Orlando Medical News October 2019

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Florida Medical Marijuana: 89 Physicians Certified, 94,850 Patients

Patient/prescriber ratio not indicative of “pill mill”

By MICHAEL C. PATTERSON

According to a new state draft report on Medical Marijuana (MMJ), Florida had 168,810 patient “certifications” for MMJ between October 1, 2018 and March 31, 2019.

More than half of the certifications came from 89 Physicians. The report has alarmed members of a special panel of MDs setup by the State of Florida charged with keeping tabs on the ordering patterns of physicians who can authorize patients to take MMJ. Sarvam TerKonda, MD, of Jacksonville and member of the joint panel, said after review-

ON ROUNDS PHYSICIAN SPOTLIGHT Jerri Johnson, MD ... 3 EOCC MEDICAL CITY

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ing the report, “To me, I look at this data and say this is just another form of a pill mill.”

The panel, created in state law, is responsible for reviewing the data for patterns and annually submitting a report with recommendations to the legislature. The concern stems from 89 Physicians (7 percent of the physicians who are eligible to write MMJ certifications) are writing 56 percent - 94,850 - of the certifications. Chronic non-malignant pain was the number one qualifying condition (34 percent) followed by “medical conditions of the same kind or class,” and PTSD (26 percent).

There are some people, including phy-

sicians, who are not familiar with the MMJ industry that will immediately assume fraud or “pill mill” activity is going on by reviewing this data. However, as someone who studies the United States and global medical cannabis industries, there are legitimate reasons why a few Florida physicians are certifying a large number of patients.

Marijuana is still illegal federally. Physicians are worried about the legality of cannabis and potentially losing their DEA license to prescribe FDA approved medications. Those concerns were real a few years

LOWEDOWN ON HEALTH LAW

ago, but with medical cannabis legal now in 34 states, there has not been one reported case of a United States Physician losing their DEA license to prescribe FDA medications due to recommending or “certifying” a patient for MMJ. Furthermore, medical practices receive the bulk of their funding from federal insurance programs (Medicare and Medicaid). Therefore, most medical practices refuse to allow their physicians to write MMJ certifications for fear of losing their federal insurance funds.

(CONTINUED ON PAGE 5)

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Clinically Integrated Networks Can Be a “Win-Win”

By MICHAEL R. LOWE AND BRIAN C. EVANDER

At its core, a Clinically Integrative Network (CIN) is a collective of health care organizations in a local or geographic region in which providers share access to electronic health record systems. It is a health network working together, using proven protocols and measures, to improve patient care, decrease cost and demonstrate value to the market. This network of systems allows practices to track shared patient populations in order to improve patient engagement and deliver the best care at the lowest cost. The main goals of a CIN are to increase efficiency and provide better care. The Depart-

ment of Justice (DOJ) and the Federal Trade Commission (FTC) define clinical integration as an active and ongoing program to evaluate and modify practice patterns by CIN participants to create a high degree of interdependence and cooperation among physicians to control costs and ensure quality patient care.

In its article, The 7 Components of a Clinical Integration Network, Becker’s Hospital Review defines CINs as individual providers and health systems that are collaborating strategically to do three things: 1) improve patient care, 2) decrease the cost of care and 3) demonstrate their value to the rapidly changing market.

•• •• • •

As care delivery methods and compensation evolve, clinical integration and CINs are being leveraged to deal with market changes, both anticipated and realized. And while changes in the market are one big reason for (CONTINUED ON PAGE 2)

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LOWEDOWN ON HEALTH LAW | the uptick in CINs in recent years – there are now around 500 CINs in existence in the United States according to Becker’s Hospital Review – many CIN members have joined networks because they believe the ultimate goals of CINs will improve the health of their patients.

Clinically integrated networks provide a legal way for independent practices to bargain with insurers for better payment rates, make IT improvements that would otherwise prove difficult to implement on their own and help patients receive the best care possible. CINs are a legal structure with benefits that extend beyond the bottom line.

“The legal structure allows them to provide more integrated and coordinated care and do some more bargaining with payers, which would not be allowed from independent providers,” Senior Associate of the American College of Physicians Neil Kirschner told the ModernMedicine Network.

CINs create mutual accountability that encourage health systems and communitybased providers to deliver high-quality care efficiently and effectively. Clinically integrated networks also allow practices to remain independent while leveraging a broader community of experts. The CIN can contract with payors, employers or health systems. These contracts can range from a specific procedure to a population of patients. Many hospital systems have reported that payors are not requiring that CIN contracts include downside risk for the network. Some hospitals have also contracted with their own CIN to realize cost

Clinically Integrated Networks Can Be a “Win-Win” continued from page 1

saving opportunities and to more effectively manage cost within their own health plan.

CINs are a win-win for Independent Practices and for their patients. The benefits independent practices receive from joining a CIN would include a practical and financial advantage without giving up or relinquishing control over their practice. Not every patient wants their care to be provided by a large institution. They may be looking for that customized, personalized high-quality care that an independent practice can give. The patients will benefit from staying with their doctors whom they know and trust while receiving higher-quality care at lower costs.

The basic idea behind CINs is that patients are best served when doctors of all specialties are working in a single integrated network to cohesively optimize care. Doctors also benefit from quality-optimization standards, as well as from the resources and support from the health care system. By maintaining control through such physician-driven clinical networks, doctors are able to instill change in both patient care and health care reform.

According to the U.S. Department of Justice, CINs all share four defining characteristics. In order to operate legally as a CIN, a network must: Have physicians play a key leadership role. Whether a CIN is a joint venture be-

tween a health system and providers (called a Joint Venture Physician-Hospital Organization or PHO), a collaboration between provider partners only (called an Independent Practice Association) or a subsidiary of a health system (called a Health System Subsidiary), physicians must be part of the CIN’s governance structure. Physician leadership and buy-in is not only essential from a legal perspective, it’s also critical to the success of a CIN.

Commit to comply with clinical guidelines. Members of a CIN commit to work-

ing on certain performance improvement activities, including improving care outcomes, increasing efficiency of delivered care and increasing patient satisfaction.

Strategically use data and technology.

In a value-based care model, data and analytics are essential. CINs need to strategically use data to shape their care strategies and to prove how they are improving outcomes, increasing efficiency and reducing costs. CINs should be continuously setting metrics and then using data to assess those metrics and make improvements.

Demonstrate its value. CINs must show how they are delivering better care at lower costs. Essentially, a CIN must be able to speak to and deliver on its value proposition.

Without each of these four components, a CIN runs the risk of becoming an organization that has the power to negotiate better rates for its members based on its size, not because of the value it provides to patients and payers.

There can be some antitrust concerns when structuring your CIN. The CIN must be structured such that it avoids a per se violation of the antitrust laws and avoids overriding anticompetitive effects. The network must be “integrated” - either financially integrated or clinically integrated. CIN requires a structure such that the network of competing providers will result in a high degree of provider interdependence and cooperation to control health care costs and ensure quality health care through the CIN. Properly structured, the CIN will avoid a per se violation of price fixing, market allocation or agreement not to compete.

Some key provisions to reduce Antitrust

Risks are: 1) Providers should enter into nonexclusive contracts with the network such that the providers can engage in contracting independently or through participation in a competing network; 2) The providers agree to participate in all payer contracts entered into by the CIN. This increases the likelihood that the providers will actively participate to achieve the quality and efficiency goals; and 3) The CIN provides a mechanism to avoid competing providers engaging in discussions and possible anticompetitive agreements outside of the legitimate business activities of the CIN, such as regular provider antitrust counseling.

Key takeaways for distributions of funds: 1) Payments to physicians must not violate the Stark law or anti-kickback statute and similar state laws; 2) Ensure overall purpose is not to induce physician referrals; 3) Document appropriate business case; and 4) Ensure payments are reasonable and are within fair market value for physician’s participation.

The rapid evolution of the health care market requires providers to consider a range of options to best meet patient and financial imperatives. The antitrust laws recognize that there are patient and efficiency benefits created when providers work together, but different forms of collaboration create different levels of opportunity and risk, which are all highly fact-specific. Those risks should be carefully assessed before moving forward.

Michael R. Lowe, Esquire is a Florida board-certified health law attorney at Lowe & Evander, P.A. Brian C. Evander, Esquire and Mr. Lowe regularly represent providers, physicians and other licensed health care professionals, and facilities in a wide variety of health care law matters. For more information regarding those health care law and such matters please visit our website https:// www.lowehealthlaw.com or call our office at (407) 332-6353.

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PHYSICIANSPOTLIGHT

Celebrating a Decade of Dermatologic Care for the Uninsured Jerri Johnson, MD, Shepherd’s Hope “At Shepherd’s Hope, I help people who have nowhere else to turn to for health care,” said Jerri Johnson, MD. “For over a decade, I have been part of an amazing group of medical professionals who change the lives of men, women and children in our community just by volunteering a few hours a month.”

An Orlando native, Johnson opened her private practice, Altamonte Dermatology, in 1991, which has progressively grown over the years. In 2018, Allison Cassedy, PA, joined her team; the practice accepts new patients. Friend and colleague Sandra Stine, MD, a Shepherd’s Hope volunteer, invited Johnson to become involved with the non-profit organization in 2009.

“Helping people who so desperately need medical care, who are uninsured and cannot afford care, strengthens our community.

It’s gratifying to know that you are helping individual people as well as providing care that keeps our community healthier,” she said. Shepherd’s Hope has provided over 275,608 free medical visits and patient services since first opening in 1997.

As a board certified dermatologist, Dr. Johnson treats patients at Shepherd’s Hope for conditions ranging from acne and rashes to skin cancer. “In many instances, patients have lived with a skin condition for a long time because they do not have health insurance. Typically, I can provide treatment on-site including the removal of most skin cancers. If the skin cancer is too large to perform the procedure at Shepherd’s Hope, the patient is referred to an ENT or plastic surgeon,” said Johnson who volunteers at the Longwood Health Center. Shepherd’s Hope also offers services at locations in East Orlando, Downtown Orlando, Ocoee and Winter Garden.

Working to provide overall health for patients, other Shepherd’s Hope volunteers often refer patients to Johnson.

“Other providers see a chronic rash, a growth or a skin condition that needs care, and let the patient know that dermatologic care is available to them through Shepherd’s Hope. The patients so appreciate that their doctors are looking out for them,” she said.

Dr. Johnson’s commitment to the community is a shared passion in her family.

Her husband, Seth Johnson, DO, Maitland Avenue Urgent Care, has also volunteered at Shepherd’s Hope since 2009. “We volunteer on the same evening each month.

We enjoy working with the other volunteers who treat patients, assist and even provide translation services. It’s such a great network of people dedicated to providing quality health care,” said Jerri Johnson.

As a dermatologist, removing lifethreatening cancers is a primary facet of Johnson’s work. “I treat a lot of skin cancer because of the effects of the sun here in Orlando. Sometimes, because Shepherd’s Hope patients could not afford preventive care, the cancers are extensive. Having access to a dermatologist gives them the ability to have skin cancer detected and treated in its early phases,” she said.

“Sometimes, though, it’s the small things that make a huge difference in a patient’s life,” she said. “A simple procedure removing a growth or treating a rash can greatly impact a person’s self-esteem. They feel their personal appearance is improved, so they gain confidence,” she said.

Her husband referred to her a Shepherd’s Hope patient who had a large, disfiguring growth on his forehead. She was able to remove the growth on-site. “I so vividly

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remember him exclaiming, ‘Oh my gosh, I can go to my high school reunion now!’

That made me so incredibly happy,” said Johnson.

“I have volunteered at Shepherd’s Hope for 10 years. What stands out to me the most with all the patients I have treated is how utterly appreciative they are. As health care providers, we help them with medical conditions they cannot fix themselves. And without health insurance, they do not have any other way to obtain the care they need. Shepherd’s Hope fills that void, and changes people’s lives with every visit,” said Dr. Johnson.

“Just one evening a month changes the lives of so many people here in Orlando. At the end of the day, it feels so good to know that you’re part of such a caring organization,” she said.

Johnson received her undergraduate degree from Emory University and her medical degree from the University of Florida. She completed her internal medicine residency at Orlando Health and her dermatology residency at the University of Arkansas. She is board certified in both

internal medicine and dermatology. She provides a wide range of medical, surgical and cosmetic dermatologic services for patients of all ages.

She is a Fellow of the American Academy of Dermatology, Florida Society of Dermatologic Surgeons, American Society for Dermatologic Surgery and American Society for Laser Medicine and Surgery.

She has been a clinical assistant professor at FSU College of Medicine since 2004. She was an assistant professor at the University of Central Florida College of Medicine from 2012-17.

With the idea that “none of us knows how to do it all, but all of us know how to do some of it,” Dr. William S. Barnes, senior pastor of St. Luke’s United Methodist Church, founded Shepherd’s Hope in 1997. The non-profit depends on volunteer physicians, nurses and other licensed health care professionals to provide quality health care for people in the community.

