Minnesota Physician December 2022

PHYSICIAN

JAK Inhibitors

A promising new drug class

BY CHARLES E. CRUTCHFIELD III, MD AND PALLAVI KANNAN, MS

JAK inhibitors have been approved by the FDA for just over a decade. However, even when patients are likely to benefit from this dramatic scientific advance, physicians often find themselves debating whether to treat patients with a medication that received FDA approval only in recent years or to continue using traditional treatments despite less efficacy.

Consolidation in Health Care

Post pandemic economics

BY DANIEL K. ZISMER, PhD

Health care trade publications are reporting that U.S. hospital-centric health systems are in for another phase of consolidation and changes in ownership control. Why? Crashing financial performance for many are driving credit rating down drafts. Threats of receivership, out-right closures, and “shotgun weddings”; i.e., forced mergers and acquisitions have returned. Additionally, a few are reporting “full beds” with negative operating financial performance. Stop and think about any other industry that is producing and selling at capacity as it’s losing money.

Two key questions loom large here. First, is this phase of health system consolidation different from all those that came before? Second, are independent physician groups

If you’ve graduated from medical or nursing school, this paragraph should make complete sense to you and might even mimic medical encounters you’ve witnessed at some point in your careers. Unfortunately, if you’re a patient, these brief sentences are full of enough medical jargon to be rendered completely nonsensical. When patients don’t understand their plans of care, they are not truly being included in shared medical decision-making.

As research continues, the JAK protein family has grown and there are now four main family members. Greater understanding of how they

Consolidation in Health Care Post pandemic economics

By Daniel K. Zismer, PhD

DEPARTMENTS

JAK Inhibitors A promising new drug class

By Charles E. Crutchfield III, MD and Pallavi Kannan, MS

INTERVIEW 8

Improving the Health of Older Adults

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.

THE HEALTH CARE WORKFORCE SHORTAGE: Facing a crisis

BACKGROUND AND FOCUS:

Prior to the pandemic, it was widely recognized there were serious workforce shortage issues facing health care delivery. Those concerns are now much worse. From physicians, to nurses, to behavioral health, to public health, to assisted living and long term care, every kind of licensed health care professional faces demand that far outstrips supply. This problem is trending steeply upward and can only manifest in serious negative outcomes. Lack of access creates higher cost, preventable increases in morbidity and mortality and systemic burnout.

OBJECTIVES:

Our expert panel will examine the root causes of the health care workforce shortage. From industry entrance barriers, to workplace dysfunction, to career satisfaction we will present examples and potential solutions. We will dissect the complex interactions between elements of health care governance and explore how industry sectors can work together more closely to solve shared problems. We will explore the numerous initiatives already underway to address these issues and share suggestions for how best to address them.

JOIN THE DISCUSSION

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

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

Kari Benson, MPA Executive Director of Minnesota Board on Aging

MN Medical Cannabis Program Expands

Qualifying Condition List

The Minnesota Department of Health (MDH) will add irritable bowel syndrome (IBS) and obsessive-compulsive disorder (OCD) to the list of qualifying medical conditions for participation in Minnesota’s medical cannabis program. Under state law, the new qualifying conditions will take effect Aug. 1, 2023. “We are adding the new qualifying conditions to allow patients more therapy options for conditions that can be debilitating,” said Minnesota Commissioner of Health Jan Malcolm. IBS is a disorder characterized by abdominal pain or discomfort, and irregular bowel movements that can result in diarrhea, constipation, both diarrhea and constipation, or bloating. OCD is characterized by recurring, intrusive thoughts that often cause significant emotional distress and anx-

affected person feels compelled to perform to reduce that distress. Research has shown that people who suffer from these conditions can see benefits from using medical cannabis to treat their symptoms. As in past years, MDH conducted a formal petition process to solicit public input on potential qualifying medical conditions and delivery methods for medical cannabis. Minnesotans submitted petitions in June and July. Following that, the process moved into a public comment period and a review panel. No petitions for new delivery methods were submitted this year. Petitions for gastroparesis and opioid use disorder were not approved. Gastroparesis, or delayed gastric emptying, was not approved as a qualifying medical because research indicates that cannabis can make the condition worse. As for opioid use disorder, MDH heard from medical and mental health providers who recommended against approving opioid use disorder

to lack of evidence for its effectiveness and the availability of FDA-approved medications for treatment. As with other qualifying conditions, patients need advance certification from a participating Minnesota health care provider. When the Minnesota Legislature authorized the creation of the state’s medical cannabis program, the law included nine conditions that qualified a patient to receive medical cannabis. With the new additions, the list of qualifying conditions will be 19. Under state rules, the commissioner of health each year considers whether to add qualifying conditions and delivery methods. For a list of qualifying medical conditions, go to Medical Cannabis Qualifying Medical Conditions.

Minneapolis Executive Order Provides Safe Haven for Gender Affirming Health Care

recently issued an executive order to ensure transgender and gender-diverse youth will continue to have access to life-saving health care. Executive Order 2022-04 prohibits all City departments and City staff from taking any enforcement action against providers or individuals exercising their right to gender-affirming health care in Minneapolis. It also affirms the rights of minors living apart from their parents to make their own medical decision regarding gender-affirming care, in accordance with Minnesota law. Angela Kade Goepferd, MD, chief education officer and medical director of the Gender Health program at Children’s Minnesota, was among those at the order signing. She commented on the importance of transgender and gender-diverse youth having access to gender-affirming care. “When transgender and gender diverse kids are seen, heard and believed, they

be who they are, we know they can grow up to be happy, healthy, safe and strong. However, too often when I’m in our Gender Health Clinic, I hear from our patients, the kids and young adults of our community, that they’re experiencing harassment and discrimination based on their gender identities and expressions.” Children’s Minnesota, and other pediatric hospitals nationwide, have experienced threats and harassment for providing health care to children and teenagers in their gender health programs. Some of the states bordering Minnesota have proposed bills restricting or criminalizing access to gender-affirming healthcare, and passed other legislation limiting the rights of trans youth. These bills could expand laws that purport to impose criminal punishment, civil liability, administrative penalties, or professional sanctions, on health care professionals who provide gender-affirming healthcare and on persons who seek, receive, or assist another in receiving gender-affirming healthcare. Under the new Executive Order “Gender-affirming healthcare” means all services, supplies, drug therapies, and other care that an individual may receive to support and affirm the individual’s gender identity, that are legal under the laws of the State of Minnesota as of the date of this Executive Order or any time thereafter. Gender-affirming healthcare has been proven to be evidence-based, medically necessary, and lifesaving by the American Medical Association, the American Academy of Child and Adolescent Psychiatry, the American Academy of Pediatricians, the Endocrine Society, the American Psychiatric Association, and the World Professional Association for Transgender Health, amongst other institutions.

DHS Declines Multimillions in Federal Mental Health Funding

The Minnesota Department of Human Sevices (DHS) made a

unilateral decision to withdraw, effective 12/31/22, from a federal program that could provide up to $30 million annually to support statewide mental health services. When asked for its rationale, DHS would not answer or offer any memos, documentation, cost benefit analysis or data they used in making this decision. Mental and chemical health care providers are deeply concerned the decision to end Minnesota’s involvement in the innovative Certified Community Behavioral Health Clinic (CCBHC) National Demonstration which has provided coordinated and accessible care to thousands of Minnesotans and increased access across the state. Minnesota was selected as one of the nation’s original eight CCBHC Demonstration states. Most recently, in the passage of the Bipartisan Safer Communities Act, Congress offered all states the opportunity to participate and extended funding through

JOIN MINNESOTA’S MEDICAL CANNABIS PROGRAM!

Approved health care practitioners can certify patients for Minnesota’s Medical Cannabis Program, which provides a treatment option for people who are facing debilitating medical conditions.

For more information on how to enroll, qualifying medical conditions, and more, visit mn.gov/medicalcannabis.

O ce of Medical Cannabis 651-201-5598 1-844-879-3381 (toll-free) health.cannabis@state.mn.us

ance on Mental Illness) expressed her

frustration with the DHS’ decision. “At a time when so many Minnesotans are struggling with their mental health it simply doesn’t make sense to end a program that has actually increased access to treatment and provided holistic care to children and adults with mental illnesses. DHS is making decisions that impact the mental health community unilaterally without engaging the mental health community.”

Walz Appoints New Commissioner of Health

In filling six cabinet positions before the Christmas break; Governor Walz announced that Brooke Cunningham, MD, PhD, would succeed retiring Commissioner Jan Malcom in the vital role of leading the Minnesota Department of Health. Dr. Cunningham was appointed assistant commissioner for the Health Equity Bureau in

2022. As assistant commissioner, she was responsible for overseeing the Center for Health Equity, the Office of American Indian Health, the COVID-19 Health Equity Team, and Diversity, Equity, and Inclusion. As a general internist, a sociologist, and an assistant professor in the University of Minnesota Department of Family Medicine and Community Health she brings a wealth of experience and resources to the position. Dr. Cunningham uses mixed methods to examine factors at both the provider and organizational levels that impede or facilitate efforts to address health equity, including how health care workers make sense of race and frame the causes of and solutions to racial disparities in health and health care. She teaches a course on race to first-year medical students and has been invited to speak to students and faculty from other medical schools about race and medicine.

