimizes gaps and is most supportive to individual patient needs. JENIFER D: The care team’s interoperability improves when the overarching culture honors, respects and embraces the diverse perspective all members bring to the team. A team that cultivates a culture of curiosity, transparency and humility can help identify bias among themselves and within the health care system and work toward inclusion. Even seemingly small acts, such as allowing a nursing assistant interested in a career as a provider to shadow the provider and care team for a few days, can help increase inclusion in health care. Leveraging the collective or individual social collateral and privilege of the team and its members can go a long way to closing the gaps in diversity, equity and inclusion within health care. The care team has inherent social power as well. People, especially legislators, generally trust the experience of the care team. Capitalizing on opportunities to support legislation that improves health equity, diversity and inclusion is another tool we can use to make progress in these areas. VIVI-ANN: For providers to promote health equity through their practice,

they need to understand the complexity of the intersection of these factors and how they impact treatment outcomes. In the health care sector, race, ethnicity and religion have become an increasingly important factor in terms of patient care due to an increasingly diverse population. Effective interoperability can support not only the sharing of records between clinics, but also the resources that match the needs and preferences of the diverse population groups. This may increase understanding of how culture influences attitudes, behaviors and expectations related to health, medications, treatment regimens, health care and health care providers. Support tools for providers can offer insight to aspects of diverse cultures, such as languages, religions, spiritual practices, traditions, customs, beliefs, preferences and values. Also, support tools can assist in notification of how and when to utilize interpreter services and address confidentiality concerns. What are some examples of care team interoperability within your organization? VIVI-ANN: Fulcrum Health’s physical medicine networks address spine and

joint conditions, a common condition that 80% of us will experience in our lifetime. However, patients are not sure where to begin care. To address this problem, Fulcrum created Care Connections by Fulcrum Health, which provides coordination of the care team by use of a Fulcrum navigator

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to support patients in finding the right care at the right time. The Care Connections navigator connects the patient to a provider close to their home or work and matches the provider with the patient’s needs and preferences. This service removes the burden of self-navigation while enabling choice and customization. Fulcrum also supports team-based care with our online provider directory. This tool allows patients and providers to search for providers by profession type and location. We encourage our Fulcrum network, which consists of ChiroCare, AcuNet and TruTouch, to work as a team when appropriate to meet the patient’s needs. JENIFER D: After the 2020 passage of Modernization law, PAs are fully

licensed to care for patients autonomously within a care team. PAs can be the identified Primary Care Provider, making clinical decisions in accordance with collaborative practice agreements. In rural and urban emergency rooms, PAs perform all necessary care and treatment, but lack of resources compel them to seek consultation, admission or a higher level of care. The PA contacts the specialist, hospitalist or transferring facility without the need of physician oversight, supervision or permission. A clinical PA evaluates a patient with fatigue and exercise intolerance, noting abnormal rhythm on an office-based EKG and consults a cardiologist. This process is seamless due to the respect granted to care team members. Both examples demonstrate how care team interoperability in a clinical setting encourages individuals to function at the highest level with increased responsibility and engagement. JENNIFER L: Stratis Health has a long history of addressing health disparities

and improving health equity in Minnesota. To advance that work in today’s environment, we set out to identify and understand current priorities and strategies for addressing social determinants of health (SDOH) among Minnesota health plans and state public programs. Stratis Health sent a brief snapshot survey of SDOH priorities and strategies to nine health plans based in Minnesota, as well as to the Minnesota Department of Human Services (DHS) public programs. All nine health plans responded, as did DHS. In addition, Stratis Health reviewed the current SDOH priorities for the 28 individual Minnesota Medicaid Integrated Health Partnerships (IHPs). Based on the information gathered and reviewed, Stratis Health offered several key findings. We found that SODH is the top priority. There is a consistency of focus statewide, especially in looking at mental health issues, food insecurity and housing instability. Many intervention strategies were similar in health plans, DHS public programs and IHPs. These included hiring or utilizing community health workers and strengthening partnerships with community-based organizations. It was also important to support providers in implementing and utilizing screening tools to identify SODH risk areas and needs. What are the most important aspects of care team interoperability facing your organization? MANDY: Many of our child and adolescent patients transfer between

different levels of care within PrairieCare. From this standpoint, care team interoperability is not only important within one individual health care episode, but it is important and imperative to provide continuity of care across all programs and all touchpoints within the organization. To achieve the best patient experience and the best outcomes, interoperability is not only needed within a specific care team, but throughout care teams at different sites and different levels of care as well.