To learn more about volunteering with Shepherd’s Hope, contact Abby Rice, Director of Volunteer and Community Based Programs, at (407) 876-6699, ext. 233; Abby.Rice@ShepherdsHope.org;

or visit

shepherdshope.org/volunteers

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EAST ORLANDO CHAMBER OF COMMERCE

CALENDAR:

La Crema de Nona NEW LOCATION Every Tuesday 8:30 – 9:30 AM GRAFFITI JUNKTION NONA

9344 Narcoossee Rd., Orlando, FL 32827

EOCC Educational Series on the Menu “8 NON-NEGOTIABLES OF SALES SUCCESS” WITH JOE PICI

Wed, Oct 9, 11:30 AM – 1:30 PM

East Orlando Chamber office 12301 Lake Underhill Rd., Ste. 245, Orlando, FL 32828

Coffee Club Goldenrod at Baldwin Fairchild Thr, Oct 10, 8:30 – 9:30 AM Baldwin Fairchild Dignity Memorial 2420 Harrell Road, Orlando, FL 32817

Ribbon Cutting: Nona Minimally Invasive Surgery Lake Nona Thr, Oct 10, 5:30 – 8:00 PM

12601 Narcoossee Rd., Ste 209, Orlando, FL 32832

2019 Education Day presented by East Orlando Chamber & Orange County SHOWCASING ORANGE COUNTY PUBLIC SCHOOLS

Sat, Oct 12, 10:00 AM – 2:00 PM

Jay Blanchard Park || 2451 Dean Road, Orlando, FL 2817

October Chamber Luncheon presented by AdventHealth “WOMEN IN BUSINESS” FEATURING DEBORAH SPIELMAN, YAMILE LUNA & SCOTT SUTHERLAND

Wed, Oct 16, 11:30 AM – 1:15 PM Rio Pinar Country Club | 8600 El Prado Avenue, Orlando, FL 32825

Coffee Club Semoran at Bonefish Grill Orlando Gateway Thr, Oct 17,

Bonefish Grill Orlando Gateway 5463 Orlando Gateway Vlg. Circle, Orlando, FL 32812

EOCC MEDICAL CITY

PRESENTED BY

Networking for Healthcare Professionals Just What the Doctor Ordered

By DOROTHY HARDEE, Chamber Administrator

Healthcare providers are some of the busiest people around dedicating significant time to their patients as well as continuing medical education to stay current in their field as required by the state, not to mention additional time balancing a family or personal time. It is easy for a practitioner to get bogged down with the daily routine of going to the office or hospital, seeing patients, performing procedures, completing paperwork/EMR then leaving the office or hospital to start over again the next day. This monotonous routine often leads to physician burnout. Little interaction with colleagues can also put a strain on patient referrals ultimately affecting the business.

ReferralMD examined the issue, suggesting positive relationships with both patients and providers was instrumental for a healthy practice. It is important to devote at least one day every quarter to visit other physicians in your area, introducing yourself and your practice. Once you have put this practice into place, reach out to existing referring providers finding time to network whether by meeting for a quick drink, meal or inviting them to

your home expressing your appreciation for their referrals. Networking opportunities can also be found through hospital sponsored events, lectures or associations.

Cultivating relationships is important for succeeding in business. Adam Small, CEO of the Strategic Business Network described networking as the “single most powerful tactic to accelerate and sustain success for any individual or organization.” Author John Maxwell was quoted saying, “your network is your net worth.” Anyone wanting to succeed in his or her chosen career, needs to build a rapport with their professional peers making networking critical to success.

Associations connect healthcare providers with others of similar backgrounds or focuses. You may ask yourself, with so many professional organizations why add the Chamber of Commerce to your arsenal.

The East Orlando Chamber (EOCC) makes the connection between healthcare and business owners and their employees giving the opportunity to expand a physicians practice.

Through the EOCC Healthcare Council, a committee will raise awareness of importance of health in the workplace and changes in healthcare options and regulations. They will examine pertinent health legislation explaining the impact on the business community. As the committee continues to grow, it will open an opportunity for workshops allowing businessmen and women to hear directly from hospital executives and industry experts,

as well as healthcare professionals.

In addition to the value of a Healthcare Council, Chamber membership offers money saving benefits for printing, merchant services, FedEx shipping and more.

Health benefits are also available for you, your employees and their household. As your practice expands, post job openings, press releases about new members of your team or procedures being offered, as well as community events giving you more exposure throughout Central Florida.

With more than thirteen events per month, you will be sure to find ways in which to connect and grow your practice. Our newest After Hours hosted by Bonefish Grill, is presented by Orlando Medical News and the East Orlando Chamber offering information you can use in the healthcare arena.

The EOCC thinks differently for members taking a close look at their needs providing events and content focused on industry. We cover everything East of I-4 and strive to be the leading resource in business advocacy, community engagement and regional connectivity.

Joining the East Orlando Chamber, becoming actively involved in all it has to offer is the perfect way to grow your business. Give us a call at 407-277-5951 or visit our website at eocc.org. Your Business is Our Business.

Dorothy Hardee is the administrator of East Orlando Chamber of Commerce. Contact her at DorothyH@eocc.org

EOCC Connect 4 Property Professional Networking Thr, Oct 17, 4:30 – 6:00 PM

Bonefish Grill Lake Underhill 12301 Lake Underhill Road, Orlando, FL 32828 Free for EOCC Members - $10 for non-members

Small Business Breakfast & Seminar with Gerry O’Brion Tue, Oct 22, 9:00 AM – 11:30 PM

Ace Café || 100 W Livingston Street, Orlando, FL 32801 RSVP’s required

Ribbon Cutting: Your CBD Store Tue, Oct 22, 5:30 – 7:00 PM

10376 E Colonial Drive, #127, Orlando, FL 32817

Coffee Club Nona at Sam’s Club Small Group Day Thr, Sep 26, 8:30 – 9:30 AM

Sam’s Club Lake Nona | 11920 Narcoossee Rd, Orlando, FL 32832

EOCC Scholarship Foundation Golf Outing Wed, Oct 30, 9:00 AM – 2:00 PM

Rio Pinar Country Club | 8600 El Prado Ave, Orlando, FL 32825 *REGISTRATION DEADLINE: TUESDAY, OCTOBER 15, 2019

EOCC 5th Thursday After Hours at Marlow’s Tavern Lee Vista Thr, Oct 31, 5:00 – 7:00 PM

Marlow’s Tavern Lee Vista | 6889 Eagle Watch Dr, Orlando, FL 32822

Please visit www.EOCC.org for a complete listing of October's events.

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Florida Medical Marijuana, continued from page 1 Physicians are extremely risk averse.

As a professional who has spent many years and hundreds of thousands of dollars to complete their medical education, physicians typically do not “jump” to start a new medical service without a tremendous amount of research and validation that their medical license or medical practice will not be negatively affected in some way. As of August 30, 2019, there were 2,466 Qualified Physicians in the state of Florida who can certify MMJ patients. The Florida statute for “Qualified Physician” is below: “A physician must have an active, unrestricted license as a physician under Chapter 458, F.S., or osteopathic physician under Chapter 459, F.S., and complete a 2-hour course and exam before being qualified to order medical marijuana and low-THC cannabis for qualified patients.”

If every MMJ certification was evenly distributed between all of the Qualified Physicians, there would be approximately 38 MMJ certifications per Qualified Physician during the period in question. So, the state has plenty of Qualified Physicians to certify MMJ patients, but very few who are willing to actually write the certifications.

“Early Adopter” Physicians are not pill mills. Ten years ago, Florida was ravaged

by physicians who were writing prescriptions for highly addictive narcotics and selling the same narcotics in their offices. This practice was made illegal by the Florida legislature and Florida physicians are now unable to sell narcotics in their offices. Based on the previous problems with pill mills, the state of Florida placed safeguards in the Florida

MMJ law (F.S.381.986), which does not allow a conflict of interest by writing MMJ certifications and selling MMJ. Furthermore, each physician must check the prescription history of controlled substances prior to issuing an MMJ certification and patients are only allowed to have an MMJ certification from one Florida physician, which prevents “doctor shopping,” attempting to get multiple certifications from multiple doctors. Excerpts from F.S. 381.986 are below: “b) A qualified physician may not be employed by, or have any direct or indirect economic interest in, a medical marijuana treatment center or marijuana testing laboratory.”

“5. Reviewed the patient’s controlled drug prescription history in the prescription drug monitoring program database established pursuant to s. 893.055.”

“6. Reviews the medical marijuana use registry and confirmed that the patient does not have an active physician certification from another qualified physician.”

MMJ certifications have become another medical specialty. Due to few

physicians willing to write MMJ certifications, specialty physician practices have been created in Florida which focus primarily on writing physician MMJ certifications. These companies provide a public service by allowing physicians, who do not want to write MMJ certifications, a place to send their patients to receive a certification. These specialty practices have become well versed in understanding the Florida law regarding MMJ certifications, qualifying diagnoses, contraindications, and (CONTINUED ON PAGE 11)

EOCC’s RX

Helping YOUR Practice Succeed!

• • • • • • • • • • •

Health Insurance Program to Deliver Benefits for Local Physicians

By FRASER COBBE

The Physicians Society of Central Florida (PSCF) Board of Directors is extremely pleased to announce the launch of a health insurance program for our members and their employees through a partnership with FBMC Benefits Management. This program signals our most significant foray into health insurance coverage for our members.

Employers continue to struggle with rising healthcare premiums, and with employees who understand and recognize the value of the benefits that are provided by the employer. Physicians that own and operate independent practices are not immune to these challenges. In fact, physicians have a most unique and frustrating vantage point since they witness first-hand the realities of trying to provide care in the current health care system, at the same time trying to secure affordable and accessible coverage for their employees. At the heart of the frustration for physician employers, is an ability to bend the cost curve and lack of transparency on how their premium dollars are spent, oftentimes limited based on the limited number of employees that they employ.

For a number of years, the broader business community has been leading the effort to take control of their health care costs through transparency and accountability. Self-funded programs enable employers to reduced fixed costs and control their overall spending by incentivizing employees to utilize health care resources in a more sophisticated manner. The success of these self-funded programs with reducing costs while providing transparency has significantly increased the prevalence of selffunded solutions.

This trend has been somewhat limited for physician practices due to the need to

have a critical mass of employees to make it possible from a financial and risk tolerance perspective. It is this limitation that PSCF has been able to address through this partnership, expanding the ability for Physicians to take control of their employee healthcare options.

With this program launch, PSCF Members can now join the captive self-funded program put together through our partnership with FBMC. FBMC has a great deal of experience providing employee benefit solutions to employers throughout the state, including Miami-Dade School District and Jackson Health System, among others. The team supporting the captive has extensive background in establishing and administering captive programs for regional and statewide organizations and understand and are able to answer many of the challenges and questions that may arise when considering joining this captive. The program will deliver transparency, control and cost savings in a turnkey solution that will not disrupt benefits for employees.

Most importantly, the program will transform health insurance benefits from an ever increasing fixed premium, to a variable cost for which they have capped risk, full transparency and the ability to keep what they save. Practices with 20-200 employees will be the ideal beneficiaries of the program.

Members interested in finding out more should contact the PSCF office, 844-234-7800.

Fraser Cobbe is the Executive Director of the Physicians Society of Central Florida. Visit https://pscfl.org/

Health Benefits for you, your employees & their household Industry focused networking Ability to post News Releases & Job Postings Access to promote Special Deals to public & members only Complimentary Notary Services Discounts on Constant Contact Discounted rates for FedEx, Office Depot, Crayola Experience Exclusive discounts Member pricing for EOCC events Conference Room Rental Special rates at Troy University & so much MORE!

EOCC’s RX

Helping YOUR Practice Succeed!

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HOUSE CALL

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OCTOBER 2019

By DAMON VAN DYKE

Being a medical professional means working year-round to provide quality care to the public. For those who choose this career path, putting the needs of their patients first is a daily goal. With such lofty priorities, it’s understandable that finding the time to become a homeowner may have taken a backseat.

Whether it’s qualifying for a home loan or the financial commitment that goes with the territory, the process can seem like a daunting task to add to an already busy schedule. For those in the medical field, it’s important to know that there are additional loan programs that may be available to you.

When it comes to deciding which loan is best, remember that no two loans are alike.

In fact, they are as different as the people who apply for them. There are many mortgage companies that match you to a loan program based solely on numbers you punch into their algorithm, but the numbers don’t always tell the whole story. Finding a loan originator who is committed to talking to their clients about their personal circumstances and helping them find the best loan option is key.

Mortgage Flexibility for Unique Financial Needs A common myth is that borrowers must put down 20 percent of the purchase price to be considered for a loan; don’t let this myth deter you from applying. Loan programs vary wildly when it comes to the required down payment, some going as low as zero percent of the purchase price. Keep in mind that generally the more money you put down initially, the lower your monthly costs will be – and vice versa.

Another misconception is that the loan process is always lengthy and drawn out, especially if you’re building a new home.

Traditionally, a construction project requires borrowers to secure two loans, one to cover the build and another for the mortgage.

There are now multiple programs avail-

able – including Silverton’s ConstructionPermanent Program – that enable borrowers to close on only one loan for a construction project, as opposed to two.

For a hassle-free loan experience, another alternative is Silverton Secure+, which allows you to have your loan fully pre-approved before you find a house. While the pre-approval is still subject to standard closing conditions and verification of unchanged financials, this program enables you to make a strong purchase offer and close quickly on your loan, giving you a distinct advantage if there happen to be multiple offers on the property.

Programs for Healthcare Professionals and Other Heroes In addition to numerous finance options, Silverton Mortgage is proud to partner with two programs designed especially for those who work in the medical community: Heroes Home Advantage™ and Homes for Heroes®. Heroes Home Advantage™ is a network of real estate agents, lenders, attorneys, home inspectors, title companies and more who recognize the importance of giving back by offering a real estate discount to the those who give so much of themselves.

Eligible participants include doctors, nurses, technicians, EMT’s, home health aides, and dispatch operators. This program offers reduced fees and lower closing costs, saving participants an average of $2,150 when they buy, sell, or refinance a home through Heroes Home Advantage™. Savings will vary based on your home transaction.

Homes for Heroes® is a similar program where it may be possible to receive rebates and discounts, including $500 toward lenders fees. According to Homes for Heroes®, those who qualify may save over $2,400 when they buy, sell, or refinance a home through this program with a Silverton Mortgage loan originator and a participating real estate agent.