Dr. Cunningham practiced internal medicine at the Community-University Health Care Clinic (CUHCC), a federally-qualified health clinic in Minneapolis that serves a diverse patient population, most of whom live in poverty. She also co-directed the University of Minnesota Medical School’s Diversity, Equity, and Inclusion Thread in medical education. In 2021, she was selected as one of four inaugural recipients of the University of Minnesota’s Justice, Equity, Diversity, and Inclusion (JEDI) Award. She received degrees in history and African-American studies at the University of Virginia; received her doctorates in medicine and sociology from the University of Pennsylvania; trained in internal medicine at Duke University Medical Center; and completed postdoctoral fellowships at the Johns Hopkins University School of Medicine and the Medica Research Institute (Academy Health).

BC/BS MN and MN Oncology Announce Value-based Improvements

Blue Cross and Blue Shield of Minnesota (BC/BSMN) and Minnesota Oncology, a practice in The US Oncology Network, recently announced preliminary cost and quality results stemming from a value-based contract that went into effect in the fall of 2019. The agreement shifted payment from a traditional model that incentivized volume of transactional care to a value-based approach built on the shared principle that the most effective outcomes for patients are determined by a holistic approach that includes quality, cost, trend, and patient experience. Based on an analysis of the first results of available data, the total cost of care for Minnesota Oncology patients with Blue Cross employer group coverage trended more than 10 percent below

the Twin Cities oncology market. The two organizations also cited the efficacy of programs built collaboratively within the agreement, ensuring that patients would receive the most effective and efficient care at the right time for their specific health situation. A critical aspect of the five-year agreement was the creation of new care coordination initiatives designed to avoid unnecessary trips to the hospital or emergency room, help patients manage side effects of treatment, and have a proactive and defined role in their care plans. The care coordinators stayed connected with patients throughout treatment with support throughout their cancer journey. “Cancer patients face a big challenge when it comes to the cost of quality, comprehensive care,” said John Schwerkoske, MD, president and medical oncologist at Minnesota Oncology. “Under this agreement with Blue Cross, we now have encouraging evidence that our model works. It is possible to offer state-ofthe-art therapies, precision medicine, genetic testing, palliative care, and access to clinical trials while lowering overall costs.” “The early successes of this agreement, along with the collaborative spirit of both organizations, is continuing to grow with a desire to evolve and further improve the model,” said Eric Hoag, vice president of provider relations at Blue Cross and Blue Shield of Minnesota. “We are pleased to be adding three new quality measures in 2023 which include social determinants.”

U of M School of Nursing and Mayo Announce New Partnership

The University of Minnesota School of Nursing and Mayo Clinic’s Department of Nursing have recently formed a collaboration to facilitate their academic-practice partnership to generate, disseminate and apply knowledge for the improvement of nursing practice, education and health outcomes. The partnership

will engage nursing faculty, nursing staff and nursing students in the development of strategies to enhance nursing education, research and practice. Initially, the partnership will center on fostering innovative undergraduate, graduate and postgraduate education degree opportunities and experiences at Mayo Clinic and advancing nursing knowledge to improve and support the health of individuals and their families through research and evidence-based practice. The partnership also will address nursing workforce needs to support a smooth transition of graduates into practice.”The School of Nursing’s physical presence in Rochester and its history of partnering with Mayo Clinic and the University of Minnesota Rochester create a unique opportunity to foster innovation,” says Connie White Delaney, PhD, dean of the School of Nursing. “Establishing a nursing collaboration formalizes our longtime relationship and offers a framework for us to further advance nursing and nursing education.” “Mayo Clinic nurses are known for their exceptional knowledge, trusted expertise and innovative patient care,” says Ryannon Frederick, chief nursing officer, Mayo Clinic. “This collaboration will help us accelerate improvements in nursing practice, education and research to benefit patients everywhere.”The collaboration will build on the partnership that University of Minnesota School of Nursing and Mayo Clinic’s Department of Nursing have had since the school first began educating Bachelor of Science in Nursing students in Rochester in 2002. All School of Nursing students in Rochester complete their clinical education at Mayo Clinic and learn from clinical instructors and preceptors who are Mayo nurses. In 2020, the School of Nursing and Mayo Clinic collaborated to provide a first-of-itskind clinical learning experience by creating a dedicated education unit in an ambulatory care setting

FRI FEB 3 8PM

SAT FEB 4 8PM

Carlos Miguel Prieto, conductor Gabriela Montero, piano DVOŘÁK’S NEW WORLD SYMPHONY

THU FEB 16 11AM

FRI FEB 17 8PM

Kazuki Yamada, conductor Alexandre Kantorow, piano

THU FEB 23 11AM

FRI FEB 24 8PM

SAT FEB 25 8PM

Dalia Stasevska, conductor Erin Keefe, violin

FRI MAR 3 8PM

SAT MAR 4 8PM

Dima Slobodeniouk, conductor Kari Kriikku, clarinet

Improving the Health of Older Adults

Kari Benson, MPA Executive Director of Minnesota Board on Aging

The mission of the Minnesota Board on Aging (MBA) is reported as ensuring that all Minnesotans can age well and live well. Would you please explain what this means?

For MBA, this means assisting older adults as they need help around the house, or they need help with personal care. We are here to connect Minnesotans to services that help them live where and how they want to live—and to help them stay independent, healthy and keep living their lives. And the concept of “all Minnesotans” really means assisting all Minnesotans from every corner of the state and from every community as we’re getting older.

Most people are not aware of how large the MBA is. Would you please give us a brief overview of the different divisions and initiatives?

MBA is made up of 25 members appointed by the governor to represent all areas of the state, and we really serve in three key roles—administrator, advocate and advisor. So for example, MBA administers over $50 million each year for caregiving services for older adults, their families and friends. The board has two direct service programs, one is the Senior LinkAge Line, a free, statewide service that focuses on helping older persons remain in their homes and communities, providing accurate information on Medicare, caregiver support and any other issues facing older adults. The other is the Office of Ombudsman for Long-Term Care which works to enhance the quality of life and services for people receiving long-term services and supports.

Some of your work follows federal initiatives and some is unique to Minnesota. What can you tell us about how funding and direction works around this?

One of the most important characteristics about the work that we do is that we’re part of a national aging services network. MBA administers federal funding from the Centers for Medicare and Medicaid Services, the Administration for Community Living and state-funded aging programs. Federal funding we receive is the same

in every state, so there are some commonalities, and there are services and resources that we all need as we age, so we really benefit from being part of that national network. While we are connected that way, there’s flexibility for each state to use the dollars and implement the funding in ways that are most beneficial to each state and its unique needs.

What can you share with us about your legislative work and priorities?

One MBA priority heading into the next session is to ask the legislature to convene a task force on aging. We’re seeking to have an exploration process to determine the best structure at the state to raise visibility that our population is aging. And we want to prepare so we have the capacity and authority to plan for that structuring—to work across state government. Essentially, we’re seeking authorization from the legislature to address that more needs to be done as a state.

And MBA really wants the legislature—and all of our other partners in the state—to really take a look at that. That way, MBA and our partners are not advocating for bits and pieces here and there, and we’re not competing with each other. We’re moving toward a much more collaborative process, which is exciting and we’re making such

good progress on that effort! Ultimately, we hope that this “AGEnda Collaborative” will help us be clearer for the legislature and possibly have more of an impact addressing the needs of what older Minnesotans need now and in the future.

What can you share with us about the MBA public policy work?

So much of MBA’s policy work is tied to the state legislature, but the Board does also advocate for policy changes needed at the federal level as needed for national issues important to older adults, for example, elder rights issues. We’ve benefited greatly from our Congressional delegation support in pushing forward elder support at the federal level.

Health care work force shortage issues are beyond the crisis point. What are some ways MBA is dealing with this?

MBA agrees it is a crisis and we’re concerned about both the health care workforce and the longterm care workforce shortage—including those who provide personal care assistance and those who provide long-term services and supports to older adults. MBA is active in two key ways: we deliver services to support family, friends and loved ones who are caregiving—those who are not getting paid for their services. And if you’re the primary caregiver, you often need a break or help and finding that help is a key role for MBA. The second priority for MBA in this area is to advocate for better pay for long-term services and support workers--especially those serving older adults. We are concerned about a lack of workers across the board in health care, and we’re troubled by the lack of training for those serving older adults in geriatrics, particularly those older adults with dementia. And with an evergrowing older adult population, there are more older Minnesotans struggling with dementia and we need to do more with our capacity as a state to serve those older adults.

What can you tell us about the Age-Friendly Minnesota Council?

The council was first established by Governor Tim Walz in 2019-2020 by executive order. In the

We need to actively combat ageism. “...”

most recent legislative session, lawmakers authorized funding for the Council for the next two years. So it’s in place now and it is made up of representatives from multiple state agencies, as well as community partners, and the goal is to develop a master plan on aging for the state and develop a work plan that makes Minnesota an age-friendly state. The World Health Organization and the American Association for Retired People have partnered to set up a framework that we are using as a guide that helps MBA determine what else we need

What are the seven area agencies on aging and how does MBA interact with them?