JENNIFER L: The completeness of data which reflects the context of a patient’s

life. Based on more than 80 interviews with stakeholders, our work is guided by a set of principles that reflect the most important aspects of care team interoperability. Supporting social needs is an essential element in assuring equity and reducing health disparities, so our work will be done using an equity lens. Authentic community engagement and leadership are necessary for success, guiding us toward community-led processes and solutions. The process and recommendations will be relevant statewide, inclusive of urban and rural needs, preferences and considerations. Cross-sector communication and collaboration are imperative to pave the way to action. Another element is design for the future—this is not a short-term solution and needs to be created to flexibly adapt as the environment, technology and users change, including direct use by patients or clients. Intentional power balancing processes are critical to ensure that all participants can effectively voice their needs and meaningfully influence the outcome in ways that achieve overall goals. The urgency of this effort must be carefully balanced with the time necessary for meaningful engagement and trust. VIVI-ANN: The majority of clinics in Fulcrum’s

facing care team interoperability for Minnesota PAs is for health care systems to adopt the PA Modernization Act. Marginalizing, restricting and limiting the practice capacity of team members beyond licensing and practice laws is counterproductive to care team interoperability. PAs are a trusted associates and collaborators, licensed to care for patients autonomously without direct physician involvement unless needed by patient care demands.

Supporting social needs is an essential element in assuring equity and reducing health disparities.

Is there anything else about care team interoperability that you would like to discuss? JENIFER D: We want to remind care team members

that PAs are trusted partners in the medical care of the population. PAs are educated and trained in the medical model, similar to physicians, but with an intentional clinical focus that emphasizes teambased care. PAs are held to the same standards of care, quality measures and credentialing requirements as physicians. PAs are experts at adapting to meet patient care delivery needs in any setting or specialty, and they share the goals of expanding access to highquality, safe and cost-effective care. VIVI-ANN: The vision of interoperability is exciting.

It offers the ability to put the patient at the center network are small independent clinics where the of their care, allow providers seamless ability to electronic medical records do not communicate securely access and use health information from with larger clinics and/or hospital groups. different sources and offers a longitudinal picture Although information can be shared by fax, of the patient’s health, not just episodes of care. this creates a time delay, and often information The collection of data can provide health care —Jennifer Lundblad ends up unshared due to administrative burden. to apply rapid learning and deliver cutting edge Another barrier is costs. Advanced EMRs are treatments. A number of benefits can be realized for cost-prohibitive for small clinics to obtain and exchange of health care information, including: care maintain. There is a lack of uniformity among coordination, improving administrative processes, the EMR vendors used, and it is difficult to and increased patient safety and satisfaction. migrate clinical records to competing EHR platforms. The third barrier is SARAH: Interoperability is key to patient care and all health care providers need protecting patient privacy. Securing data access and mitigating the risk of to be included: physicians, physician assistants, nursing, nurse practitioners, breaches are paramount for moving to a digital-based health care system. pharmacists, occupational therapists, physical therapists, etc. JENIFER D: Our perspective as Minnesota PAs differs from that of the health care MANDY: Care team interoperability is complex, yet critical, to effective system’s top-level management. Per the American Academy of PA’s guidelines outcomes in creating a positive patient experience. When performed well, few for state regulations, care team goals are reminiscent of Optimal Team Practice people notice. However, when interoperability is compromised or otherwise (OTP). OTP occurs when care team members work together to provide quality short-circuited, the effects can be amplified and create risk for the patient. care without burdensome administrative and clinical practice constraints. The impact of interoperability is especially important within mental health MAPA worked with legislatures to modernize PA practice statutes to reflect care, where such a large variety of staff participate in assessment, treatment the function and utilization of PAs in all aspects of health care delivery. The planning and care delivery. PA Modernization Act took effect in August 2020. The most important aspect