Both programs provide welcome and (CONTINUED ON PAGE 7)

All loans subject to credit approval. Vanderbilt Mortgage and Finance, Inc., dba Silverton Mortgage | 1201 Peachtree St NE Ste 2050, Atlanta GA 30361, 855-815-0291, NMLS #1561, www.nmlsconsumeraccess.org/, AZ Lic. #BK-0902616, Loans made or arranged pursuant to a CA Finance Lenders Law license, GA Residential Mortgage (Lic. #6911), MT Lic. #1561, Licensed by the NJ Dept. of Banking and Insurance, Licensed by PA Dept. of Banking, RI Licensed Lender. Equal Housing Opportunity. All information is believed accurate and is subject to change without notice. MLO NMLS 355447 09/19

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DOCTORS CORNER

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The Internet is Still Great for Your Business and Medical Practice

Mortgage Programs Designed for Medical Professionals, continued from page 6

By QUINTIN L. GUNN SR.

In June of 2015, I wrote an article on Linkedin entitled Is Social Media Good for Your Practice? Most of what I said then still applies now because it showed how the internet, in general, remains an integral and necessary part of business and practice growth for consumer engagement. This thought process applies to both new and current clients.

The internet, in truth, is really the lifeblood of any fee for service business or practice.

much-deserved savings to healthcare professionals who dream of becoming homeowners. Orlando has a thriving and diverse medical community, and when our local doctors, nurses and other healthcare professionals decide to become homeowners, Silverton Mortgage wants them to know that there are options designed especially for them.

Because we live in a Mobile First world It’s where patients find out about who you are, what you can do for them, and if your products or services meet their budget.

is your walking, talking testimonial, recommendation, or referral.

Practice Website - This is your 24-hour online brochure. It should be clean, easy to read and navigate, mobile, and have multiple ways to contact you or your business for service. With it, you can tell the who, what, when and how. Cost may vary based on the number of pages, design selection, content that is needed and modules used within the site to attract new business. Your baseline cost will range from $1500 to as much as $12,500.00. WordPress is the most consistent design platform that is accepted today.

Here are some typical things that go into your website: About Us, Product Images, Before and After images, Video, Contact Form or Patient Portals, Blogs, and Frequently Asked Questions (FAQ), Testimonials or Recommendations.

In the aesthetic industry, the more before and after images you show to consumers the better the proof of results and finally request for an appointment.

Videos, on the other hand, provide a live view of the possible experience a customer can expect when being treated at your practice or place of business.

Having a Patient Portal provides a way for some of the pre-authorization forms to be processed, thereby reducing wait times.

FAQ - (Frequently Asked Questions) Provide answers for some of the most fre-

From the outset, a monthly marketing budget must be established. Why? Because you can’t reach your income goals unless you know how many customers are needed and what it will cost to reach that number of paying customers.

In today’s competitive environment, marketing isn’t free. But if you set a budget, make a plan for every month, and use all or most of the listed tools, you’ll find continued and sustained growth in your business or medical practice.

How much do you need to spend?

Typically, a budget of 20 percent or no less than 15 percent of your monthly gross income. That number is based on the fact that marketing is a necessary expense and should be viewed as a part of the monthly expenses.

When you start your marketing program, what are the tools you should use?

Word of Mouth Referrals - This is a great, yet free source of advertising and usually has a higher conversion rate. Why do you ask? Because in most cases a friend confirmed the quality or benefits of a product or service after treatment or purchase. This

quently asked questions your business gets from inquiring customers. It is also a nice way to educate your patient population on some of the many services or treatment plans that are requested most often.

Social Media Is Key to Brand Building and new patient awareness. While this is often a free tool for your practice or business to start out, there are some costs. However, the general idea is to create a lot of buzz about your business or medical practice.

Most, if not all fee for service businesses utilize these tools. Why? Because they are fast becoming the required and dominant source for attracting and keeping attention.

Today’s consumers run hot and cold based on the time of the day, month, or year, it’s best not to put your eggs all in one basket.

Trial and error will determine what works best for your business or practice. Be patient and stay the course because it may take time for branding to take place and traction to begin - no less than six months.

Let’s take a look at some of these easy to use tools Facebook - Uses images, allows live streaming of events, allows video, you can also post articles, and promote services via online coupons. It is one of the most interactive platforms today! In truth, at its core, it is an online website that provides viral marketing, testimonials, recommendations, and lead (CONTINUED ON PAGE 8)

Supporting Orlando’s Healthcare Heroes Silverton’s team in Orlando has worked with plenty of medical professionals and understands the erratic schedules and high-stress situations they encounter every day. To avoid adding another headache for them with the mortgage process, the team takes great care in working to make the experience as smooth as possible.

We’ll work around medical professionals’ challenging schedules to get the job done.

As Orlando residents, our branch appreciates what medical professionals do to keep our community healthy and thriving.

We’re proud to work for a company that has chosen to partner with Homes for Heroes and Heroes Home Advantage™ so that in some small way we can say thanks.

Silverton Mortgage appreciates those who work to make the world a better place.

By offering so many diverse mortgage options and participating in programs that support our heroes, we strive to be the preferred lender for those who work tirelessly to support the communities that we live in. If you’d like to learn more about Heroes Home Advantage™ or Homes for Heroes® and how you can utilize their benefits to help you secure a mortgage, contact a mortgage professional at http:// www.silvertonmortgage.com.

Damon Van Dyke is the manager of Silverton Mortgage’s East Orlando branch. He has more than 20 years of mortgage experience and a thorough knowledge of mortgage lending across Central Florida.

Website Older than 2-Years?

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How you look online will attract or repel new patients. If your image colors and design layout are outdated, new patients might think your practice is outdated.

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DOCTORS CORNER |

Internet Still Great for Your Business, continued from page 7

generation tools. You can also pay to promote your page or product using the Boost Page Option. The paid option can source by topic, specialty, location, age, gender, etc.

Twitter - Uses 140-character content, with images and video options for promoting and finding new customers or a target audience of like-minded people. This is also a good lead generation tool if you pay a fee, and again uses sorting methodologies related to the topic, specialty, location, age, gender, etc.

It helped Trump win the Presidency and is one of the primary ways he communicates to the country as strange as that sounds.

Instagram - Uses images, video, and live streaming of events to help attract new prospects and customers. A paid option also exists for this platform. The downside is that many of your followers may not actually be buyers. But it is a tremendous branding and exposure tool. You can search and source by topic, specialty, location, age and gender.

Pinterest - Image and now video-based platform with many infographics, graphs, charts, and useful tips for your followers to use and to be shown for improved response Google My Business - Is a free online website that Google provides for business introduction and updates. What makes Google My Business a great tool is that it gives you everything you need in an organic way to attract new business. You can post video clips, in office specials, patient testimonials, location map which can be the life cord to consumers trying to find your office. But the most important feature is the Click to Call

feature that is often overlooked. Tremendous tool when its fully optimized and claimed.

Snapchat - Image-based mobile platform, limited in what it can offer business, but is a fan favorite due to live stream moments, instant stories and events and targets mostly the younger crowd between the ages of 16 – 28. Young people like this format as the images dissolve after a time period. This allows a little more questionable behavior but it’s becoming one of the most popular tools on the internet as the more mature crowd starts getting the hang of it.

LinkedIn - This is a wonderful tool for business professionals, students, and consumers of all types. Additionally, as your audience grows, your email contacts begin to grow by the company, position title, product type, specialty groups or communities, which provides very specific targeting for products or services you want to sell or make available. You can also share ideas or gain business insights within your field from some of the most important thought leaders.

Google Ad words/Pay Per Click - Used to accelerate and enhance your ability to jump to the front of the line in order be found at the top for online search engines.

Large and small companies alike use Google Ad words with the goal of jumping to the front of the line for new consumers and businesses alike. Users must keep in mind that this is a pay to play model, and some view it as online extortion, because of traffic of new prospects slows or stops completely if you lower or eliminate your ad word bud-

get. Another recent downside or negative is Google can disallow certain medical marketing based upon industry intolerance.

Regardless of how a business or medical practice may feel, if you don’t feed them, they won’t feed you new prospects of any kind beyond intermittent organic leads.

In our view at Social Media Solutions for Doctors, Google Ad Words can still be an essential part of any marketing or new website design program as it enables businesses to set a daily, weekly, monthly, or annual budget for lead generation and new customer acquisition via online advertising.

Google Ad Words are largely focused and/or targeted via specific keywords which again identify products, services, people and brands that a person or company might search for or has expressed an interest in via their Google, Yahoo, or Bing searches Every practice and business has high and low revenue cycles, know what your business highs and lows are and adjust the marketing budget accordingly. We tell all our clients, plan ahead for slow months, and expect to spend more during these slow times as your competition is likely adjusting their own budget upwards to reach those buying prospects during this down cycle.

The great part with Google Ad words is that you only pay when people click the featured link that takes buyers to a dedicated landing page or your website contact page where questions get answered, services get promoted or where you can display products that get purchased online. It also provides

the ability to understand your buying audience, their customer needs and what types of leads become buying consumers who pay most often from your website.

Because Google Ad Words has the ability to move you to the front of the line and above Organic search results. You should expect to pay a premium for this opportunity of the preferred placement. Otherwise, without great content related to the topic or service, most businesses or resources find themselves languishing just beneath paid search placement with little or no traffic. So the rule of thumb with Google AdWords is Pay To Play!

Newsletters, Email Blast, Blogs: Newsletters: A newsletter’s primary goal is to keep current patients or prospects up to date on the latest and greatest related to products, services, or planned events. This should be done quarterly and is most effective when you’re announcing some milestone or major business achievement.

Email blasts: Email blasts should be used monthly and provide a list of in-office specials or online specials which the business or practice offers. You can also list upcoming events, new patient testimonials or before and after images from happy patients. However, we advise before you use any patient images, that you have the patient release forms completed and in the patient’s record showing approval to use their online image in your marketing information. This can be a great tool, but overuse can cause even your (CONTINUED ON PAGE 9)

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Voluntary Benefits Values & Savings DOCTORS CORNER

By JOSEPH FILICE

Business owners today are faced with rising healthcare costs and slimmer bottom lines. Many companies have looked to voluntary benefits to help ease the cost of healthcare while still offering a robust employee benefits package. Voluntary benefits have proven to lower company expenses on healthcare costs, provide the employees with multiple coverage options at different price ranges and helps make the company competitive in the market.

Voluntary benefits range from life, dental, vision, telehealth, accident, cancer, critical illness, medical insurance and much more. These benefits are offered to the employees through payroll deduction and the employee either covers a percent of the cost (contributory coverage) or it is 100 percent voluntary and the employee covers 100% of the associated costs. Voluntary benefits can be offered on their own with groups with less than 50 fulltime employees or can tailor to the major medical insurance if medical insurance is offered through the business.

Through offering voluntary benefits the business owner is still able to offer a robust employee benefits package while adding no additional cost to the company’s bottom line.

The value of voluntary benefits extends beyond the savings found by the business owner, but also through the employee. When a voluntary benefits package is offered the employees have the opportunity to choose what coverages would benefit themselves and their dependents best based on the employees’ own personal needs. Employees can then

Internet Still Great for Your Business, continued from page 8

choose the price range that they feel most comfortable with. This capability to customize their own benefits selection takes them out of the traditional one size fits all mold. Voluntary benefits allow the employee freedom of choice when it comes to coverages offered and price ranges desired tailored to their own personal demographics and needs.

Voluntary benefits allow companies to stay competitive in the market-place and with their local competitors. Employee benefits are one of the main factors (outside of compensation) employees decide to take a job or stay at a job. The more robust your employee benefits package is the more attractive your company is for a current employee or prospective new hire. Having a robust employee benefits package helps companies attract and retain their best talent. Most companies today that offer employee benefits advertise this proudly on their website.

As you can clearly see, voluntary ben-

efits offer value to both the business owner and the employees. Through offering voluntary benefits a company can offer an extensive employee benefits package with no additional added cost to the company’s bottom line while allowing the company to stay competitive in the market-place by attracting and retaining the best talent. Employees love voluntary benefits because they allow the employee to tailor their benefit selection to their personal needs and cost. To learn more about voluntary benefits and how your business can offer them contact your local employee benefits broker today.

Joseph C. Filice M.B.A. is the owner of Avalon Insurance Services, LLC located in Avalon Park Florida.

Joseph has been in the insurance industry for more than 13 years and is a proud member of the National Association of Health Underwriters (NAHU). Email him at jfilice@ avaloninsuranceservices.com. Visit www.avaloninsuranceservices.com

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most loyal customers to unsubscribe.

Blogs: Blogs provide an ongoing update of information and lead generation related to treatment pathways or services that your most frequent users care about. It also provides a great resource for helping with organic ranking. Because Google is nothing more than a big online library the Google spiders tend to always source new information for the search engines to display.

YouTube: Is a video catalog of instructional, entertaining, and informative video from a multitude of topics, countries, businesses, and individuals. It is one of the premier ways to show off your services, skill, and knowledge. In fact, many people use YouTube as an online television.

By adding meta tags (internal keywords for sourcing the video) for each video that relates to a topic, you can post a video that is sourced by category, products, services, interviews, how to demos, and music selection.

YouTube videos can be shared across most if not all social media platforms, newsletters, blogs, websites, landing pages and pay per click programs.

Now that we’ve identified several of the major players in capturing new business, or patient leads. Expect that there will be more on the horizon. And you can also expect that within each company that we’ve listed, they will continue to make updates and modifications within their own platforms as their goal is to capture you in their net or have you select them as the go-to company used to acquire new business or patients.