MBA is designated by the federal government to administer funds for the Older Americans Act, so we’re the state unit on aging for Minnesota. Part of our responsibility is designating the Area Agencies on Aging regions for the state. We designate the entities and allocate funds to them for delivery of services to older adults and family caregivers. Area agencies in Duluth, Sartell, Warren, Cass Lake, Mankato, Rochester and Arden Hills play a key role in administering the Senior LinkAge line—and six of the seven agencies have call centers that make up the LinkAge Line,

and MBA manages that infrastructure. The big thing for physicians to know is that our partners are very willing and ready to help them assist older clients navigate care transitions. So, for example, if an older adult is in the hospital and is going to be discharged, Senior LinkAge can help with that process and follow-up. For more on that, I would direct readers to Minnesotahelp.info.

What are some of the initiatives you have undertaken to assure equity in your services?

MBA has a Diversity, Equity, Inclusion and Access Strategic Directive in place and that’s been used to guide efforts in addressing and advancing equity for all older adults. One of the biggest ways MBA implements this is to contract with providers in cultural and ethnic communities and tribal nations to provide culturally appropriate service for elders, so communities get the services that make the most sense for them and their families. That has been a big priority of ours and we’ve made significant progress in that area. Of course there’s still much to be done, and we are going to continue to work toward giving often underserved people and communities the resources and support they need. Also, we’re trying to make our services accessible to individuals, so we’ve got Senior LinkAge materials

available in various languages. We’re working to put native-language-speaking staff in place across multiple communities, especially in the Twin Cities metro area, so they can conduct outreach in their communities and help people navigate through sometimes complicated processes, particularly Medicare.

How can your work help physicians deliver better outcomes to their senior patients?

To expand a bit on what I mentioned earlier, the Senior LinkAge Line provides many opportunities for partnerships or closer working relationships with physicians to help older adults find services they need. So when a physician sees that an older patient needs help with care, they can encourage that patient to take advantage of the service. MBA thinks it could be helpful for physicians to write prescriptions for older adults directing them to take advantage of MBA’s range of classes promoting health, exercise, chronic disease management, fall prevention and mental health wellness. And I recommend that, because people are often reluctant to take the classes,

the Health of Older Adults to page 304

Improving

necessarily swept along in the macro-economic tides that are dragging down the financial performance of growing numbers of community and academic health systems?

Looking at the first question, is the financial performance swoon simply a repeat of bygone market cycles or is it something different? Clearly, SARS CoV-2 and the COVID pandemic, caught many health systems ill-prepared to care for so many so quickly, fighting the unknown as best they could with what they had. Resources got stretched and strained. Performing more profitable elective procedures was put on hold, and health systems had to do what they could with the economics and financial effects handed to them, all to be sorted out later when the flood drained.

As health systems emerged from the pandemic, they ran full face into galloping inflation and supply chain pressures. Spiking inflation rates provided labor unions the fuel for hammer and tong negotiations yielding unprecedented wage and benefits increases, which would not be matched by increases from third-party payers. Income statements and balance sheets became pressured and will be for years to come.

Then enter the more recent triple threat, COVID /flu/RSV. Again, beds fill, reimbursement rates are uncertain and profitable, elective clinical strategies are once again put on hold. The lessons learned are community health systems are constrained and hobbled by relatively fixed capital structures, inflexible mission commitment and high fixed cost operating expense structures. Moreover, many are overly dependent upon

the loyalties of private, independent physicians who aren’t necessarily dependent upon community health systems or academic medical centers for their existence.

So, is the current state of economic and financial performance affairs for hospital-centric health systems the same as with past “down cycles”? The answer is yes and no. “Yes”; it is difficult when market dynamics and macro-economic shifts challenge health systems’ clinical programming and business model assumptions regarding how the world around them should work, but doesn’t. “No” community health systems could not have expected the totality of what a pandemic and the aftermath could throw at them. Those that did survive more than likely have fortress balance sheets and leadership with the permission of governance to pivot on a dime when economic market conditions require.

Independent Physician Groups

Now, on to whether independent physician groups are necessarily to be swept along in the same maelstrom of macro-economic issues as their community hospital and academic health systems counter parts. The answer is “it depends”. While it is true that independent medical groups are subject to some of the same macro-economic and market pressures as community health systems, such as downward pressures on price, utilization and total costs of care, as well as upward pressures on operating expense inflation trends and related credit risks, independent medical groups have fewer constraints on their abilities to act and react as market dynamics shift negatively under the struts that support their business models.

Clinical and business models for independent medical group practices differ from those of most hospital-centric health system models. The greater proportion of community-based health systems operate from not-for-profit, tax exempt corporate structures and are governed by community-based lay boards. Mission directions, and related strategies, are directed by these boards. Mission strategies can be directed, and mis-directed, to a wideranging scope of activities that consume financial resources beyond a business model’s ability keep up, such as ambitious financial commitments to serving the indigent, taking on responsibility for the health status of communities served and delivering on—and maintaining—multiple clinical service lines and programs regardless of their financial performance. Likewise, many are committed to serve all regardless of third party coverage plans, i.e., regardless of what the governmental and commercial payers agree to pay.

Academic medical centers carry the financial burdens of teaching and research, as well as the need to supply complex medical and surgical care to patients whose third party coverage may leave these institutions holding the bag for high levels of uncompensated care.

Independent medical and surgical-focused group practices have mission commitments as well. However, governance is typically controlled by the owners of the practice. They are personally at risk for the financial decisions made, as well as the business model’s abilities to perform financially. These operating medical services entities are not tax-exempt, nor are they eligible for lower rate debt financing nor special grant and research funding. Consequently, non-funded mission strategies need to be affordable, over and above meeting the compensation expectations of the providers who own the practice.

Leveraging the Value of Business Consolidation

of community-based health systems are not, in fact controlled locally. It is more the case, these days, that they are a member

a larger system, including multi-state systems. Much of the consolidation of these systems has been driven during times of financial challenge, serial mergers of financially-challenged, smaller health systems into a larger system are not stemming from macro-economic dynamics, or state and federal driven health policy shifts.

Corporate consolidations for the purpose of “getting bigger” don’t always payoff. During challenging times, even the largest health systems are usually forced to ration capital and jettison unprofitable clinical services. With consolidations, health system boards are no longer in control of mission strategies or clinical care programming. Physician services strategies are also controlled from the headquarters. Few large scale health system consolidation strategies are ever as fruitful as advertised. The reasons are not as complex as one might be led to believe.

Acquiring companies in most industries look for “accretive transactions”; those that will be financially productive based upon changes in operations that benefit the acquirer. Consequently, history demonstrates that with each successive merger of a financially troubled health system by one larger, the financial effects are often dilutive, nor accretive. The acquirer typically is never fully aware of the risks not evident in the financial statements of each merger transaction, those such as years of under-investing by the

acquired, competitive market risks, payer contracting risk, risks inherent in the potential reactions of the affiliated medical staff and achieving proposed or promised operating economies that almost never work out as planned. The reason is reducing localized costs generally requires staff reductions, and the consolidation of “back-office functions” with the corporate headquarters. Few members of local community health system governing boards that authorize their organization to “merge”, want to be responsible for the aftermath that comes with layoffs in their home town communities.

Independent medical groups, on the other hand, can be much more strategic and focused with consolidation strategies Such transactions are typically focused locally or even regionally. They can be like-to-like specialty focused or they may be multi-specialty by design. The integrating structures are operated more like partnerships than “take-overs”, and physicians are more likely to treat new partners as peers rather than as adversaries in a “take-over” transaction.

With most medical group integrations, size, scope and scale leverage opportunities can be baked into the plan at the front-end. The more typical consolidation strategies address keeping patient referrals “in

Consolidation in Health Care to page 124

Think about any other industry that is producing and selling at capacity as it’s losing money.

house,” thereby minimizing the need to send patients out for necessary and profitable medical and procedural care. This achieves the required size, scope and scale to create the economics sufficient to add and control profitable ancillary services, such as imaging centers, ambulatory surgery centers, infusion therapy centers, rehabilitation services, as well as the sale of complementary retail products, for example, eye wear, pharmacy services and durable medical equipment. Other opportunities include joint payer contracting, consolidation of “back office” support services, creating an affordable shared electronic medical record and creating size, scope and scale of services sufficient to afford expansive satellite site placements.

Sufficiently-sized new facilities expansion projects attract well capitalized and experienced private medical facilities development and management firms. These firms partner with medical groups to co-design, co-capitalize, and co-manage “bespoke” specialty medical facilities—facilities designed and developed to specifically facilitate a strategy of aligned physician group partners. The larger, well-established medical facilities development firms will also manage the developed properties, the co-investment structures for the physicians partner, and will provide financial liquidity opportunities for physicians that retire out

of the real estate partnership; i.e., the facilities partner will “cash out” the individual physician facilities partners who wish to retire and walk away.

Accessing Capital

Not-for-profit community hospitals, whether free-standing, or as members of larger, dispersed systems of care, typically access capital through the tax-exempt debt financing markets. Essentially, the tax-exempt debt markets are public markets. The majority of debt financings for community health systems are accessed through these markets. Tax-exempt debt is traded in public markets, much like the stock market. It is a highly regulated sector of the financial securities industry. Consequently, applications of tax-exempt debt to community health systems are highly regulated, tightly controlled and publicly reported. Community health systems with this type of debt fall under routine performance and reporting requirements. Stringent debt covenants can apply, meaning when community health system financial performance falls below covenant standards (bond ratings), the borrower’s credit rating can be lowered sending a “flashing” signal to bond holders; e.g., “dump the bonds”. The borrower operating under such conditions can be put “on watch” for long periods of time. When the credit ratings are lowered

Consolidation in Health Care to page 284

Corporate consolidations for the purpose of “getting bigger” don’t always payoff.