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PHARMACY

The Primary Care Team Pharmacist A Vital Tool to Prevent Hospital Readmissions BY SANDRA LEO, PharmD

he 21st century has brought many new challenges and opportunities to the world of health care, and they are not just due to the ongoing COVID-19 pandemic. As value-based and other alternative payment models have become more prevalent following passage of the Affordable Care Act in 2010, health systems are transitioning their focus to providing quality rather than quantity of care. Value-based programs have developed to incentivize health systems to improve quality measures and increase efficiency. As the face of reimbursement continues to evolve, so should practice in all areas of health care. Evolution of primary care practice models is no exception. One area in which health systems continue to struggle is with hospital readmissions. Hospital readmission rates are a key player in determining reimbursement rates for large health systems and are associated with significant costs both to the patient and the health system. The Hospital Readmissions Reduction Program, a key part of the Medicare value-based purchasing program, penalizes hospitals up to 3% of their Medicare reimbursements based upon readmission rates for chronic conditions such

as COPD, pneumonia and heart failure. Some of the most important and preventable contributors to hospital readmission are poor medication adherence and medication-related errors. Patients with multiple chronic conditions often have complex medication regimens, which can leave even the most medically literate patients daunted. Around 45% of Americans have more than one chronic condition, and about 20% take at least five medications on a daily basis. However, according to the World Health Organization (WHO), adherence to chronic therapy in developed countries is only around 50%. This difficulty is often compounded by the older age of this patient population and lack of health literacy. For example, say hello to Bob. Bob, who to this point had enjoyed good health, was recently discharged from the hospital following an extended ICU stay. He was diagnosed for the first time with Type II diabetes. When he was discharged, Bob was given prescriptions for both long-acting and short-acting insulin pens (as well as new prescriptions for a beta blocker and an ACE inhibitor); he was not given any oral antihyperglycemic medications. He had never used any injectable medications, had no idea how to use them and was given no education regarding them. He faces a difficult time adjusting to a new phase of his life, including a level of self-care that he’s never had to face before. Following his hospital discharge, rather than starting to use these new insulin pens, he goes without any medication treatment for his diabetes because he does not want to risk using his insulin pens incorrectly.

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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.

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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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During hospital stays, medications for chronic and other conditions are often changed, discontinued or added, leading to medication discrepancies (differences between what medications the patient takes after they are discharged and what their care team intends them to take), further intensifying the risk for readmission. Following hospital discharge, patients with medication discrepancies are twice as likely to be readmitted to the hospital within 30 days. A systemic review of nine studies published in 2018 found that rates of medication-related readmissions ranged from 3-64%, with a median value of 21%. This study further found that approximately 69% of these readmissions were avoidable if these medication discrepancies had been resolved. Transitions of care present a difficult and challenging time for the patient and the health system, but also a substantial opportunity to improve patient care and reduce readmission rates through changes in the primary care treatment model. In 2017, WHO targeted transitions of care (along with polypharmacy and high risk medications) as one of the three key action areas where interventions are needed to reduce medicationrelated harm. When moving from the acute setting to the community setting, communication and medication management can play a vital role in keeping our patients from readmission and may have a vast impact on reimbursement rates within our health systems.

Enter the pharmacist The role of the pharmacist has vastly changed in recent years. No longer limited to the dispensing of medication, the incorporation of pharmacists

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into clinical practice has greatly increased as team-based care has become the standard of practice. Nowhere has this been more evident than in clinical hospital practice, as pharmacists have taken lead roles in antibiotic stewardship, medication reconciliation and medication use evaluation. Multiple studies have shown that medication reconciliation performed by hospital-based pharmacists reduces hospital readmissions, with one major meta-analysis demonstrating a 19% reduction in all-cause readmissions.

studied the effects of pharmacist involvement on multidisciplinary teams, both in the acute and primary care setting, on the probability of hospital readmission. Compared to usual care, the utilization of multidisciplinary care teams that included pharmacists resulted in a 32% lower risk of hospital readmission.

With more clinical pharmacist incorporation into primary care, more information regarding their role and potential benefit has emerged. One metaanalysis published this year, which included 14 randomized control trials,

them, he connects with the ambulatory care pharmacist on the clinic team, who educates him regarding how to use his new insulin pens, discusses what his other new medications are used for and updates his medication list within his electronic medical record. In addition, that pharmacist meets with his primary care provider and discusses potential oral treatment options that may allow Bob to avoid needing injectable insulins. Any medications we use to treat patients only work as well as we are able to get patients to use them; in Bob’s case, he leaves feeling more confident he is able to understand how to use his medications and more capable of using them; his blood sugar is more well controlled as a result. Incorporation of a pharmacist CMM visit when a patient visits for a post-hospital discharge visit can help to dissolve these medication discrepancies, and in Bob’s case, may have helped to keep Bob out of the hospital again.