The truth is, no one size fits all since each company impacts different audiences.

All the new or current services you provide are tied to your ability to be seen, heard, or identified. Using all or some of the listed tools will help you maintain and grow your business or medical practice. Failure to use these tools properly, show misleading information or images or having a budget that is too small for the audience you want to reach will slow or kill your business brand or medical practice profits.

Set a budget, be willing to modify if needed, and try as many tools as you can.

Our next discussion will center around third-party marketers, and directories. Who are they? Do they help or hurt, or can you do it yourself ?

Quintin L. Gunn Sr. is a Practice Development Consultant with Social Media Solutions for Doctors. Visit SocialMediaSolutionsforDoctors.com

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Questions to Ask When Upgrading/ Building MRI or Radiology Facilities

By MARK BAY

Whether you are planning an upgrade to your existing MRI/Radiology facility or are planning to open a new one, there are extremely important and preliminary questions that should be asked that are often overlooked in the planning stages, and have an enormous effect on overall costs that can even derail the project altogether. We are assuming that you have contacted an experienced general contractor to ask these questions, which brings us to our very first question: Why should I speak to a General Contractor (GC) first? Isn’t he/she just in charge of the construction phase of the project?

While the GC oversees construction of the project, the GC often has the most comprehensive knowledge of all phases of a project from design to estimating to permitting to construction to commissioning of the equipment. Often, the design team, a permit technician, MRI/radiology equipment supplier or real estate broker can only provide information in their area of expertise. A general contractor with previous MRI/Radiology experience will know the ins and outs of the permitting of a project like this, can assist the design team in designing equip-

changes. It is possible your power requirements for the new equipment are different and your existing electrical design cannot accommodate the new equipment without an upgrade. This would require an electrical engineer. So, there are many questions that arise regarding the specifics of the facility, the existing physical plant as well the equipment itself that need to be discussed before this question can be answered accurately.

ment locations and space requirements, ask the proper questions of an existing building owner, the power company and the local authority having jurisdiction and even answer questions and solve issues regarding the equipment itself so large purchases are not made without prior knowledge, which could cause major issues before or worse, after installing equipment. This leads to our second question once we are talking to an MRI/radiology experienced GC. Do you have a design team in place, and who would make up the design team if I need one?

The answers to these two questions will largely depend on the type of project you are planning. If you have an existing facility

and are seeking to upgrade your equipment but not necessarily perform additional construction upgrades, then you may not need a design team. This will depend on factors including but not limited to if the old equipment can be removed from the building, and the new equipment installed into the building without breaching the building’s structure. Some facilities were constructed with future upgrades in the design. Others may require creation of an access for the equipment to be removed and installed which will likely require a structural engineer. If the new equipment requires ancillary equipment, is there enough space inside the existing building to accommodate the new equipment configuration. If not, an architect may be required to design interior room

Once it is decided and agreed that a design/construction team is necessary, who do I put on this team and what is the importance of beginning with a good collaborative team?

This will depend on many many factors some of which include the type of project; is this a new building or existing building?

Is there existing equipment being replaced?

Does the existing infrastructure and engineering fit the requirements of the new equipment? There is a myriad of answers to this question and almost as many more questions arise from this one as there are a multitude of scenarios that experienced MRI/radiology contractors have encountered. Projects that are a collaboration of the entire design team; architects, engineers, the construction contractor and his key subcontractors, the shielding contractor, the equipment supplier (CONTINUED ON PAGE 11)

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Florida Medical Marijuana,

Questions to Ask When Upgrading/Building MRI or Radiology Facilities, continued from page 10

continued from page 5

delivery methods of MMJ. Medical Marijuana Physician practices are becoming a medical specialty no different than referring a patient to a cardiologist, oncologist, radiologist, orthopedic surgeon, infectious disease physician, or other physician specialty practice.

Many Physicians are now employees.

With consolidation of healthcare across the United States and the increase of ACOs, more and more physicians do not own their own practices. Physicians are becoming employees of major healthcare providers, just like other traditional healthcare specialists such as nurses, ARNPs, PAs, physical and occupational therapists. With fewer physicians able to own their own businesses, their employer determines whether they can participate in writing MMJ certifications. So far, none of the major Florida healthcare providers have publicly announced that they will allow their physicians to write MMJ certifications.

As the Florida MMJ system progresses, we must continue to evaluate the program and ensure there is balance between the 3 pillars of the industry – public safety, patient access, commerce. However, we must also recognize potential factors contributing to any data procured through this new industry and not jump to conclusions that are invalid or not accurate based on individual bias of medical cannabis or past experiences with other health programs.

Michael C. Patterson, founder and CEO of U.S. Cannabis Pharmaceutical Research & Development of Melbourne, is a consultant for the development of the medical marijuana industry nationwide and in Florida. He serves as a consultant to Gerson Lehrman Group, New York and helps educate GLG partners on specific investment strategies and public policy regarding Medical Marijuana in the U.S. and Internationally. He can be reached at mpatterson@uscprd.com

and equipment engineers, the owner, as well as an experienced equipment operator wind up being the smoothest projects with the least number of glitches and cost overruns along the way. With the collaboration of all the team members, many if not most of the typical repeat issues for projects of this type can be eliminated. When one member of this team does not participate from the beginning, nine times out of ten some portion of the work will have to be undone or removed or relocated, and then redesigned and constructed or installed a second time. Collaboration from the beginning eliminates afterthoughts, and afterthoughts equate to cost overruns which equate to a bad experience.

How long can I expect my project to take and who can best inform me?

This is where a general contractor can give a client the most accurate information.

Many individuals with some construction knowledge but little actual field experience believe they know how long a project “should” take and this is not always based on fact or field experience, but mostly speculation, theory or comparison to other projects that may appear similar on the outside but once a detailed examination takes place, are vastly different in content and complexity. This question is best and most accurately answered by a contractor who has visited the site of the project, examined the design plans, collaborated with the major participants of the potential project and is familiar with the jurisdiction in which the project is located. The economy also influences the duration of a project regardless of how large or small it may be. We will explore that variable at another time.

Do I need a permit for my project?

Once again, this answer often depends on the size and type of the project, however it is best to assume that you do. Legally, if a construction project exceeds$1,000, a permit is required with many exceptions to this listed in detail in the Florida Building Code. As a rule of thumb most projects involving the replacement of, relocation of or installation of new or used MRI or radiology equipment will require a permit issued by the authority having jurisdiction (local building department). Once the parameters of the work are defined, this question can usually be answered quickly.

In the upcoming second part of this article, we’ll take a look at contracting for an existing facility or tenant buildout. Questions we’ll address are: How long does design and permitting take?

Is MRI/Radiology construction different or specialized compared to standard commercial office construction?

What type of construction is your existing building?

Do you have an equipment supplier and how well do you know what they supply?

Are you buying or leasing new or used equipment?

Is there a shield in place or do you need one? Copper or Steel?

What about your budget?

What is the access to your building for the equipment?

Do you know if the power requirements for your equipment can be met in the existing building?

Mark Bay is owner and CEO of Tri-Bay Construction LLC, a Commercial Contracting firm located in Oviedo. Mark is an alumnus of Columbia University and has over 30 years’ experience in the construction business including numerous MRI and radiology facilities throughout Florida. Tri-Bay Construction has partnered with an internationally renowned shielding company, radiology facility designers, equipment suppliers, equipment transporters and subcontractors offering a unique team approach to imaging facility construction. Visit www.tribay. com or email mark@tribay.com

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.com

Should My Lease Rate Go Down During a Renewal Negotiation?

By DOUG PRICE

There are many variables that affect the success of a commercial real estate lease renewal negotiation: timing, market conditions, supply and demand, representation, the tenant’s needs and several more. Assuming the market is relatively steady and nothing unusual happens at the time of renewal, it is very common for lease rates to go down during a negotiation, not up. However, what ‘should’ happen, doesn’t always. Let’s take a deeper look.

Most leases contain an annual increase that compounds year-over-year from the beginning of the lease term. Those increases often outpace inflation and cost of living increases. This creates a scenario where lease rates climb faster than the economy climbs over a five, seven or ten-year period. The result is an above market lease rate, higher than what the landlord would be asking on a vacant space of the same caliber. By the end of the contract the lease rate is often way-above market.

However, getting a landlord to voluntarily reduce the lease rate back down to a market rate is something few landlords will do. It means they would potentially forfeit

tens to hundreds of thousands of dollars over the next lease term. Unless they are forced to or at risk of losing that tenant, reducing a lease rate is not something they will do without a fight.

Another question asked during lease renewal negotiations is, “Are similar concessions available to what you would receive on a new space?” The answer to that question has the same answer as the first. A lease renewal negotiation ‘should’ contain concessions, just like a new tenant would receive. But again, getting a landlord to do what is fair in the eyes of a tenant doesn’t happen without firm negotiation and a strategic plan of action.

Most landlord’s definition of a market lease rate is, ‘the highest they can get a tenant to pay.’ The same is true with concessions. Most landlord’s definition of a market concession is, ‘the least they can get a tenant to accept.’ On the surface it may appear that the landlord is trying to be deceptive but that is likely not the case. It simply has to do with the fact that commercial real estate is an investment. Just like you have investments and want the highest return on your portfolio, the landlord wants the highest return as well.

At the end of the day, most people are looking out for themselves.

Even the most gracious people prefer themselves, their opinions and financial incentives when it comes to real estate and what concessions should be given or received. Landlords are no different. They want the highest return as well. The reality is, lease renewal or new lease, the tenant needs to be treated fairly and obtain a market deal with market terms.

This is where an expert commercial real estate agent who is trained to represent healthcare professionals as tenants and buyers comes into play. An expert agent will help you begin your transaction at the appropriate time. Next, they will make sure you fully understand all your options and how to execute on each one. During this process they will invest dozens of hours of their valuable time, while saving you dozens of hours of your valuable time. They will work with you to create a custom real estate strategy with the goal of maximizing your profitability through real estate; while ensuring that your interests are always first and protected.

The difference between a properly or poorly negotiated transaction can impact every aspect of your practice. Make the most of your next negotiation by refusing to be taken advantage of by the landlord in your new lease or lease renewal.

Doug Price is an agent with CARR Healthcare, the nation’s leading provider of commercial real estate services for healthcare tenants and buyers. Every year, thousands of healthcare practices trust CARR to achieve the most favorable terms on their lease and purchase negotiations.

CARR’s team of experts assist with start-ups, lease renewals, expansions, relocations, additional offices, purchases, and practice transitions. Healthcare practices choose CARR to save them a substantial amount of time and money; while ensuring their interests are always first. Contact Doug at Doug.Price@carr.us

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Why Aren’t More Doctors Treating Addiction with Medication?

By COLETTA DORADO

I wrote in the September issue of Medical News about medication-assisted treatment (MAT) and counseling in opioid use disorder recovery to manage withdrawal symptoms. On September 9th the American Medical Association and Manatt Health had a press release announcing a new national policy targeting patient access to care, opioid overdose reversal medications, medication-assisted treatment (MAT). As the opioid crisis rages on, states are putting pressure on easing restrictions to treatment. Why, then, are more physicians not looking into treating addiction?

In 2018, the National Institute on Drug Abuse (NIDA) outlined MAT in these four settings: • Emergency Medicine Setting – A 2015 NIDA study suggest that MAT, initiated by emergency departments, increases engagement in opioid-dependent patients and reduces the risk of opioid misuse, as opposed to just a brief intervention and referral.

• Pediatric/Adolescent Medicine Setting – MAT in this setting is aimed at treating opioid addiction in children and young adults, mainly those in the range of 15-21 years old. Pediatric practices and medication-assisted treatment are especially compatible, as many of the skills necessary to engage young people in MAT—practicing family-based care, understanding developmental stages, and knowing how to speak to young people, for example—are all skills practiced by pediatricians every day.

• Federally Qualified Health Center Setting – FQHCs focus on communitybased outpatient care in underserved areas. They approach healthcare in a holistic way, which makes them such a good fit for integrated medicationassisted treatment for opioid use disorder.

• Primary Care Setting – Office-based opioid treatment (OBOT) programs provide another avenue for those with SUDs to seek treatment. Rather than undergoing medication-assisted treatment through a stand-alone drug treatment clinic, patients can receive treatment for addiction right through their physician.

That last item points toward the defining difference between use of buprenorphine and use of methadone as opioid agonists.

Since 2003, buprenorphine has been approved for office-based prescribing, creating the OBOT method that took the forefront over methadone.

OBOT marks an important step in the destigmatization of MAT as well as in treatment of OUDs. Conceding that MAT is a viable and mainstream treatment method and should be available in the primary care setting (albeit with a waiver) helps to normalize the practice and, more importantly, ensures greater access for those with OUDs.

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Evidence-based analysis supports the efficacy of MAT, particularly in comparison to abstinence-based programs. SAMHSA reports only a 5 percent success rate for abstinence-based programs, for patients in their first year. Studies have shown higher rates of success in programs that integrated medication along with recurring counseling sessions during the first year. In an experiment in Sweden of people addicted to heroin, the group receiving buprenorphine had 75 percent retention and negative urine tests after one year of treatment. The group receiving placebos had 0 percent retention.

A 2015 NIDA study suggests that MAT, initiated by emergency departments, increases engagement in opioid-dependent patients and reduces the risk of opioid misuse, as opposed to just a brief intervention and referral. A 2008 study by Gunderson & Fiellin reported that OBOT programs were effective for a “substantial” portion of patients, or about 50-80 percent.