Elevate everyday the

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

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

work and can be manipulated has led to 8 different pharmaceuticals FDAapproved for their dermatological applications, with strong potential for more, including the ability to treat certain cancers.

Current Status

Presently, the numerous products available have proven especially successful in treating several common chronic conditions, many which relate to dermatological, inflammatory, and autoimmune conditions, such as rheumatoid arthritis, psoriatic arthritis, alopecia, atopic dermatitis, and plaque psoriasis. FDA-approved products come from a wide range of pharmaceutical manufacturers including, Pfizer, Eli Lilly, Bristol Meyers Squib, AbbVie, and many others.

Beyond improved outcomes for many fairly common conditions, many patients have found that JAK inhibitors can reduce the number of medications they had been taking while achieving superior outcomes. Examples of some conditions that responded to this new class of drugs with improved outcomes, and how they have most commonly been treated include:

• Atopic Dermatitis: conventionally treated using topical corticosteroids (e.g., clobetasol, hydrocortisone, triamcinolone), phototherapy, hydrotherapy, topical non-steroidal medications

(e.g., pimecrolimus, tacrolimus), calcipotriene and Dupixent® (dupilumab delivered via injection)

• Alopecia: often treated using topical corticosteroids, phototherapy, minoxidil (topical, oral), oral immunomodulators (e.g., methotrexate, cyclosporine), and 5-alphareductase inhibitors (e.g., finasteride, dutasteride)

• Psoriasis: commonly treated with topical corticosteroids (e.g., clobetasol, triamcinolone, betamethasone), topical non-steroidal medications, phototherapy, coal tar, and oral immunomodulators

Another benefit to patients is that JAK inhibitors can be taken orally, and in the case of Opzelura (ruxolitinib), applied topically. In some cases of extreme Rheumatoid Arthritis, treatment involves injections, which some patients do not tolerate well. It is never desirable when a patient has to wonder which is worse—the disease or the treatment.

All in this new class of drugs come with the usual extensive list of Black Box warnings. When they were first introduced, there were some initial negative reactions which might be the most salient features some patients or physicians recall about the medications. Ten years later, they have proven to be very safe, but it is always important to review the warnings with the patient before prescribing. Even if the patient has no specific concerns or worries a review of the warnings is always helpful.

FOR ALL STAGES OF LIFE

Low- and high-risk obstetrics, including advanced maternal age. Certified nurse midwifery.

Gynecologic care, including well-woman screenings and in-office procedures

Gynecologic surgeries, including minimally invasive surgeries and robotics for conditions such as endometriosis and pelvic organ prolapse

Menopause Clinic, including management of peri-menopause

Center for Urinary and Pelvic Health, including urodynamics. Nutrition and wellness consultations.

Infertility evaluation and treatment.

Patients have found that JAK inhibitors can reduce the number of medications they had been taking.

Contraindications

As with any medication there some conditions that preclude use and JAK inhibitors are no exception. Some conditions that are important to check for before prescribing include:

Pregnancy: JAK inhibitors are contraindicated in pregnancy. Female patients of child-bearing potential should be tested for pregnancy. Patients should also be provided contraception counseling and be informed that contraception will need to be used for a duration even after discontinuing the medication.

Lactation: Breastfeeding is not advisable during treatment and in the posttreatment wash-out period.

Serious infections, active tuberculosis, viral hepatitis, and herpes virus: JAK inhibitors are contraindicated in patients with active tuberculosis and active viral infections. Patients should be evaluated (and treated for) latent and active tuberculosis (TB), viral hepatitis, and herpes virus infections prior to initiating therapy. Patients should also be routinely monitored for signs and symptoms of serious infections and viral reactivation. Therapy should be interrupted if any of these conditions develop and should only resume once the condition has been successfully treated.

Indication Brand Name Generic Name Dosing Range Generic Name

Alopecia Areata Olumiant baricitinib 2mg-4mg qd; upon establishing adequate response, consider 2mg qd maintenance Eli Lilly; Incyte

Ankylosing Spondylitis Rinvoq upadacitinib 15mg-30mg qd abbvie Inc.

Atopic Dermatitis

Cibinqo Opzelura Rinvoq Rinvoq

abrocitinib ruxolitinib upadacitinib upadacitinib

100mg-200mg qd bid x 8w 15mg-30mg qd 15mg-30mg qd

Pfizer Incyte Corp abbvie Inc. abbvie Inc.

Graft-versus-host disease (acute or chronic) Jakafi ruxolitinib 15mg-30mg qd Incyte Corp

Juvenile Idiopathic Arthritis (polyarticular course) Xeljanz tofacitinib

Based on body weight (w): 10 kg ≤ w < 20 kg: 3.2mg (3.2 mL) bid 20 kg ≤ w < 40 kg: 4mg (4 mL) bid w ≥ 40 kg: 5mg (5 mL) bid

Pfizer

Plaque Psoriasis Sotyktu deucravacitinib 6mg qd Bristol Myers Squibb

Psoriatic Arthritis Xeljanz Rinvoq tofacitinib upadacitinib

Rheumatoid Arthritis

Olumiant Jyseleca Jyseleca Xeljanz Rinvoq

Ulcerative Colitis

Jyseleca Xeljanz Rinvoq

baricitinib filgotinib filgotinib tofacitinib upadacitinib

filgotinib tofacitinib upadacitinib

5mg bid or XR 11mg qd 15mg-30mg qd Pfizer abbvie Inc.

2mg-4mg qd 100mg-200mg qd 100mg qd 5mg bid or XR 11mg qd 15mg-30mg qd

100mg-200mg qd 10mg bid or XR 22mg qd for 8w-16w (max), then 5mg bid or XR 11mg qd thereafter 45mg qd x 8w, then 15mg-30mg qd thereafter

Eli Lilly; Incyte Galapagos; Gilead Sciences Galapagos; Gilead Sciences Pfizer abbvie Inc.

Galapagos; Gilead Sciences Pfizer abbvie Inc.

Vitiligo Opzelura ruxolitinib bid x 24w Incyte Corp

JAK Inhibitors to page 164

The Crutchfield-Kannan-Brownstone-Lebwohl JAK Inhibitor Reference Chart

Live vaccines: Live vaccines (immediately before, during, and after) are also contraindicated. Update patient on immunizations before initiating treatment.

Major cardiovascular events and thrombosis (monitor sreatine phosphokinase): The use of JAK inhibitors increases the risk of major adverse cardiovascular events (includes cardiovascular death, non-fatal myocardial infarction, and nonfatal stroke) and thrombosis (includes deep vein thrombosis, pulmonary embolism, and arterial thrombosis). Patients with a history of such events, with cardiovascular risk factors, and current or former smokers are at an increased risk, and therefore should be monitored closely. Patients who experience thrombotic and/or major cardiovascular events during treatment with a JAK inhibitor should discontinue its use. Renal and hepatic impairment: Depending on the specific JAK inhibitor, patients with renal impairment may require dose adjustments and routine monitoring. Furthermore, depending on the severity of renal impairment, the use of specific JAK inhibitors may be contraindicated as their use in such populations has not been studied. Depending on the specific JAK inhibitor, monitor in patients with known or suspected liver disease. Some JAK inhibitors have not been studied in patients with severe hepatic impairment and therefore may not be indicated for use in these populations.

Laboratory abnormalities: Patients should be routinely monitored for elevations in triglyceride levels. Providers should manage hyperlipidemia according to clinical guidelines.

Concomitant use of certain other drugs: Concomitant use with other immunosuppressants or with other JAK inhibitors is not recommended.

Cancer: Use of JAK inhibitors may increase the risk of non-melanoma skin cancers and secondary malignancies.

Data on off-label use is growing, with potential benefits covering a widening range of conditions including Alopecia Areata, Dermatomyositis, Graft-Versus-Host Disease, Granuloma Annulare, Hidradenitis Suppurativa, Lichen Planus, Necrobiosis Lipoidica, Psoriasis, Pyoderma Gangrenosum, Sarcoidosis, Systemic and Cutaneous, Lupus, Morphea/ Systemic Sclerosis, and Vitiligo.

Barriers to Widespread Adoption

There are many reasons why JAK inhibitors are not more widely prescribed. Some of these involve the “first to fail” syndrome whereby physicians fear using their patients as trial participants. Until a new medication shows up on a formulary list there may be little motivation to learn about something new.

Additionally, although the pharmaceutical industry spends extensively on direct-to-consumer messaging, no advertisements mention “JAK inhibitors” directly and almost all include the call to action “ask your doctor”. Furthermore, primary care providers will refer the most extreme cases to a specialist, who may have more experience with the superior JAK inhibitor outcomes. However, considering the number of existing medications to treat those conditions, many patients may not get access.

Another important element of this involves cost. JAK inhibitors cost more than existing products that treat the same conditions. Even though outcomes are clearly superior, quality of life considerations rarely register in the decision-making process of creating health plan formularies. Obtaining coverage for patients often includes the prior authorization process, which has been terribly detrimental with respect to patient care and a bane to the existence of many medical practices. Authorizations are extremely timeconsuming and there’s no way for medical practices to recover the cost invested in obtaining them. On average, physicians spend ten hours a week dealing with prior authorization concerns.