Another recent meta-analysis published in 2021 shows that pharmacist intervention in post-discharge care can reduce 30-day hospital readmission rates by 22% and decrease overall readmission rates by 13%. All of the studies Important and preventable included in the trial involved intervention As team-based care continues to evolve, contributors to hospital readmission by a pharmacist after hospital discharge and utilization of pharmacists has become increasingly are poor medication adherence. included communication that occurred between vital in primary care as well. With the advent of the pharmacist and the patient’s primary ambulatory care programs, such as medication care provider. Subgroup analyses within this therapy management (MTM), comprehensive study further demonstrated that the effects of medication management (CMM) and primary care pharmacist intervention were more effective when medical home (PCMH) over the past twenty years, the pharmacist was more actively involved, such as during a comprehensive prevalence of pharmacists on the primary care team has grown greatly. MTM medication review, and when the pharmacist was more actively involved services specifically have not only been associated with improved clinical with the care team through direct communication, (such as a face-to-face indicators, such as lowering blood pressure, lowering LDL, increasing rates care discussion, as opposed to more indirect means, such as fax or email). of smoking cessation and lowering HgA1cs, but also with increasing patient adherence and quality of life. It has also shown significant financial benefits, Let’s return to Bob. Bob has his follow-up appointment with his primary with a return on investment (ROI) of $1.29 per $1 spent on MTM services. care provider a week following his hospital discharge. Before he meets with

Moving forward

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So why is pharmacist involvement on the primary care team still a problem in some settings? One study from Australia may hold the answer. Although the study acknowledged that, within primary care settings, pharmacists are respected for their clinical insight and well-accepted into clinical practice by physicians, nurses and patients, this meta-analysis identified multiple barriers cited by key stakeholders on the primary care team. The most consistently recognized barrier in this study was lack of funding. However, as payment models become increasingly more value-based, the value of a pharmacist in primary care likely far exceeds their cost. While some studies have shown that MTM services are associated with cost savings, further studies about their economic impact in light of value-based care have become increasingly important and should be prioritized to continue improvement. Pharmacists themselves identified another vital barrier—the absence of training programs for clinical pharmacists. Expanding pharmacy residency programs in ambulatory care also plays a role in developing the ambulatory The Primary Care Team Pharmacist to page 304

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3The Primary Care Team Pharmacist from page 28 medical home initiatives is the collaborative aspect of treatment decision care team and should be prioritized. Other barriers were identified as well, making. Along with pharmacists, health professionals, such as nurses and including lack of role clarity, lack of clinic space, overburden on the patient’s social workers, may provide valuable insight into how to achieve the most time and medical culture among staff. Education effective care. Just like performing rounds on a of our clinical staff may be important for MTM hospital unit, collaborative discussions in clinic as well. Multiple articles mentioned in this can help determine the treatment paths most likely Australian review suggest that unawareness on the for patients to adhere to. part of medical staff played a role in pharmacist As reimbursement models in health care Utilization of pharmacists underutilization. continue to evolve, so must primary care practice has become increasingly How do we build a better care team that models. The COVID-19 pandemic has presented vital in primary care. uses pharmacists to their full extent? First, unique challenges and heightened the urgency by allow pharmacists to work at the top of their which practitioners must integrate these new models license. MTM visits are a perfect opportunity for into primary care to achieve the highest ideals of value-based care. As our health systems continue to optimization of medication therapy for chronic be taxed by high levels of hospital admissions and conditions when pharmacists are allowed to face potential shortages of health care staff in the face of the current pandemic, operate under a protocol with a provider. Similarly, pharmacists can be primary care teams can play an important role in optimization of health care highly involved in the management and billing of services related to drug delivery. Pharmacists stand in a unique position to increase positive clinical therapy management for specific conditions, including anticoagulation, outcomes and reduce provider burden, as well as add financial incentives to the immunizations, osteoporosis and smoking cessation. Second, we can clearly health system. We just need to give them the opportunity. identify and delineate roles for pharmacists and educate our clinic staff regarding what this entails. As demonstrated in the Australian study, most clinic staff are not aware of what pharmacists can do. And lastly, we can include pharmacists in the discussions regarding the direction of treatment for individual patients. One of the most advantageous aspects of primary

Sandra Leo, PharmD works in the Mille Lacs Health System as part of the University of Minnesota Post Graduate Pharmacy Residency Program. Prior to this, she worked as a research scientist in the area of Cytogenetics.

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DECEMBER 2021 MINNESOTA PHYSICIAN

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Sofia Lyford-Pike, MD

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