Chris Hassan, the Symmetria Health CEO who played a role in the establishment of OBOT, wrote, “Only 23 percent of publicly funded treatment programs report offering any FDA-approved medications to treat substance use disorders, and less than half of private-sector treatment programs reported that their physicians prescribed FDA approved medication. In some areas, geography can contribute to difficulties in accessing MAT. For example, 53 percent of U.S. counties do not have a physician with the special waiver required to prescribe buprenorphine,

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one of the medications used for OUD treatment.”

This all brings us to this point: why aren’t more physicians treating addiction?

The number of opioid overdoses has increased every year over the last two decades.

SAMHSA lists 2,364 physicians with buprenorphine waivers in the state of Florida.

That is, 2,364 practitioners waived to provide buprenorphine for the treatment of OUD in a city, state or zip code. Within 50 miles of Orlando, there are only 104 locations certified to provide buprenorphine.

Buprenorphine prescription waivers fall under the Drug Addiction Treatment Act of 2000, or DATA 2000, with these regulations.

A qualified practitioner: • Is licensed under their state’s law • Is registered with the DEA to dispense controlled substances • Can only treat a limited number of patients at a time within the first year • Has undergone mandatory training Training lasts at least eight hours (24 for nurse practitioners and physician assistants) and could include classroom learning, seminars, or electronic training. Training for a buprenorphine waiver qualifies for continuing medical education (CME) credit. After their first year, qualified prescribers may apply to increase their patient limit from 30 buprenorphine patients at a time to 100 patients or 275 patients. SAMHSA reports that 75 percent of waived practitioners are certified for only 30 patients.

Florida, also, has statutes pertaining to

MAT. The short list - nine total - consists of largely common sense regulations. For example, one requires the medications that are prescribed to be packaged and labeled with instructions.

The most important statute is the first one: “Providers of medication-assisted treatment services for opiate addiction may not be licensed unless they provide supportive rehabilitation programs. Supportive rehabilitation programs include, but are not limited to, counseling, therapy, and vocational rehabilitation.”

This emphasizes a point that’s sometimes taken for granted but crucially important in MAT: withdrawal management medication is to be prescribed as part of a more holistic treatment approach and in conjunction with therapy, not in place of it.

AMA President Patrice A. Harris, MD, MA, stated when announcing the national policy that “Physicians must continue to demonstrate leadership, but unless these actions occur, the progress we are making will not stop patients from dying.“ After all, it’s called medication assisted treatment. Licensed prescribing physicians are needed to work with the clinical therapists and counselors on long term treatment plans to improve outcomes in the opioid crisis.

Coletta Dorado is the Founder and CEO of AZZLY®, Inc. With more than 30 years business process experience, Dorado and her team are passionate about delivering a powerful EHR and Billing Solution for addiction treatment and behavioral healthcare providers. Based in the GuideWell Innovation Core, in Lake Nona Medical City, contact hello@azzly.com or visit azzly.com to learn more.

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Neurobehavioral Program – It’s All About the Outcome

By MICHAEL SAMOGALA, RN, CRRN, CBIS

Traumatic Brain Injury is a major cause of death and disability in the United States contributing to about 30 percent of all injury related deaths. In light of the recent and continuing focus regarding brain injury, as well as the specialized care and post-acute rehabilitation that may be required, a brief discussion describing an outcome-based neurobehavioral rehabilitation program’s components and process may be beneficial to those individuals who have sustained a brain injury, as well as their healthcare providers, case managers, caregivers and/or significant others. Brain injury is often referred to as a “life changing or catastrophic injury” depending on the type of brain injury, the severity and the outcome. Acquired Brain Injury (ABI) by definition may be traumatic, such as caused by excessive motion or a delivery of force/impact or velocity to the head, or non-traumatic including stroke, hypoxia, post substance abuse, or chemo toxic exposure such as from chemotherapy treatment.

ABI is always an “individual” injury and never exactly the same for any two individuals, as we all utilize our brains in a unique fashion with areas of dominance and various degrees of compensation and or plasticity.

ABI may result in short or long term deficits involving cognitive function (problem solving, attention and memory), motor function (extremity weakness, impaired ambulation, coordination and balance), sensation (hearing, vision, smell, impaired perception and touch) and behavior (emotional regulation, depression, anxiety, aggression, impairments in behavioral control, personality changes).

The effect and outcome of the ABI may depend on many factors, along with the type and quality of not only the identification and treatment of the injury, but also the type and quality of the post-acute rehabilitation the individual may receive.

Post-acute rehabilitation for an individual with ABI should, in its most simple form, be based on an outcome focused neurorehabilitation process, including a neurobehavioral program which focuses on the patient achieving the maximum possible level of function and independence. The program itself involves the individual and significant others, through a systemic, comprehensive, multidisciplinary assessment in the development of realistic, measurable, functional goals which directly influence each individual’s progression towards their maximum potential, leading to successful community re-entry and a sustained successful outcome.

This being stated, the neurobehavioral component of the program must be dynamic as to begin with the pre-admission assessment information, which is confirmed by a medical records review conducted by a licensed Clinical Liaison and a recommendation for admission presented to a specialized brain injury credentialed multi/intradisciplinary team.

The team itself should optimally include:

• Rehabilitation Specific Case Manag-

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ers (Nurses and Social Workers) • Board Certified Physiatry services (Rehabilitation Specific MD) • Board Certified Rehabilitation Nurses (CRRN) • Board Certified Brain Injury Specialist • Neurology services (Individual or Accessible) • Board Certified Psychiatry Services • Neuropsychology Services • Cognitive, Dysphagia and Speech Therapy (MS, CCC-SLP) • Registered Clinical Dietician Services • Neurobehavioral and Behavior Program with supports as needed • Physical Therapy • Occupational Therapy/Functional Independence Team • Licensed Mental Health Counselor (Certified Substance Abuse Counselor) and support – clients and family members • Client/Family Support Team Ideally upon admission, a Board-Certified Physiatrist and a Board-Certified Psychiatrist lead the multi/intradisciplinary team members which assess, identify, describe and intervene using a personalized fluid approach to each clients’ strengths and barriers relating to their maximum potential for independence and community re-entry. Very often after an ABI, the individual experiences various behaviors that cannot only be socially unacceptable but dangerous to the individual, significant others or the community in general.

The Board-Certified Psychiatrist, Neuropsychologist and Licensed Mental Health Counselor develop ongoing and dynamic behavioral and therapy plans based on assessment criteria, subjective observable behaviors and identifiable triggers and consequences.

As indicated, the therapy consists of scheduled individual sessions as well as group interaction under the headings of anxiety and worry, self-help and empowerment.

The Purpose and Intent of the optimal neurobehavioral program is to assist the client in managing their behavior using a structured behavior plan and process that: • Defines behavior as response to stimuli, observable, perceivable or inert and with a purpose or meaning.

• Respond to the client’s behavioral, cognitive and physical needs.

• Presents a positive, consistent therapeutic approach to self-behavior management • Incorporates medical, nursing and therapy services which are supported by a facility inclusive environment to promote positive behavioral management techniques.

• The behavior plan from initial to full intervention are communicated and consistently available to all significant others, caregivers and staff as appropriate and applicable • Provides ongoing education and training for the individual and significant others. Program behavioral techniques are taught and reinforced

in order to support long-term goals of achieving the most successful and productive discharge outcome.

As community reintegration remains the primary goal for these individuals, a vocational rehabilitation component within the total program structure should encompass both direct and non-direct assessment, evaluation and access to both in-facility and community based vocational experiences.

The most successful programs often accomplish the inclusion of vocational experience criteria utilizing established partnerships with community-based organizations. Such programs with a dual centered focus greatly add to the successful outcome

of these individuals, their support system and the community itself.

In addition, community re- integration is promoted with each individual outside of the significant others’ realm of participation. This is effectively accomplished by neurobehavioral team members providing

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What Your LGBTQ+ Patients Want You to Know

By Dr. Jan Kaminsky, PhD, RN • LGBTQ+ people face worse health outcomes than straight and cisgender peers • Health care providers receive little to no training on LGBTQ+ health during their pre-professional programs • Stigma and discrimination against LGBTQ+ people prevent them from accessing and receiving appropriate care

Compared to their heterosexual and/ or cisgender peers, the LGBTQ+ community faces health disparities in access to health care, quality of care, and outcomes.

LGBTQ+ patients and families confront stigma from health care providers who may not understand the specific health concerns they face. Some health care providers err by omission, not even asking directly about sexuality or gender identity, therefore not realizing that their patients have these specific needs, risks, and concerns. Many health care providers have good intentions but may not know how to approach what they perceive as sensitive subjects. LGBTQ+ individuals face some of the same health problems faced by all Americans, such as heart disease, substance abuse, and mental health problems, but also have significant health disparities that must be addressed and not ignored.

Discrimination against LGBTQ+ individuals and families exists in housing, employment, marriage, adoption, retirement, and health insurance. Depression, suicide, obesity, cancer risk, long-term hormone use, HIV/AIDS and STIs disproportionately impact LGBTQ+ people. Increased rates of substance use and abuse including alcohol, smoking, and other drugs have been identified as priorities for research and represent some of the concerns that face the LGBTQ+ community at disproportionately high rates. Additionally, LGBTQ+ people, especially Black transgender and gender diverse women, are victimized and experience violence at higher rates than the general population. Lack of acceptance and other societal factors impact the mental health of LGBTQ+ people.

Healthy People 2020 has also brought these health concerns to the forefront, with the understanding that these health needs are different in many ways from the general population. As providers, we must start with our society’s youngest members, even those who may not yet identify as LGBTQ+, with efforts to prevent bullying, HIV, suicide, and home15

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lessness in our youth. These building blocks of health will serve to decrease the gaps in care as these youth mature. Medical, nursing, and allied health students must be thoroughly educated on LGBTQ+ health issues in order to provide appropriate care. Preventive care for adults is a key factor as well, through LGBTQ+-affirming health centers and STI/ HIV prevention and treatment programs. As adults, lesbian and bisexual women are at higher risk of obesity and late detection of cancer. Gay men have higher rates of STIs and HIV, and transgender individuals face high rates of mental health concerns, STIs/ HIV, risk of suicide, access to needed hormones and medications, and victimization.

The relationship between health care providers and their patients can range from very distant to very close, and the amount of information that patients feel comfortable disclosing can range widely as well. Creating a warm environment in which patients feel that they can share their multiple identities with their providers is essential, and in addition, health care providers have a responsibility to ask patients about their lives. A full health history should include not only identity but also behavior, as sometimes these can be disparate. Incorrect assumptions about sexuality and sexual behavior can cause providers to miss important data about their patients that may have significant impact on their care.

Frequently, I hear from health care providers that it is challenging to ask the important questions about sexuality and gender because it feels too invasive, but we know that we as providers ask many “sensitive” questions. We have become used to asking about violence in the home and use of substances, for example, and there is no reason that we can’t get used to asking these questions about sexuality, gender identity, and sexual behavior as well.

Patients may be afraid of judgment and many are used to a long history of constantly debating whether it is “safe” to come out to a variety of people in their lives. They may not want to initiate the conversation themselves, but may be likely to open up to a provider who asks them kindly, but directly, about their sexuality and gender. Developing an office culture that openly and outwardly supports the health of LGBTQ+ people and families will directly impact the health disparities that these communities face.

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Advanced Practice Provider Closed Claims: What Can We Learn?

By HOWARD MARCUS, MD, FACP, and SUSAN SHEPARD, MSN, RN

The Doctors Company analyzed claims against two types of advanced practice providers (APPs): physician assistants (PAs) and nurse practitioners (NPs). Of the 649 claims that closed between 2012 and 2017, approximately 60 percent were against PAs and 40 percent were against NPs. The study provides insights into patient allegations, identifies underlying issues that contribute to patient harm, and outlines strategies for mitigating risk.

Diagnosis-Related Allegations The analysis revealed that the most common patient allegations in both PA and NP claims were related to diagnosis. Diagnosisrelated allegations were made in the setting of a missed, delayed, or incorrect diagnosis.

Case Example: PA A 59-year-old female underwent redo quadruple coronary bypass grafting surgery times four, including a left internal mammary artery graft. Her medical history was significant for the original coronary artery bypass grafting 12 years earlier and

well-controlled Type II diabetes. Surgery was performed uneventfully by the cardiothoracic surgeon. It is noteworthy that the patient’s white blood count (WBC) was 11.8 preoperatively; four days later, her WBC was 13.9 prior to discharge.

When the patient was next seen, the physician noted that she reported feeling well but complained of lightheadedness.

The sternal wound was noted to be healing well, and the balance of the exam was unremarkable.

The patient’s spouse subsequently testified that his wife complained of neck and shoulder pain during the visit. He called the physician’s office two days later and spoke with a PA, who advised him to increase the patient’s pain medication.

The spouse reported contacting the physician three days later and was again directed to the PA. He reported a continued complaint of pain. Although the medical record had no documentation of either phone call, the plaintiff produced evidence that the PA had, in fact, called in a prescription for pain medication.

The following day, the patient called and spoke with the PA, indicating that she

was experiencing chest pain with movement and deep breathing. She was instructed to report to the ER for evaluation. The ER physician noted that the patient was taking hydrocodone for chest pain. An EKG was unremarkable. Her WBC was 14.8. The patient was prescribed Ultram and discharged with a diagnosis of “chest wall pain.” The ER physician testified that he spoke with

the physician’s PA, but no documentation of that call was found in either the hospital record or the patient’s chart.

The following day, the patient again phoned the physician and complained to another PA of neck and shoulder pain. She was instructed to continue taking the pain medication prescribed by the ER. Because of continuing severe neck pain and spasm, the patient sought care from a chiropractor, who noted a reddened, swollen area at the incision site and directed the patient to contact the physician.