It is fair to ask, if most of the medications we prescribe have similar costs, why do we have prior authorizations? It’s clear that the purpose of many prior authorizations is not necessarily to improve quality of care, but merely to reduce costs for the insurance companies. In fact, one insurance representative claimed that a guaranteed percentage of prior authorization requests will not seek appeal upon receiving denial of coverage. Even more damning is the reality that denied prescriptions are often funneled to medications for which the health insurance company receives a more significant rebate. It may be argued that

JAK inhibitors are a game changer for many patients.

The importance of post-acute care

As a physician, you want your patients to have the right post-acute care when they leave the hospital. Regaining strength and restoring function are crucial parts of the recovery process.

According to the Good Samaritan Society’s Vice President of nursing & clinical services, Rochelle Rindels, everything done for a patient after a hospital stay should be based on helping them get back on their feet.

That’s where the Good Samaritan Society comes in. Its post-acute services help stabilize a patient’s health with a variety of care that includes therapy to maintain their wellness.

“We’ve been doing this for 100 years. We specialize in it,” states Rindels. “We provide support that meets people where they are.”

More options for care

The Society’s support starts immediately after someone is discharged from the hospital.

“We work with our hospital and physician partners. That’s a special level of collaboration and integration,” Rindels says.

The Society is an affiliate of Sanford Health, one of the largest health systems in the U.S., which gives it a unique advantage in the long-term care industry.

Each patient has a team of caregivers using innovative solutions to support them, including Sanford Health physicians and nurse practitioners.

“That’s a win for the patient and a deeper bin of resources for them,” she states.

After post-acute care is completed, the Society has a process to get patients back to their primary care physician so they can pick up where they left off.

Maintaining independence

If your patient is leaving the hospital and trying to decide if assisted living is the best option, it’s important to remember they can maintain their independence in this home-like setting.

“It’s a place between their own home and the nursing home where we can supplement their support system,” says Rindels. “The individual is living on their own but benefitting from assistance.”

This assistance can include a nurse who helps set up medications, home health services, housekeeping and more.

Flexible, home-based support

For your patient who is on the road to recovery, but not quite ready to do everything on their own, they might consider the Society’s home-based services.

“It’s a step in the right direction for people who are almost ready to go home, but not completely independent,” Rindels states.

“With home health we have patients moving toward total independence.”

Caregivers will usually make two to four visits a week to help patients with dressing changes, bathing and medications or to provide rehab therapy.

Whatever level of care your patient needs when leaving the hospital, the Society is ready to help restore their well-being with a proven history of quality care.

Visit our Health Care Partners page at good-sam.com to learn more.

55TH SESSION

Care Coordination

Improving Communication and Outcomes

The following report from the 55th session of the Minnesota Health Care Roundtable continued on the theme of our last two programs, which focused on improving the interoperability of care teams and care transitions. In this session, we focused specifically on care coordination, completing exploration into a highly interrelated trilogy of emerging and related responses to the necessary evolution of health care policy. The role of care coordination is growing quickly across all phases of health care delivery. Data clearly shows it saves money, improves outcomes and increases patient engagement. Our panel brings diverse perspectives on how care coordination may be used. We extend our special thanks to the participants and sponsors for their commitments of time and expertise in bringing you this report. In the spring we will publish the 56th session of the Minnesota Health Care Roundtable, which will address the fundamental causes of the health care workforce shortage crisis along with potential solutions to these problems. As always, we welcome comments and suggestions.

How does your organization define the term care coordination?

BONNIE: Health Care Homes (HCH) defines care coordination as a team approach that engages the patient, personal clinician, and other members of the health care home team to improve the patient’s wellbeing by organizing timely access to necessary care and resources in a way that builds trust and ensures continuity of care. In primary care, care coordination needs vary among populations and individuals receiving care at the clinic. Some

TODD ARCHBOLD, LSW, MBA is CEO of PrairieCare, a division a Newport Healthcare, the nation’s largest provider of specialty mental health services for youth and young adults. He leads the statewide Psychiatric Assistance Line (PAL) and Mental Health Collaboration Hub – services designed to increase collaboration and support between psychiatry and primary care.

JESSE BETHEKE GOMEZ, MMA, is a member of the leadership team for Disability Hub MN and Executive Director of Metropolitan Center for Independent Living, a provider of comprehensive services assisting people with disabilities in the seven county Minneapolis–St. Paul area. He has worked in leadership roles in behavioral health care at CLUES, the American Red Cross and the United Way.

CHRISTINE CHELL, MBA, is lead Regional Healthcare Preparedness Coordinator (RHPC) for the Metro Health & Medical Preparedness Coalition. She is responsible for grant deliverables and working with hospitals. The Metro Healthcare Coalition is comprised of members from hospitals, EMS, emergency management, local public health, home care, hospice and long-term care from the seven-county metro area.

MAGGIE FRESONKE, MPH, is the Population Health Coordinator for Perham Health with over 10 years experience in helping improve the health of the population in rural Otter Tail County. Currently, Maggie oversees the Connected Communities pilot project for LeadingAge MN called Elevate with the goal to better connect the community to help everyone age well.

BONNIE LAPLANTE, MHA, BS, RN is the health care home (HCH) program director, in the Health Policy Division, at the Minnesota Department of Health, where she has worked for over nine years. She has 16 years of leadership experience as a clinic services nursing director, as well as experience as a director of a home health agency and a coordinator in long term care.

ABOUT THE SPONSORS:

LeadingAge Minnesota Foundation supports initiatives to transform and enhance the experience of aging by building the workforce for tomorrow, advancing promising new approaches to service delivery and developing leadership at all levels.

The Metropolitan Center for Independent Living (MCIL) empowers members of the disability community on a pathway to overcome barriers and to discover access, choices, and the possibilities to realize their goals and aspirations. Through programs and active advocacy for policies that better serve people with disabilities, we assist thousands of individuals in achieving independent living and accessible integration with and in the community.

Metro Health & Medical Preparedness Coalition facilitates integrated planning, response and recovery activities critical to an effective response to an event or emergency with public health and medical implications in the metro area.

PrairieCare provides psychiatric care to individuals of all ages and is a division a Newport Healthcare, the nation’s largest provider of specialty mental health services for youth and young adults.

care coordination is provided to the clinic’s entire attributed population with services such as appointment reminders, notification of gaps in care, transition of care support, or medication management. For emerging risk, high-risk and high-cost individual patients, one-on-one contact (intensive care coordination) with a designated care coordinator provides support through “between visit” tracking, appointment follow-up, education, and coaching. This additional support to patients and families allows for an enhanced understanding of personal care needs and more effective care management.

TODD: Care coordination has a beginning, but no end. It encompasses all aspects of appropriate care—ranging from triage and pre-assessment to treatment planning and discharge planning. Beyond a single episode of care, care coordination needs to be a dedicated function within a care system. In mental health care, the team is often broadened to county caseworkers, social workers and school staff for younger patients. Care coordination is a core part of the treatment itself. Mental health care should be delivered within the context of a broader psycho-socialbio-spiritual frame that is dependent upon good care coordination. While visits with providers may end, and treatments may conclude, care coordination remains ongoing and relevant for the next step in one’s journey to managing their health. Children’s mental health can be a misnomer, as our mental health system delivers care – and care coordination – to the child within the context of the family. Indeed, the inclusion of caregivers and family as part of a child’s treatment is fundamental to successful treatment outcomes.

to achieve the best outcomes. An important element of care coordination is proving connections to community resources outside our facilities which can assist in achieving those best outcomes.

CHRIS: The Metro Health & Medical Preparedness Coalition (Coalition) defines “care coordination” as a service provided to stakeholders in the community. The Coalition brings partners together to coordinate services, resources and information for situational awareness.

What are the biggest benefits that care coordination offers?

MAGGIE: Providing an easier path to the best outcomes. Without a care coordination more is left on the shoulders of the individual and the odds of something important to their care falling through the cracks increases. Offering care coordination builds trust with patients and helps them set realistic goals and improves follow through.

When care coordination is done well, nobody notices.

JESSE: Minnesota’s heath care platform includes hospitals, clinics and ambulatory services on one end - and home and community based services, also known as long term services and supports, on the other end. We define comprehensive care coordination as continuity, and interoperability of primary and behavioral health care coordination with long term services and supports for an individual.

MAGGIE: Care coordination is a service that is provided by a point person who can see the bigger picture of how health care interrelates and represents the needs of the patient or individual receiving those services. In our organization, a Medicare-aged individual will oftentimes be assigned a person who can provide these services, which can cover a range of variables, such as chronic care coordination, for example. A care coordinator is an advocate inside the organization to individuals and to internal and external resources

CHRIS: Stakeholders of the Coalition are often in competition with each other. However in response to a scarce resource or a mass casualty event, coordination is key to delivery of service to the patient. Currently in the pediatric crisis we are facing with RSV and influenza, pediatricians and nursing leaders are brought together for a daily call to discuss cases, identify bed availability and make transfers if possible. In a scarce resource situation, such as CT contrast shortage, hospitals coordinated weekly to discuss their status (red, yellow, green), and then mitigating strategies are implemented to conserve the resource. The coordination allows for sharing best practices and ideas for getting product replacements. A secondary benefit is the support that is found in coordinating. When critical care physicians coordinated daily during the pandemic because they found themselves in similar situations, they were not alone, someone did understand, and they would call back the next day for coordination, information and support.

—Todd Archbold

JESSE: Care coordination can increase the interoperability across a multidisciplinarity of providers, which can lead to greater continuity of care and efficacy of both health services and long-term services and supports.

BONNIE: A primary benefit of care coordination is partnering with and engaging patients to enable the delivery of high-quality, high-value health care. This means the patient’s needs and preferences are known and used to guide delivery of safe, appropriate, and effective care within and across health

SPONSORED BY:

systems. Care coordination is high touch and builds strong relationships between patients, primary care clinicians and care teams. Holistic and ongoing support helps patients and designated family members find the best approach to manage care, establish short term goals to improve current health, prevent worsening of health conditions, and access care at the right place and at the right time. With improved care team communication and collaboration, care coordination also has the potential for saving money by decreasing hospital and emergency room use, unnecessary testing or other duplicative procedures, problems with transitions of care and overall care fragmentation. Chronically ill patients often report poor medical experiences and being overwhelmed by the complexity of their care. Care coordination helps patients become more confident when taking an active role in their care plan. Instead of taking it all on themselves, they have someone helping them keep everything organized.

TODD: When care coordination is done well, nobody notices. The benefits are more seamless and efficient care which results in a better patient experience. It also mitigates risk and potential for decompensation. Mental health care requires coordination of both the psychiatric and somatic issues, which when done well, become one and the same. It is important for the mind and body to be treated within the same plan and coordinated similarly

JESSE: For people with disabilities or older adults who require an assessment for long-term services and supports, the assessment by a county (Lead Agency) does not require the input from the individual’s physician. When an assessment is less than accurate, the process is an adjudicated one. We need to figure out, legislatively, how to incorporate a coordinated care framework to long-term services and supports assessments, on behalf of individuals, so their primary health care providers have input as a standard. This would lead to greater continuity of primary care, and behavioral health care coordination along with the individual’s long-term services and supports.

TODD: Care coordination within mental health care has a variety of obstacles, including the lack of parity and the stigma surrounding psychiatric illness. However, the two most common obstacles are that mental health records are kept separate from traditional medical records and require specific consent to be released. State consent laws regarding mental health treatment differ when it comes to sexual history and chemical use. In some cases, a patient may not consent to share information, which creates barriers in care coordination, and frustration among providers. For minors, it may also mean that parents/ guardians do not have access to information regarding the minor’s mental health treatment. Additionally, when children and families are accessing care from social services and mental health systems, there are numerous professionals responsible for delivering and coordinating care. These professionals may come from different systems with different approaches that

can be confusing or even operating at cross-purposes. Another barrier is in accessing care, largely due to a shortage of providers. AspireMN has built a network of mental health providers who are working on strategies to break down these barriers and improve coordination.

MAGGIE Lack of reimbursement for the efforts. It takes a lot of time, and it is not reimbursed evenly or like any other element of health care delivery. We would definitely provide a wider range of care coordination and offer more of it if there was better reimbursement. Our status as a critical care facility in a rural area does not allow us to be part of an ACO and therefore further limits out access to adequate reimbursement.

—Jesse Betheke Gomez

BONNIE: Integrating care coordination into a health care organization requires changing the way things have always been done. Successful integration requires communicating the reason for the change and what can be accomplished, along with a clearly defined strategy and a collaborative, team-based implementation process. Celebrating successes is important for buy-in, along with periodic auditing of the process to ensure positive outcomes. Patients are often unaware of care coordination programs. They need to know what to expect from a care coordinator and how their physician stays involved, and be reassured that the care coordinator is a key member of their primary care team. Some patients may have barriers to participating in care coordination, such as cost or lack of access to transportation or technology. Hiring the right person to provide care coordination services can be challenging, especially in this time of work force shortages. Understanding the clinic’s target population is a key ingredient in selecting a care coordinator. The scope of practice, training, tools, and resources for care coordination should align to meet population health needs and create a successful foundation for the patient, care coordinator and care team.

CHRIS: In some situations, it is a challenge to get the right person to the table to coordinate. The Coalition relies upon their liaison contact to identify the right person and share the contact information.

What are the biggest problems that care coordination presents?

TODD: If it is not documented, it didn’t happen – and if information is not shared/coordinated between providers and systems, we cannot align efforts. More and more youth with acute and chronic psychiatric conditions have been boarding in hospitals and EDs, and in our juvenile justice system, and a lack of cross-system coordination creates delays in care and potential worsening of psychiatric conditions. The impact of the social determinants of health are amplified for those struggling with mental illness, which also makes care coordination more complicated between mental health and medical providers. We are currently a part of a pilot project that aims to better identify which care settings are increasingly inaccessible, leading to boarding situations. This is not being tracked or shared outside of individual systems. We hope to have concrete data by early 2023 showing the actual needs for specific mental health treatment settings.

What are the biggest obstacles to the integration of care coordination into the work done by your organization?

We need to figure out, legislatively, how to incorporate a coordinated care framework with long-term services.

MAGGIE: The workload and increased staffing needs. When done properly, it is a labor intensive process and requires increased staffing. Fielding multiple calls per day from patients at home requiring care coordination takes time away from serving the needs of in-house patients. With each call comes charting and documentation. Referring an individual to the right resources and connecting each patient with a closed loop referral is time consuming. Not everyone will accept care coordination when we offer it, but when they do, we pretty quickly become their best friend and they will call all the time.

BONNIE: Three difficulties come to mind: interoperability between different patient information and record keeping systems, reimbursement, and work force availability. Lack of interoperability in medical records between health care and community-based care organizations inhibits timely communication of patient information. Improving the ability to share patient information can prevent delays in care, duplicative testing, and medication prescribing errors. This leads to improvements in the efficacy and safety of care and reduces the cost of care for the patient and the system. Reimbursement for care coordination is limited. Administrative costs associated with operating an effective care coordination program can be high. Payments do not fully cover the upfront investment necessary to staff programs, adjusting workflows, and allocating time to address complex health issues. More support is needed for care coordination and advance primary care practice. The current health care workforce shortage is looming large. The pandemic heavily impacted health care providers and their teams who have been on the front lines during the pandemic. Staff shortages impact the access to care and cause organizations to make hard choices on how they will staff their organizations.

and abilities of the patient in terms of their culture, language and world view. Their health status and conditions for which they are being treating vary widely, as do their values, health literacy and cultural perspectives on health care. It is a problem if we fail to meet the patient where they are, both as a person and in terms of the communities that they come from. Greater awareness of the value of a person-centeredness is required across the health

How can care coordination be improved?

In some situations, it is a challenge to get

right person to the table to coordinate.

—Christine Chell

BONNIE: Evaluation is a critical tool for demonstrating a care coordination program’s impact, return on investment, patient satisfaction, and identifying future needs and opportunities. Primary care organizations will want to institute a quality improvement process to establish and measure program goals, taking into consideration what is important to various stakeholders –leadership, clinicians, patients, staff, regulatory bodies. Quality improvement should focus on both patient outcomes and care coordination processes. Research on care coordination is limited. More research on best strategies for care coordination is needed to improve health care delivery and patient outcomes. Best practices should be widely distributed to help clinicians and care teams build comprehensive and sustainable models of care coordination.

CHRIS: Hospitals throughout the state have taken great measures to modify their operations to improve coordination and meet the needs of the patient. The lessons learned and the gap that has been identified is the need for real time data sharing, for instance bed availability, and an ongoing mechanism for transfer coordination that involves clinical providers as well as caretakers. There needs to be a mechanism to ensure that the critically ill patient is able to get access to services needed.

JESSE: Health care can be discipline-centered, whether at the institutional-level or provider-level. Sometimes this can overlook a very important element—the humanity of the patient, their world view, and values. Engaging all patients in terms that are understandable in communicating with them is necessary. To do so can be life enhancing. Part of the goal of care coordination is to focus on the patient as the center of all care services. We have the opportunity to transform medical and related services to become “patient-centric,” or in other words, “person-centric.” Otherwise, if care coordination ignores the very important person-centric focus, much can be lost to the individual in a multi-disciplinary framework. It is critical to focus on the individual needs

MAGGIE: By solving the dilemma that by providing care coordination in an under-reimbursed way, we decrease patient need to utilize the services from which we generate fee for service income. It would also be a big improvement if we could improve electronic search and referral services for community –based assistance. Another concern for us involves getting the e-referrals, telehome monitoring, electronic reminders, and the like, which require broadband access we often do not have in rural areas. Even texting can be a problem, as can using things like MyChart, because there sometimes are issues involving a low level of tech literacy, such as downloading the app and using passwords.

the

SPONSORED BY:

TODD: The Metro Health Coalition and AspireMN have been facilitating a grassroots pilot project to increase coordination between hospitals and mental health providers. They host a bi-weekly videoconference call that is open to all care providers, and typically attracts more than 40 organizations each time. These efforts have helped many kids get out of boarding situations, and it is helping to build a stronger health care community at-large. Participants have developed a better understanding of respective care settings, which is leading to more constructive ways to communicate. For example, many youth in boarding situations are described as having concerns about aggression. However, understanding the nuance of this descriptor is critical. For example, is it physical or verbal aggression? Is it isolated or persistent? It is directed towards a specific person? They are also collecting data on specific trends so they can break down barriers in accessing care.

JESSE: Whether by Minnesota’s electronic health care statutes, or the 21st Century Cares Act, there is real need for greater standardization, and interoperability while maintaining the highest level of safety, security, gating and accountability for care coordination to achieve strategic optimization.