That evening, the patient called the physician and was directed to a PA. She described her symptoms and was given instructions to continue the pain medications. Although the PA acknowledged the phone call, she had not documented it. The patient’s spouse testified that he called the physician five times the following day, demanding that the patient be seen, before being given an appointment. Upon arrival, the patient was evaluated by a PA, who summoned a physician in the group to examine the incision. The physician admitted the patient, but she ultimately experienced (CONTINUED ON PAGE 17)

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Advanced Practice Provider Closed Claims: What Can We Learn? continued from page 16 diminished sensation below the diaphragm and underwent surgery for a ventral epidural abscess. Unfortunately, the patient was rendered an incomplete C6 quadriplegic.

A suit was filed against the physician, the physician’s three PAs, and the physician’s medical group practice, alleging that a delay in diagnosis of the sternal wound infection resulted in progression to an epidural abscess and subsequent quadriplegia.

Case Example: NP A 41-year-old male presented to a primary care practice with complaints of fever and abdominal pain for four days with bright red clots from the rectum, anorexia, dehydration, nausea, and straining to defecate.

The NP noted recent antibiotic therapy for methicillin-resistant Staphylococcus aureus (MRSA). Family history was negative for colon cancer. The NP noted the abdomen was soft with diffuse tenderness and hypoactive bowel sounds but no masses. The anus and rectum were examined and were also negative for masses, fissures, or hemorrhoids.

The NP suspected Clostridium difficile colitis and prescribed Flagyl, Lomotil, and Percocet and documented: “Possibly needs colonoscopy if tests yield nothing.”

Laboratory results revealed an elevated WBC at 12,700 mcL (normal 4,500–10,500 mcL) and erythrocyte sedimentation rate (ESR) at 43 mm/hr (normal range for males under age 50 is 0–15 mm/hr). The stool tested positive for Clostridium difficile toxin.

Four days later, the patient returned with complaints of bloody diarrhea and abdominal pain. The physical exam of the abdomen showed normal bowel sounds and was positive for diffuse tenderness. There were no masses or distention. A urinalysis revealed a moderate amount of blood. The NP recommended continuing Flagyl and a repeat urinalysis.

One week later, the patient presented with bright red blood from the rectum and a moderate amount of abdominal pain. The abdomen was soft and showed normal bowel sounds. The urinalysis was negative, and the NP recommended continued antibiotics.

One month later, the patient presented with complaints of persistent abdominal pain.

The NP noted the abdomen was soft, and no further treatments or testing was ordered.

Two months later, the patient was seen for bloody diarrhea and abdominal pain over three days. The NP ordered a stool culture. It is unknown whether testing for Clostridium difficile was repeated. The NP recommended that the patient avoid dairy products and take probiotics.

The patient continued to be seen over the next year with similar complaints and no additional evaluation. The NP did not consult with a physician.

One year later, due to persistent diarrhea, the patient was referred for a colonoscopy, which revealed a large sigmoid mass positive for Stage IIIA cancer.

Factors Contributing to Patient Injury While multiple factors—such as clinical judgment, technical skill, patient behaviors, communication, clinical systems, or docu17

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mentation issues may contribute to patient injury, the major contributing factor in the study involved timely and accurate assessment of the patient.

Nearly half of all PA and NP claims involved inadequate assessments that resulted in a failure or delay in diagnosis. Issues included failure to establish a differential diagnosis, failure to order diagnostic tests, inadequate history and physical examinations, and failure to address abnormal findings.

A second factor was communication among providers. In 22 percent of the PA claims and 25 percent of the NP claims, the APP did not communicate the patient’s condition or failed to read the medical record. Contributing to this factor was insufficient or lack of documentation. Medical record entries made

by APPs were criticized for insufficient or lack of clinical findings and clinical rationale.

Liability Concerns Many malpractice claims attributed to APPs can be traced to clinical and administrative factors:

• Failure to adhere to the scope of practice.

• Inadequate physician supervision or oversight.

• Absence of written protocols.

• Deviation from written protocols.

• Failure or delay in seeking a referral or physician collaboration.

Risk Mitigation Strategies The practice of medicine is a collaborative effort. APPs should have a low threshold for involving the physician, and the physician must provide a practice environment that encourages formal and informal collaboration. This is particularly true when symptoms persist and the patient does not

respond to treatment as expected. The following strategies can help physicians avoid issues revealed by the claims analysis:

• Follow up on patient complaints, especially when patients return to the office with the same or similar complaints.

Reevaluate management when patients do not respond as anticipated. In this situation, it is important for APPs to involve the physician. Promote an environment without barriers in the patient management process.

• Develop written guidelines and protocols that specify an APP’s responsibilities relative to examinations, assessments, diagnoses, treatment, prescriptive privileges, and administrative functions.

• Delineate in written guidelines and protocols how often the physician must see the patient and under what circumstances the physician must personally assess the patient. Include how frequently the physician must review the APP’s documentation.

• Reduce exposure to liability by establishing a protocol to review charts for quality assurance purposes. The protocol can include criteria for periodically reviewing and evaluating APP medical record documentation.

• Establish a system for tracking incoming telephone calls (both during and after hours) that includes procedures for documentation and for including the provider’s responses.

• Engage the patient as part of the team.

Have the patient verify understanding by repeating back care instructions, the medication regimen, and the follow-up

plan. This can usually be done with a written after-visit summary.

Learn More The guide, Advanced Practice Provider Liability: A Preventive Action and Loss Reduction Plan, includes additional strategies for practitioners who employ or supervise APPs. Complimentary Online CME A new on-demand CME activity Advanced Practice Provider Closed Claims: What Can We Learn? further explores factors that contribute to claims involving advanced practice providers and outlines strategies to mitigate risks. This course is an updated, expanded version of our popular on-demand course How to Reduce Liability for Advanced Practice Providers.

Authored by Howard Marcus, MD, FACP, and Susan Shepard, MSN, RN, Senior Director, Patient Safety Staff Education the Doctor’s Company Reprinted with permission. ©2019 The Doctors Company (http://www.thedoctors.com). This article originally appeared in The Doctor’s Advocate, third quarter 2019.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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Helping Your Patients Understand CBD Oil

By CONNIE ORTIZ

Finding the straight-forward, informative answers to patient questions about CBD is sometimes elusive. Here are some of the often-asked questions patients have about CBD and CBD products.

Will I get high?

The quick answer is no. The legal limit for THC in CBD products is .03 percent.

That is a trace amount, not enough to cause a high. However, the misnomer about CBD is that it is not psychoactive. CBD can calm you if you have anxiety, so in a sense it is psychoactive just not going to be walking around in a stupor. You will be able to function normally.

How does CBD work?

We all have an endogenous system, known as the endocannabinoid system. This

system is found in every animal and regulates a wide range of biological function, with receptors that accept some cannabinoids and are not affected by others. This is known as the lock and key. The receptor being the lock that only a certain key can open. We have these receptors all over our bodies. A phyto-cannabinoid works the same way as our naturally occurring cannabinoids. They can either cause a receptor to act the same way or it can prevent the receptor from binding and causing, for example, pain to be diminished or altered.

How much should I take?

This is the question I always get, and my answer is always the same.

Everyone’s body is different. We come in large, medium and small sizes. Our metabolism is different, and our chemical make-up is different. Just as there are many pharmaceuticals out there and one works

Neurobehavioral Program – It’s All About the Outcome, continued from page 14 the individual with scheduled functional integration activities, incorporating goal oriented multidisciplinary skills and abilities learned and practiced within the general facility program, then utilized within the outside community under supervision as part of an organized therapeutic regimen.

As discharge planning begins on admission, as soon as possible each member of the intra/multidisciplinary neurobehavioral and clinical rehabilitation team will evaluate the individual and assign a period of time when the significant others can spend at least twenty-four hours with the individual learning, observing and assisting the individual to manage any behavioral or functional deficits contributing to a successful sustained discharge outcome.

In summary, the success and final out-

come of the individual with an acquired brain injury from a traumatic or non-traumatic source will depend on many factors; one of the most influential being the type and quality of the post-acute rehabilitation program and neurobehavioral program the individual completed.

Michael Samogala RN, CRRN CBIS has been directly involved in providing professional nursing and education services to the healthcare community for over 40 years. Most notably receiving board certification in rehabilitation nursing and as a brain injury specialist, he continues to provide professional credited continuing education programs to multiple professionals across the country, and remains in the position of Director of Corporate Education, NeuLife Neurological Services. The CARF accredited Brain Injury Specialty Program at NeuLife Post-Acute Rehabilitation (residential or outpatient) offers comprehensive neurorehabilitation services resulting in eighty percent discharge to home or community. Visit www.neuliferehab.com

for me but not you, the same goes for CBD. The amount I need will be different than the amount someone else needs. When we talk about the CBD oil, I usually always say to start small and keep adding every couple of days until you find the amount that works for you, and then drop back a drop or two.

But the thing that sets me apart, is that I am a Certified CBD Coach, and I am always available to help guide my customers.

How do I take CBD? There are several methods. The most common is the drops (oil, tinctures). These are used sublingually. The advantage of the drops is the effect lasts longer.

There are also gummies. Gummies are very portable, and once you know how much you need, taking the right amount is easy.

Vaping has also become popular, so I only provide cartridges from a trusted source. Now, CBD pre-rolls have hit the market. One pre-roll can last up to 3-4 days depending on how much you need.

The advantage of this method is that you feel the effect almost immediately, but it will only last two to three hours, so you will be using it more often.

Will I pass a drug test?

If you’re taking a CBD that has THC at the legal amount, .03 percent, there is a possi-

bility that you will not pass a drug test. If you’re in a job where you get tested regularly, the best thing to do is use a product that contains zero THC. I am in the process of getting a “broad spectrum” CBD with zero THC. Anyone who is tested can use this product.

Connie Ortiz, who has been serving customers for over 25 years, is CEO of Nona Oils, LLC, and is a Certified Health and Wellness Coach. She discovered the benefits of CBD and after 6 years in the industry, now has her own products as well as certification as a CBD Coach through the CBD Training Academy. Contact her at NonaOils@outlook.com

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What Your LGBTQ+ Patients Want You to Know, continued from page 15 The Institute of Medicine and The Joint Commission have both expressed the importance of asking and collecting data about patient sexuality and gender, and plentiful research supports the importance of knowing the details of patients’ lives. Normalizing the asking of these questions can go a long way towards preventing and decreasing the health disparities faced by LGBTQ+ patients.

If you are a health care provider, consider adding questions about sexual and gender identity to your intake and other patient forms. If you are also an LGBTQ+ patient or client, and you feel comfortable doing so, disclose your sexual and gender identity to your health care providers. This will enable your providers to better serve you.

We as health care providers must begin to more thoroughly explore the health care needs of our LGBTQ+ patients and clients, 18

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starting with our youth and with preventive care. Only through decreased stigma, increased acceptance and access, and a deepened understanding of the specific health concerns of LGBTQ+ people and families can we begin to decrease the gaps in health quality for the community. Finding fellow providers who ask respectfully and appropriately about gender identity, sexual identity, gender expression, and sexual behavior can make all the difference in patient outcomes, and that should be our highest priority.

Jan Kaminsky, PhD, RN is the Director of Education for Rainbow Health Consulting, which works with health care providers and health-related organizations to train employees on how to better serve their LGBTQ+ clients, patients, and families. To contact or learn more about how your organization can support your LGBTQ+ patients, go to www.RainbowHealthConsulting. com or email Jan@RainbowHealthConsulting.com.

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Finding Freedom – The 411 on Gene Therapy for Hemophilia

By Hemophilia Foundation of Greater Florida

Tommy Maguire loves to travel—for pleasure and for the good of the order.

For the past two years, he has journeyed to South America to volunteer with the Columbian Hemophilia Foundation. While seeing the world and helping others is gratifying, he wishes that trekking factor was not part of the itinerary.

His wish may soon be granted.

As part of worldwide trials for gene therapy being administered to those living with Hemophilia, the 22-year-old Clearwater paralegal is joining scores of other hopefuls who are riding the wave of this cutting-edge medical procedure.

“They are very careful not to call it a cure, but at the hospital they are very excited about it,” he says.

And that really comes as no surprise.

Gene therapy has been referred to as a wonder treatment with the ability to tackle a disease by allowing lab-enhanced genes to “tell” genes in the body how to function, and in turn, fend off the disease in question.

Currently gene therapy is being applied to incurable diseases with positive results, Hemophilia being one of them. In the case of Hemophilia, only trials are currently underway and gene therapy is commercially unavailable at this time. Moreover, the therapy is not available within the Pediatric population at this time and not every adult with a bleeding disorder is an eligible candidate. The selection process is rigorous, even if a patient’s Hemophilia Treatment Center team recommends them for the therapy.

Nonetheless, encouraging outcomes from both Hemophilia A and B ongoing trials do have the medical community enthusiastic about the therapy moving forward.

“Researchers are interested in gene therapy for Hemophilia because it is a disorder that is caused by one gene, making it ideal to target with directed gene therapy,” says Anita Rajasekhar, MD, MS, Associate Professor, University of Florida, Department of Medicine, Division of Hematology/Oncology. “Also, gene therapy is ideal for Hemophilia because patients with severe Hemophilia [<1% factor] may be able to significantly reduce bleeding risk by increasing their factor level by a few percentage points.”

Dr. Rajasekhar says the goal of gene therapy in Hemophilia is to allow the person’s own body to make a functional form of the clotting factor they are missing, that being either FVIII or FIX. How Does it Work?

According to Dr. Rajasekhar, normal factor is packaged in the laboratory into an outer shell of a virus called adeno-associated virus (AAV). The AAV, also known as a vector, contains the normal factor gene and is delivered to the person’s liver intravenously as a one-time infusion. The new gene then “tells” the liver cells to create the normal clotting factor that was previously missing.

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“Some use the analogy of a car, passenger, and destination,” she says. “The AAV vector is the car and the gene is the passenger. The car (the vector) drives the passenger (the factor VIII or IX gene) to its destination (the liver).”

As relatively new therapy, Dr. Rajasekhar says side effects are being closely monitored. During the actual IV infusion of the gene therapy, patients can experience pain or irritation at the injection site called an infusion-related reaction. Other commonly reported side effects include fever, chills, runny nose, sneezing, cough, fatigue, nausea, muscle pain, feeling light- headed, and generally having signs of an allergic reaction.

“The vector that is used in most clinical trials, the AAV, cannot multiply or cause infection,” she adds. “People who have been treated with gene transfer in many studies have not been shown to ‘infect’ others.”

One of the biggest challenges facing AAV gene delivery is the host immune response, she explains, especially liver toxicity.

This destruction of liver cells can lead to the loss of therapy efficiency. Further, some patients house antibodies for the AAV, which means they are immune to current therapy.

One and Done Jonathan Lebron of Orlando, diagnosed with severe Hemophilia A as a baby, underwent the procedure at the Hemophilia Treatment Center at the University of Miami and is now being monitored at the University of South Florida Hemophilia Treatment Center. He says after a litany of testing, he spent two days and nights in Miami receiving gene therapy.

“My hematologist recommended me as a good candidate for gene therapy,” he says.

“I was one of the last patients in the trial in Miami.”

On arrival to the HTC, Jonathan says the product was first defrosted then infused, which took about six hours. That was followed by continuous monitoring for the next day and night. Since close vigilant monitoring is required, clinical trials are only conducted at Hemophilia Treatment Centers or similar locations with expertise in Hemophilia and gene therapy.

Back home, Jonathan’s twice-a-week infusions of factor are now history. Jonathan only has to infuse in the case of an emergency. He feels great and looks forward to positive results from tests that will be administered for a year. That includes lab work twice a week for three months, then once a month until given the all clear.

Diagnosed with severe Hemophilia A during circumcision, Tommy Maguire will receive his gene therapy at St. Joseph’s Hospital Center for Bleeding and Clotting Disorders.

He initially consulted his hematologist about a new drug designed to drop the level of his Hemophilia from severe to mild.

“He said, ‘how about the cure?’ He was talking about gene therapy. But we don’t like

to use the word cure. We don’t want to jinx it.”

Tommy says after the initial levels of testing are through, the actual procedure is simple.

“It’s one time and done,” he says about the infusion process. “It will be exciting not to take factor anymore. I have self-infused since I was six.”

Future Looks Bright No one can predict a target date if and when gene therapy for Hemophilia will be widely accessible for the bleeding disorders

community and how affordable it may be for the masses. But initial findings are cause for hope.

“Since studies are still in clinical trials with relatively short follow-up time, I think it is too soon to say one way or another,” says Dr. Rajasekhar. “But preliminary data is very promising.

There have been studies in both Hemophilia A and Hemophilia B that have shown positive clinical results in terms of increased factor activities, decreased bleeding events, decreased need for factor prophylaxis, and improved quality of life.”

Hemophilia B trials began earlier and are farther along than Hemophilia A trials.

Brett Palaschak, diagnosed with severe Hemophilia A when he was three days old, embraced his affliction by making a career out of gene therapy research and production.

At the University of Florida, Brett worked in labs conducting research with mouse models, and today he is employed by a gene therapy drug manufacturer.

Based on his work, Brett believes gene therapy treatments will be widely available to the bleeding disorders community in the next five years, if not sooner, pending FDA approval.

“It is really, really promising,” he says (CONTINUED ON PAGE 21)

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Are You Asking the Right Questions About Healthcare Deregulation?

From SEACOAST BANK

As these new laws take effect, it’s important to take stock of your practice or office and make sure you’re prepared for the changes. Here are some questions you may want to ask yourself:

Health care in Florida is a competitive market. Your patients have options when it comes to their insurance, doctors and medical professionals. The 2019 legislative session brought some changes to how Florida’s health care system will operate in years to come – are you prepared? Keep reading to find out what changed and how that impacts you and your patients.

Two New Laws Gov. Rick DeSantis signed 15 health care-related bills into law in June 2019.

To view a complete legislative session recap, visit the Florida Hospital Association (FHA) Advocacy page. Two of these laws will change the way patients access health care, and they may have a big impact on the way you provide it as well.

• House Bill 21 (HB 21): Eliminates the certificate of need (CON) requirement to open a new general hospital and tertiary services (medical rehabilitation, neonatal intensive care, etc.). Prior to HB 21, a hospital needed state approval before building new facilities or adding space for additional

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services. This made it difficult, and costly, to open new medical facilities.

Under the new law, most health care facilities will not need to follow this regulatory step prior to opening.

Portions of the law took effect on July 1, 2019. Additional measures will be implemented Nov. 1, 2019, and July 1, 2021. Hospital expansions and new medical facilities are expected as a result of this law.

• House Bill 1113 (HB 1113): The Patient Savings Act creates a health

insurance savings program for Floridians. Insurance providers and HMOs can offer financial incentives to patients when they choose their health care providers off a shoppable provider list. This bill becomes effective Jan. 1, 2020. With patients able to choose from an approved list, you may see a shift in visits, which will impact doctors, hospitals, medical and laboratory diagnostics, and pharmacists.

Questions to Ask Yourself About Your Business

• Do I understand the new Florida health care laws? It’s important to research and learn about how these new laws may impact your business.

Being educated on them yourself will help you communicate them to your patients.

• Is my information accurate and up-to-date? There is a lot of misinformation out there. You should use trusted sources to get yourself up to speed. These include professional organizations, government branches and departments, and nonprofit advocacy groups. (We’ve put together a resource list below to help you get started.)

• Do I need to change my business plan to adapt for any of these changes? Consider the financial implication of these laws on your office or practice. If you need to adjust for the potential impact of these laws, it’s a good idea to get a head start. This could include allocating more money (CONTINUED ON PAGE 21)

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Are You Asking the Right Questions About Healthcare Deregulation? continued from page 20 toward marketing materials and patient handouts or planning ahead for a potential dip or increase in patients.

• How will I communicate this to my patients? Once you have a handle on the new regulations, you can plan for how you’ll let your patients and prospective patients know about them. This could include printed materials like flyers, mailings or handouts; updating your FAQ section of your website; or sending an email explaining what will change for them. Be sure to use clear, transparent language so that you’re understood.

Resources for Florida Medical Professionals This list can help you get started with

your research on how health care deregulation and the Patient Savings Act may impact your office or practice.

• Florida Board of Medicine: The board oversees all physicians and medical practitioners and offers resources on all aspects of practice and patient care.

• Florida Hospital Association: Hospitals and practitioners working within their systems can find helpful information on regulatory changes, improving patient care and more.

• Florida Medical Association: The FMA offers resources, continuing education seminars and more for Florida’s doctors.

• Florida Health Medical Quality

Assurance: Information for all types of health care professionals, from licensing requirements to license renewals and verification can be found on this site.

• Florida Health: The Florida Department of Health website has legislative updates, statistics and educational materials for health care professionals in the state.

• Florida Nurses Association: The FNA website offers resources for registered nurses, including legislation that impacts their practice.

• Professionals Resource Network: The PRN consults with the Florida Departments of Health and Business and Professional Regulation.

They offer resources for medical

professionals as one of two stateapproved organizations for impaired practitioners.

• American Medical Association: Find information on national issues in medicine, as well as resources to help navigate payments and insurance companies on the AMA site.

Seacoast Bank is one of the largest community banks headquartered in Florida with approximately $6.7 billion in assets and $5.2 billion in deposits. The bank provides integrated financial services including commercial and retail banking, wealth management, and mortgage services to customers through advanced banking solutions.

Finding Freedom – The 411 on Gene Therapy for Hemophilia, continued from page 19 of the advancements being made. “The science is there, it just takes time. The trouble will be how to pay for it.”

Fran Haynes, executive director of the Hemophilia Foundation of Greater Florida, says gene therapy for the bleeding disorders community could be a game changer, but she remains cautious.

“This is an opportunity, not a cure,” she says. “The therapy may last five years, maybe ten years. We don’t know.”

In the meantime, the National He-

mophilia Foundation is developing a Gene Therapy Initiative to offer a multi-pronged approach to ensure accurate information, tools and resources are available to everyone from patients to policy makers.

In the future, Dr. Rajasekhar believes gene therapy may also be available to patients with mild or moderate disease or patients with current inhibitors or a history of inhibitors.

“It is an exciting time for Hemophilia since we now have several different types of

therapies for Hemophilia patients, not just simply replacing the missing clotting factor they are missing.”

If you are an adult member of the bleeding disorders community and would like to look into gene therapy treatment, talk to your hematologist at your Hemophilia Treatment Center.

Gene therapy trials are currently enrolling patients with severe Hemophilia since these are the patients who would benefit the most. Clinical trials are enrolling only

patients without concurrent liver disease.

Inhibitor patients are generally excluded in current open trials.

The Hemophilia Foundation of Greater Florida is a 501(c) (3) nonprofit organization that has supported the bleeding disorder community throughout the state of Florida since 1996. For over 20 years, the HFGF has been helping those living with and affected by bleeding disorders live without limits through much needed services and programs.

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GrandRounds Winter Garden Named Best Place In Florida To Raise A Family

Winter Garden was recently rated by Forbes magazine as the second fastest growing sub-market in the U.S., named “Best place in Florida to raise a family” by Smart Asset. com and “Orlando’s coolest suburb” by the website Thrillest. The charming downtown boasts dozens of historic buildings listed on the national register—today converted to art galleries, boutiques, sidewalk cafes, bicycle shops, and unique eateries.

Over twelve physicians and their families new to Orlando have purchased homes during 2018 and 2019 in the Winter Garden community of Canopy Oaks.

Medical centers ten minutes or less from Canopy Oaks include: Orlando Health ER and Medical Pavilion-Horizon West; Orlando Health UF Health Cancer Center Health Central Hospital and Advent Health Winter Garden.

The new home community of Canopy Oaks, an intimate gated community of only 49 homes with four, five and six bedrooms, three-car garages, and in-home offices has benefited from the area’s growth in the medical industry, particularly among physicians new to Florida. The homes, priced from the $700’s to $1.2 million, are recognized as a Triple Grand Winner at Orlando’s Parade of Homes and Excel Award winner for “Best Model Home in Florida.”

Developer Mason Simpson says physicians and their families are choosing to make Canopy Oaks their home due to a plethora of top-rated public and private schools and award-winning new home innovations such as kitchen layout features with double islands, hidden walk-in pantries and European styled walk-in wine cellars for entertaining in grand fashion. Owners enjoy a state-of-the art security system which allows parents to monitor their children at the community’s bus stop from their cell phones, as well as monitor guests at the front gate.

Simpson is currently building four “developer spec homes” for families who wish to move in prior to the end of the year.

For more information contact: Canopy Oaks’ sales center and models at 12902 Roper Road, Winter Garden 407-488-5588 or visit www.canopyoaksfl.com.

tion consultant in the areas of marketing, business development, public relations and an author, has contributed in a book with other authors that has reached the bestselling list status on Amazon. Di-Anne’s has joined other authors in contributing, sharing insights and inspiring other people to seek to live beyond purpose with the bestselling book “Living Beyond Purpose”. DiAnne and the contributing authors wrote this book in hopes that other people, would find something to take away. Something that would inspire others to seek to live beyond purpose. To understand that what we are going through does not define us but can undoubtedly refine us. Sometimes it’s easy to feel like life has no purpose. Other times we can live without being fulfilled, regardless of how much we accomplish.

There is a reason why and a solution to fill the void.

Di-Anne has been a contributor in the medical field by revolutionizing marketing at its best. With her passion for branding and purpose, she has helped not only hospital medical groups but also health professionals educate the public in order to get a better understanding on how they could improve their patients’ lives. Di-Anne has been able to impact the medical community by providing business communication and marketing creative services in order to inform and make a difference in the medical health community.

Join Di-Anne Elise and other contributing authors along with Best Selling Author Mike Rodriguez, as they share how you were created with precision, purpose, and your own unique talents. We were also given the ability to know, act on, and use

those talents to become great and strong in your own way, for God’s purpose.

To contact Di-Anne Elise email her at info@dianneelise, dianne@mediaresourcesenterprise.com or call at 407-579-9903.

For more information visit her website at: www.dianneelise.com and www.mediaresourcesenterprise.com.

PONTE HEALTH Names Validus Construction as Diversity Advisor for Vertical Medical City – Orlando

First Diversity Open House Scheduled for December Join PONTE HEALTH and Validus Construction, and meet the Owner as well as the A/E and Pre-Construction Teams, for Vertical Medical City - Orlando.

The Diversity Open House is taking place on December 12, 2019, starting at 9 AM sharp at COURTYARD by MARRIOTT ORLANDO SOUTH : 4120 WEST TAFT VINELAND ROAD, Orlando FL 32837 Diversity Goals for VMC Orlando are more steep than the generally required in Public Projects by Agencies, shooting for a 30% Minority participation with a 15% Women participation.

The project seeks candidates for both Pre-Construction and Construction activities, as well as Services and Product post Occupancy.

Candidates can register online via : http://tinyurl.com/vmcorl-diverse , free of charge to attend.

Dr. Podberesky of Nemours Children’s Hospital Recognized as Veteran of Influence

Orlando, F la.