When a patient receives care coordination from several sources, what problems can this pose?

CHRIS: There are other agencies that provide coordination like the Coalition, and we find duplication of services. In some situations, we can identify efforts that are duplicated, and the coordinating agencies will work together, or one would discontinue their work. There is a strong pharmacy coordination group in an agency other than the Coalition. When a pharmacy issue needs to be coordinated the Coalition will work with the other agency to address the situation. If it is not appropriate to address it in the other agency, then the Coalition will convene a group that takes the lead in this area.

TODD: Fragmentation between care providers and lack of EHR interoperability is sadly the norm in mental health care. Insurance coverage can be complicated, and low margins prohibit adequate investment infrastructure.

JESSE: It is important for all providers to hold person-centeredness as a value so that ultimately the individual’s needs are met in the most mindful way possible. We must remember to recognize the role of decision making by the individual. Oftentimes there are silos in health care services, particularly in terms of which health care professional is providing what kind of care. Lack of communication between these providers can worsen if it is followed by conflicting information from multiple care coordinators. It can be problematic when medical, dental, behavioral health and human services professionals do not have adequate interoperability. A person may be receiving as much as ten hours of PCA care a day and yet when they go to the doctor that detail and how it can be leveraged may not be clear to the physician or care coordinators who follow up on the medical exam.

BONNIE: Individual patients may be contacted by multiple care coordinators (maybe with a different title but with the same purpose) from organizations connected to their care: health providers, public health, insurance companies, or other support agencies. While care coordinators in each setting have value, consistent communication and collaboration among care coordinators is challenging. Care coordinators need to work together to minimize confusion, reduce duplication of efforts, and align health goals while keeping the patient at the center of care.

MAGGIE: It can create several issues, and each coordinator may have their own agenda coming from either a county, VA, or health insurer perspective. Sometimes a patient can receive conflicting or overwhelming advice and the patient could get turned off from it. There is not always coordination between coordinators, who may not even know a patient is receiving coordination from multiple sources. This could lead to negative outcomes such as avoiding necessary or unnecessary hospitalizations. Too many cooks in the soup can be confusing for everyone.

How does your organization use care coordination?

BONNIE: A care coordinator works with patients who have complex medical and social needs to help them set health goals, manage their conditions, and receive care at the right time and in the right place. Care coordinators help patients better understand their conditions, options, and how to navigate a complex system. They facilitate communication with providers to ensure patients and family members get information to make decisions about their health care needs. Developing a care plan and providing self-management education is especially important for patients with chronic diseases and emerging modifiable risks. There are many resources to meet patient needs, and one size does not fit all. The care plan starts with a comprehensive assessment which provides insight into the medical and non-medical needs of the patient. The assessment is used to identify patient-centered goals that address health and wellness gaps. Using a patient-centered approach which is responsive to patient preferences, needs and values improves patient satisfaction and engagement, ultimately leading to improved outcomes and wellbeing.

JESSE: For us, case managers provide very essential work in care coordination. We are always guided by thinking in terms of person-centeredness and independent living when assisting people with disabilities. Community Access for Disability Inclusion (CADI), and Elderly Waiver (EW) services for example, provide funding for both home and community services for children, adults and the elderly. Care coordinators help make sure CADI waivers are used to provide adequate long term services and supports such as PCA services, as well as transportation to and from physician appointments, medication pick up, medication management and even address housing and food security. Care coordination includes the activities around hospitalization such as getting properly checked in and then returning patients to incommunity after discharge.

MAGGIE: Health care is messy and providing a resource to help guide a patient through the system is important. Aging patients can face a range of issues dealing with chronic illness. These can include social isolation, and medication compliance concerns such as not understanding dosage instructions or even not picking up the prescription. We use care coordination to help keep the patients from falling through the cracks and provide follow-up to be sure compliance is occurring. We help deal with health literacy concerns and without this level of care there could be unnecessary deaths.

CHRIS: Coordination is primary to the work of the Coalition. Coordination is done through telephone calls, situation briefings, and situation reports. The Coalition is often requested to support coordination of a group experiencing a challenge or disruption to its normal service. The Coalition can bring the group together for a brief period of time to address a shortage or crisis. The Coalition has regional health care preparedness coordinators to support the variety of coordination groups. In some situations, once the crisis has passed, the group recognizes the benefit of coordination and will agree to meet on a

scheduled basis. An example of this is the blood supply group. They began out of a crisis blood shortage and found value in coordinating on policy, procedures and status definitions so they could support one another in future crisis situations.

TODD: Youth admitting to our inpatient psychiatric setting often have care providers in place, and have experienced a recent trauma, or triggering event/ situation. We don’t diagnosis psychiatric conditions with labs or imaging, though they can rule-out medical conditions. We rely on comprehensive assessment that includes interviews, rating scales, and social history, including medical records. Accurate assessment of the situation is contingent upon timely care coordination. In some situations, patients or guardians may be hesitant to share all of the information, or may not recognize certain aspects as relevant. In this regard, the coordination of past medical records may be an ongoing task. We must also be diligent in coordinating relevant and permissible sharing of information to existing and future care providers.

What feedback do you have from patients around their experiences with care coordination?

JESSE: There is appreciation by our clients in our Case Management Services Department when our case managers can help to solve problems that require working across many areas of services, providers and supports. Yet throughout the journey of working with multiple providers, at the center of this work is the individual and assuring that their needs, hopes and communication with them remains constant. When that assistance is made clear in a way that addresses language, culture and concerns by the client, that assures there is follow through by all providers, and positive client satisfaction, we promote perfect occupancy of care coordination by doing the right thing, at the right time, in the right way, all the time.

MAGGIE: They love it. We get feedback from patients all the time expressing their high level of appreciation for the personalized extra care they have received. They go quickly from concerns that we are meddling in their private business to genuine gratitude that we have taken the time to help them understand their health issues. A good example involved a husband dealing with cancer whose wife was providing a lot of care and support. She was concerned that she could not take care of her hair which caused a lot of stress. Something as simple as sending someone over to take care of her

hair made a huge difference in both their lives by helping her to be a better care giver. Whereas she may have been able to arrange this on her own, it had never occurred to her. Everyone has been very grateful the services were available.

CHRIS: The stakeholders of the Coalition value the coordination. During situations of scarce resources when a request for a product is made the Coalition asks the stakeholders if any can share. The feedback is profound gratitude when a resource is shared by a competitor in the industry for the good of the patient/community.

TODD: Care coordination is the Achilles heel of high-quality mental health care. When done well, nobody notices. When it is lacking at any point during preventative or active treatment, it can limit progress and patient engagement. When patients withhold relevant information for their care, or if they have to repeat stories – it can be discouraging and often traumatizing to recount painful events to all involved in their treatment and ultimately detrimental to their care.

BONNIE: HCH contracts with individuals outside of MDH to gather patient feedback. During the certification site visit, contracted representatives talk directly with patients to learn about their experiences with care coordination. Certification and recertification visits are also an opportunity to hear from clinicians, care coordinators, and other care team members about how care coordination has impacted patients. The feedback we have heard from patients is overwhelmingly positive. Patients appreciate the support care coordination provides them in reaching their health and wellness goals and having a direct contact to help them access the care they need.

What levels of regulation and accountability should be applied to any organization providing care coordination?

JESSE: All health care services and home and community- based services are subject to regulation and accountability. Care coordination also requires the proper level of regulation and accountability consistent with the statutory scope for such services.

BONNIE: HCH program standards require certified providers to have a position description for care coordinators and dedicated time to provide care coordination services. Care coordinators work collaboratively with patients to set goals, identify action steps and resources needed to achieve

An important element of care coordination is providing connections to community resources.

—Maggie Fresonke

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them, and determine frequency of patient encounters. Certification requires the care coordinator and primary care provider to engage in regular communication. Meaningful communication across the care team is key to effective coordinated patient care. Every three years, certified HCH clinics undergo a required recertification process; they can elect a check-in visit at 18 months. HCH program staff and contracted evaluators verify processes and workflows with clinic staff and patients to assure the requirements are being met. The program uses a benchmarking process to measure a clinic’s progress over time in improving patient outcomes. The HCH standards inform clinics “what” they need to put into place to meet certification requirements, but not “how” to implement the requirement. Clinics implement requirements in the way that best meets the needs of the population they serve. Guidance is provided by the HCH program with education, resources, and technical assistance.

MAGGIE: You would not want so much regulation that you create barriers to those who could make a difference. It would be helpful to have some minimal level of certification and this should include a background check.

How should the efficacy of care coordination be measured?

TODD: Effective care coordination can be directly correlated to aggregated care outcomes and the trajectory of illness/wellness (on a spectrum). As our system grows to meet the needs of children and families, we increasingly calibrate success with feedback from those we serve. Effective care coordination is often unnoticed, and that lack of attention to this foundation for excellence in treatment is a positive measure of success.

CHRIS: The Coalition has many thank you emails from stakeholders who appreciate the service provided. Coordination may have other outcomes which are positive but not meeting the initial intent of the coordination. The Coalition is currently providing coordination between hospitals and community mental health providers for children waiting in the emergency department for mental health services who do not need acute care. The efficacy of the coordination will take time to gain traction. Bringing community mental health providers and hospital staff together has had successes other than finding placement for children. Gaps in service have been identified, relationships have been created, and some children have been discharged from the emergency department.

MAGGIE: The individuals receiving the care coordination should be able to tell they are benefiting from the efforts. Even if they are healthy they could be struggling socially and preventing future chronic disease is important. Standard health outcome scores may not be the best way to measure the value of care coordination.

BONNIE: Measurement is important and outcomes of patient satisfaction, care outcomes and cost are beneficial when evaluating the effectiveness of

care coordination. Some organizations monitor cost savings from decreased emergency department visits and hospitalizations, or by comparing avoidable high-cost utilization before and after care coordination implementation. Patient and staff stories are impactful; improved patient outcomes are often discussed when measuring efficacy of care coordination. Many clinics also measure clinician satisfaction with having a care coordinator work with their patients. Most HCH clinics report greater clinician satisfaction since care coordinators allow clinicians to practice at the top of their license.

JESSE: Each discipline in health care has its own standards. A multidisciplinarity of providers need to work together, along with patients and patient advocates, to arrive at standards of measurement, nationally and in Minnesota.

Is there anything else about care coordination that you would like to discuss?

CHRIS: The state has eight Healthcare Coalitions. There are some variations in capacity and ability, but all Coalitions coordinate at some level in their community.

—Bonnie LaPlante

MAGGIE: There is a big improvement in before and after situations; even in a rural setting, there should be some kind care coordination available. Having it will help patient willingness to come in for care when they need it. It definitely improves patient rapport, which goes a long way to making the odds of improved outcomes more likely.

JESSE: For individuals with complex care needs, there is a wide spectrum of potential gaps in their continuum of care, which, if not addressed properly, can lead to disastrous outcomes. Care coordination can help mitigate these problems so it is vital to maintain adequate support across board. This is especially difficult as all of health care is dealing with a work force shortage crisis. There are two other very important things to bear in mind with care coordination; understanding the additional legal and business requirements thereof. All health, behavioral health and related health and human services need to assure care coordination meets state and federal laws, all regulatory requirements and, maintain the highest ethical best practices. In so doing, it is important to be aware of anti-steering laws, conflict of interest laws and financial disclosure laws as they pertain to patient rights in the process of care coordination.

BONNIE: Care coordination models are ever evolving as patient needs and clinic resources and capacity shift. It seems HCH clinics are always working to “get it right.” It’s important to stay flexible and continue to work on a model that fits each clinic and the patients they serve. Patient needs remain high, and overall health is impacted by a range of physical and social factors. Care coordinators are one way in which we can address the broader range of issues. By investing in care coordination, we can improve not only the quality and cost of care, but improve health equity within our communities. It’s a good investment.

Care coordinators allow clinicians to practice at the top of their license.

prior authorizations are simply a cost-reduction strategy for insurance companies. Clearly, better legislation is needed (some of which is being currently debated) to better regulate prior authorizations and minimize their negative impact on health care delivery.

There is another problem. Most medications cost so much in the United States because the vast majority of people cannot afford brand name products on a long-term basis, especially for treating chronic medical conditions. Many of these medications can cost $10,000 per month and upward. Because the JAK inhibitors are a new class of medications, without generic alternatives, insurance companies are not quite sure how to deal with them. Fortunately, like coverage for all new medications, the more prescriptions are written the more likely the insurance companies are to eventually develop a policy to enable payment for them. Additionally, pharmaceutical companies will have patient assistance programs to help the medication break into the market. Many times, for the first several months to a year, patients can get their medicines at an extraordinarily reduced cost. I always tell patients that if their insurance is not covering a prescription to check with the pharmaceutical company, as there may be pharmaceutical assistance programs for that medication.

Conclusions

JAK inhibitors are a game changer for many patients. They are a prime example of the value of investing in scientific research and the more widespread their use, the lower their costs will become.

Since their initial development, there has been rapid expansion of JAK inhibitors and their applications, with numerous new drugs in the pipeline as well as repurposing of FDA-approved drugs for other dermatological conditions. These include: Cibinqo (abrocitinib) for prurigo nodularis and pruritus; Jakafi (ruxolitinib) for hidradenitis suppurativa and alopecia areata; Corectim (delgocitinib) for chronic hand eczema and atopic dermatitis; and Sotyktu (deucravacitinib) for alopecia areata, psoriatic arthritis, and psoriasis. If you have patients who may benefit from this new class of drug, there is ongoing new research and outcomes data that is well worth some exploration. The insurance industry will continue to push back on spending; however, enough requests will help justify more patient-centric policies.

Charles E. Crutchfield III, MD, is a clinical professor of dermatology at the University of Minnesota Medical School and Benedict Distinguished Visiting Professor of Biology Carleton College. He is also medical director at Crutchfield Dermatology.

Pallavi Kannan, MS, is a clinical researcher at Crutchfield Dermatology with a background in pharmacology.

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to “dangerous levels” the system runs the risk of receivership. With receivership, an external trustee steps in to take control. Typically, some form of consolidating event occurs hereafter, i.e., before the community health system fails to turnaround. Larger, better capitalized health systems are always on the prowl for failing turnaround candidates i.e., the debt owed is downgraded to a point of what is determined to be “distressed debt”; it is repriced to a fraction of its formerly listed “par value”, and the acquirer walks away with a bargain basement price on a health system ripe for a turnaround artist to step in.

Independent medical groups operate in much more expansive and less restrictive capital markets environment, including the ability to access less regulated private debt and private equity investors. The larger the practice, the more expansive are the opportunities. Bank debt is often more readily available, and medical real estate development firms will finance multiple facilities investments, as cited above. Recently, a growing number of private equity firms have emerged to acquire all or portions of medical practices. Independent medical practices with sufficient size, scope and scale can be much better positioned for the financing of various pieces and parts of their business strategies. Investors in medical practice opportunities may have little or no interest in how community hospitals are faring with their financial performance challenges. Why not? Because as sophisticated Wall Street investors often say “these two general asset classes are non-correlated”, meaning negative market

conditions for one class (community hospital and health systems) does not, necessarily affect the value propositions available in another (private medical practices); the market conditions of one potential investment class doesn’t affect the other.

Closing Observations

I have often reminded governing boards of community health systems and medical practices, large and small, that while the focus of their efforts intersect at the point of patient services and care, community hospitals, academic medical centers and independent medical practices are not in the same business. Community health systems, especially the not-for-profits, are governed by community representatives charged with serving defined communities with an array of omni-available medical and health services, abiding by rules and regulations defined at federal and state levels, including by tax-exempt codes. Independent practitioners, on the other hand, operate private businesses they own, govern and control. The independent medical practice business model differs from that of the community health system and the academic health center. All should not be “lumped together” when considering market-based opportunity and risk.

Daniel K. Zismer, PhD, is professor emeritus, endowed scholar, and chair, School of Public Health, University of Minnesota. He is also co-chair and CEO, Associated Physician Partners, LLC and the co-founder of Castling Partners. dzismer@appmso.com.

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prescribing the classes may make people more inclined to participate. Ultimately, our goal is to partner with physicians in encouraging older adults to maintain or improve their health; a healthy lifestyle is still possible when you’re older, and it can have such an impact on quality of life.

What would you like physicians to know about how they can contribute to your work?

MBA is encouraging physicians to support older clients to stay active, support their health and really maintain their independence. MBA wants to dispel stereotypes about getting older and remind physicians and patients that there are things we can do as we get older to stay active and live the lives we want to live. Often it’s too easy to perpetuate stereotypes when you have such a short window to see people in your office, but we need to remember that life isn’t over when you turn 70, 80 or even 90.

What are some of the continuing challenges facing MBA amid COVID?—

MBA’s main concern is that while we’re doing what we need to do to be safe—there’s been—at

times—an alarming degree of social isolation. That’s not unique to older adults, but when you have mobility limitations and it’s harder to get around, it’s easy to get isolated. We’ve seen a skyrocketing trend of isolation in older adults, which impacts their health. It’s something we’re asking physicians to discuss with their older patients and ask them whether they feel lonely, are they connected, who are they connected to, are they seeing people—even if it’s virtually? A lot of us are experiencing that isolation. And for older adults who are fearful about COVID, it’s important to remember there are guidelines to help us whether it be from the Health Department or Centers for Disease Control. Older adults need to know the measures they can take— things they can do in a safe way, get out of the house and live their lives.

What are some of the challenges MBA is focused on in the future?

MBA’s biggest concern is that as a state, we could be doing more than trying to meet the challenge of a growing older population. We can look at this demographic shift as an opportunity, not necessarily a negative thing. Really, the underlying issue is ageism. Statewide,

nationally and internationally we could do more to acknowledge ageism exists and it is limiting to us as individuals as we get older. We must promote the fact that older adults can be active in our communities, and for each of us, our health plays a big part in that contribution. We need to actively combat ageism and not feed into the existing stereotypes that we have about older people.

Kari Benson, MPA, is the director of the Minnesota Department of Human Services Aging and Adult Services Division (DHS). In that role she also serves as the Executive Director of the Minnesota Board on Aging (MBA). She provides statewide aging services leadership and oversees planning for and providing sustainable service and support options to help older Minnesotans live well at home. Kari manages Minnesota’s state and federally funded home and community-based services programs and critical services such as the Senior LinkAge Line®, Adult Protection and the Long-Term Care Ombudsman.

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

Sofia Lyford-Pike, MD