(September 20, 2019) – Dr. Daniel J. Podberesky, Radiologistin-Chief for Nemours Children’s Health System, was recently recognized with a ‘Veterans of Influence’ award, which identifies military veterans who have made a significant achievement in their careers, have a strong record of innovation and outstanding performance in their work, and are involved in the community.

“At Nemours, we believe it’s important that our team members give back to our communities, and we’re blessed to have among us many providers who have served in a huge way – dedicating their lives to our country during time spent in the military,” said Dana Bledsoe, President of Nemours Children’s Hospital in Orlando. “Dr. Podberesky is a deserving recipient of this recognition, having trained with some of the best in the industry, and bringing his skills and expertise to the patients and families of Nemours Children’s Health System.”

Dr. Podberesky was stationed at Wilford Hall Medical Center at Lackland Air Force Base in San Antonio, TX, for much of his military career, including his internship and diagnostic radiology residency training, from 1998-2003. He left only briefly (CONTINUED ON PAGE 23)

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GrandRounds (2003 – 2004) to complete his pediatric radiology fellowship at Cincinnati Children’s Hospital Medical Center, world-renowned for its many pediatric healthcare services and known to be one of the foremost pediatric radiology facilities in the world. Upon his return to Wilford Hall from Cincinnati Children’s, Dr. Podberesky quickly became the Chief of Pediatric Radiology at the Air Force’s flagship quaternary care hospital in the world at the time.

“My time in the military was formative,” stated Dr. Podberesky, who joined Nemours in 2014. “It played a large part in the radiologist I’ve become, the leader I’ve become, the person I’ve become, really. I look back at that time and realize that – had I not served as Chief of Pediatric Radiology at Wilford Hall – my career trajectory may have looked much different.”

After joining Nemours, Dr. Podberesky pushed hard to create a completely integrated radiology department of 38 radiologists located throughout Florida and the Delaware Valley, many with varying areas of expertise and sub-specialties. This team of radiologists works seamlessly together to bring their world-class knowledge to children throughout the Nemours system and to non-Nemours partner hospitals. Beyond the integration of the radiology departments, Dr. Podberesky has also been instrumental in ensuring that Nemours Children’s Hospital has a dedicated, full-time child-life specialist embedded in the Radiology Department.

Axiom Bank, N.A. Hires Joe Dear as SVP, Commercial Team Lead

Axiom Bank N.A., a Maitlandbased, leading community bank, recently hired Joe Dear as SVP, Commercial Team Lead. In this role, Dear is responsible for helping the bank’s commercial clients in Central Florida grow their businesses.

Dear has nearly three decades of experience in asset management, commercial real estate loan originations, valuation and investment sales.

“Joe brings both extensive knowledge and experience to Axiom Bank,” said Ted Sheppe, Executive Vice President of Commercial Banking of Axiom Bank. “He will be able to draw from those deep reserves when helping clients develop solutions to meet their business goals.”

Dear graduated from Florida State University with a bachelor’s degree in finance.

For more information about Axiom Bank and to find the nearest location, visit AxiomBanking.com.

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Rainbow Health Consulting Is Changing the Conversation Around LGBTQ+ Health

Rainbow Health Consulting provides diversity and inclusion education for health care providers around issues of LGBTQ+ health, a topic only touched upon by most healthcare providers. Our mission is to ensure that every health care provider can deliver culturally competent, barrier-free healthcare to all LGBTQ+ patients; and lessen the disparities in access, treatment, and outcomes that persist. Additionally, we give healthcare providers and staff the opportunity to engage in respectful dialogue and to ask questions in a safe and professional environment. For too long LGBTQ+ healthcare disparities have gone unchecked.

It is time to ask more of our healthcare providers and we believe our company is going to be the shift in the healthcare conversation that LGBTQ+ patients deserve.

Selected courses include: Caring for the LGBTQ+ Patient, an introduction for health care providers to the health concerns of the LGBTQ+ community. Topics such as terminology and definitions; and issues of access, discrimination, and specific health differences of LGBTQ+ patients and families will be covered in this module.

Caring for the Transgender and Gender Fluid Patient, an introduction to the health care concerns of transgender and gender fluid individuals throughout the lifespan. Topics such as terminology and definitions; and issues of access, discrimination, and specific health differences of

transgender and gender fluid patients will be covered. Special emphasis will be placed on the periods of social and medical transition for this population.

Caring for LGBTQ+ Elders, which focuses on the health care concerns of LGBTQ+ elders. Special emphasis will be placed on issues of housing, social support, behavioral health, substance abuse, discrimination, and chronic conditions.

“Since Dr. Jan Kaminsky worked with our staff, we have heard from patients that they have felt more comfortable sharing their concerns. Additionally, a patient reported that it was the first time in her life that she felt that she could speak openly about her (female) partner in a medical setting because of the feeling of non-judgment in our offices,” said an office manager.

“Dr. Kaminsky worked within our parameters to ensure that our providers had a thorough understanding of how their actions can impact the lives of our LGBTQ clients.” — CNO Rainbow Health Consulting is Florida’s leading expert in LGBTQ+ healthcare education. Our specialists ensure that your organization’s practitioners will immediately feel at ease in our seminars and workshops, which will translate into better healthcare outcomes for your LGBTQ+ patients.

Floridians to Gather for Latest on Number One Cancer Killer in US at LUNG FORCE Expo

Lung cancer is the nation’s leading cause of cancer deaths among both men

and women. To raise awareness about this deadly disease, the American Lung Association in Florida is proud to host the 2019 LUNG FORCE Expo presented by Advent Health on Friday, November 8 at SeaWorld Orlando: Sea Harbor Pavilions (7007 Sea World Drive Orlando, FL 32821) from 8 a.m. – 4 p.m.

The LUNG FORCE Expo is a program designed for patients, caregivers and healthcare providers to learn more about the latest trends, resources and research surrounding lung cancer, chronic obstructive pulmonary disease (COPD), asthma and other respiratory issues.

Lung disease patients and professionals from Florida will gather to watch speakers from a variety of fields present the latest medical based research on lung disease.

Topics for professionals include screening and advancement in lung cancer treatment, pediatric asthma, treatment and prevention of COPD, and more. Speakers from these fields will present current research on topics that have the greatest impact on those whose lives are touched by these conditions.

Topics for patients include pulmonary rehab, creative stress management for caregivers, better breathing tactics, palliative and respite care, and more.

This program is targeted to all lung disease patients and caregivers. It will give participants a sense of camaraderie, a chance to learn from each other and from the local medical community, access to an abundance of resources, and the opportunity to view products that might be helpful to them in their disease management.

The keynote speaker Tarek Mekhail, MD, MSC, FRCSI, FRCSEd; AdventHealth

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GrandRounds Cancer Institute.

Central Florida Regional Hospital Introduces Minimally Invasive Heart Procedure For High-Risk Patients

Central Florida Regional Hospital now offers a minimally invasive alternative to open-heart surgery for high-risk patients.

The hospital is the only hospital in Seminole County to provide transcatheter aortic valve replacement (TAVR) - a sophisticated procedure not performed at many hospitals.

TAVR repairs the aortic valve, which connects the heart’s main pumping chamber (the left ventricle) with the main artery to the body (the aorta). In patients with aortic stenosis, this valve is too narrow to fully open, and the heart becomes overworked.

Usually valve replacement requires physicians to surgically separate the chest and perform an open-heart procedure. But TAVR can be performed through very small openings that leave all the chest bones in place.

Rather than removing the damaged valve, the surgeon inserts a new valve into its place.

TAVR can provide treatment options to people who may not have been candidates for them a few years ago - including older adults and those with other medical conditions that increase their risk. This procedure also provides a faster recovery in most cases.

“TAVR is a natural addition to our comprehensive cardiac program,” said Trey Abshier, CEO of Central Florida Regional Hospital. “We’re proud to offer new treatment options that extend and improve our patients’ lives.”

Poinciana Medical Center Welcomes New CNO

Amber Smith has joined Poinciana Medical Center, an affiliate of HCA Healthcare’s North Florida Division – Orlando Market, as Chief Nursing Officer (CNO).

In her new role, Smith will be responsible for key administrative duties, as well as maintaining the highest clinical and patient care standards. She will also lead the nursing team by upholding best practices and cultivating a professional, collaborative work environment. Additionally, Smith will serve as an advisor to executive leadership and act as a liaison to ensure effective communication among administration, nurses and physicians.

Smith comes to Poinciana Medical Center with 19 years of experience in the medical field, most recently as Assistant Chief Nursing Officer (ACNO) at HCA Healthcare’s Ft. Walton Beach Medical Center. Prior to that, she served as Critical Care Director at Oviedo Medical Center, also in HCA Healthcare’s North Florida Division - Orlando Market. She holds a Master of Science in Nursing (MSN) and is expected to 24

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receive a Doctor of Nursing Practice (DNP) from Walden University in December 2020.

“The role of CNO not only requires an extensive understanding of patient care procedures and policies, but strong leadership skills,” said Chris Cosby, CEO, Poinciana Medical Center. “Amber’s diverse medical background in different types of facilities provides valuable organizational insight.

This expertise helps us to ensure that our staff is well-supported, and aids in our ongoing mission to provide innovative, compassionate healthcare in our community.”

Central Florida Regional Hospital Earns Silver Plus Achievement Award

Central Florida Regional Hospital, an affiliate of HCA Healthcare’s North Florida Division – Orlando Market, has received the American Heart Association/American Stroke Association’s Get With The Guidelines® – Stroke program Silver Plus Achievement Award.

Central Florida Regional Hospital achieved the silver award level by meeting the program’s quality achievement measures for stroke diagnosis and treatment for 12 consecutive months. These benchmarks include using up-to-date, evidence-based guidelines to expedite patient recovery and reduce stroke-related deaths and disabilities. Hospitals recognized by the Get With The Guidelines® – Stroke Program also demonstrated a consistent commitment to scheduling necessary follow-up visits for patients before they’re discharged, as well as providing them with the tools and education needed to manage their health.

“At Central Florida Regional Hospital, we’re committed to providing the highest quality care and treating every patient like family,” said Trey Abshier, CEO of Central Florida Regional Hospital. “Achieving the Silver Award level in the Get With The Guidelines®-Stroke initiative helps showcase our dedication to not only treating patients, but empowering them with education and tools to improve their quality of life long after they’re discharged.”

According to the American Heart Association/American Stroke Association, stroke is the No. 5 cause of death and a leading cause of adult disability in the United States. On average, someone in the U.S. suffers a stroke every 40 seconds and nearly 795,000 people suffer a new or recurrent stroke each year.

risk individuals with mental health and/or substance abuse disorders interact with different stages of the criminal justice system, determine gaps and strategic interventions.

Ultimately the goal is to develop a strategic plan for diversion from jail/prison to community-based programs by increasing access to treatment services and increasing public safety. The targeted, at-risk population includes those who are homeless or in other unstable living situations, a history of victimization or abuse or a history of involvement with the criminal justice system.

As part of the grant, on October 2nd and 3rd, key stakeholders will gather to participate in a Sequential Intercept Mapping (SIM) lead by the University of South Florida Technical Assistance Center. Stakeholders will include representatives from court system, behavioral health provider agencies, law enforcement and counselors, among others. The SIM process is a strategic planning tool used to assess available resources, determine gaps in services and plan for com-

munity change. For more information, see here. The SIM meeting will take place at the Space Coast Health Foundation located at 1100 Rockledge Blvd, Rockledge, FL 32955.

At the end of the planning grant, Central Florida Cares and partners will seek funding to move learnings into action by applying for a Criminal Justice, Mental Health and Substance Abuse Implementation grant, the next step towards initiating change. One such learning could potentially be an expansion of Mental Health courts. As Mark Van Bever, Court Administrator for the 18th Judicial Circuit, notes “Mental Health Courts perform an invaluable service to our communities by serving an important portion of our population in a respectful and effective manner. These courts transfer individuals with mental health illness from the criminal justice system into a treatment system, with the goal of reducing future offenses.”

Central Florida Cares Awarded Criminal Justice, Mental Health and Substance Abuse Planning Grant

Central Florida Cares Health System, Inc. was recently awarded a Criminal Justice, Mental Health and Substance Abuse Planning Grant for Brevard County. The one-year grant is funded through the Florida Department of Children and Families (DCF). The goal of the planning grant is to better understand and identify how those atorlandomedicalnews

.com

October 2019

Outreach autism Services Network Hosting Neuro Medical Conference Nationally-recognized autism specialist Dr. Richard Frye will keynote an ambitious one-day conference Nov. 2 aimed at educating families and doctors about medical conditions that are often intermingled with autism – a growing epidemic that impacts more than 3,000,000 children nationwide.

Outreach autism Services Network (OaSN) is hosting an array of prominent speakers at the conference, which is seeking to reach families and medical professionals in rural areas and surrounding communities about the co-morbid conditions of autism and related neuroimmune disorders. The conference organizers also hope to educate families about making lifestyle changes to optimize their child’s health.

“Once a child receives a diagnosis of autism, medical investigations often stop,” says OaSN’s Education Specialist Ann Sossong. “Autism has many co-morbid medical conditions which can be overlooked in a non-speaking child who is unable to express things like tummy pain.”

Among the topics the conference will explore are: immunodeficiencies and other autoimmune issues, developmental delays including autism, genetic issues, mitochondrial disorders and dysfunction, autoimmune encephalitides, including PANDAS

(Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections), allergies, and metabolic disorders.

“Many medical issues which are common to children with autism, such as gastrointestinal issues or seizures, can be associated with the behaviors we identify as part of autism,” Sossong says. “When these are treated, these behaviors often improve, and the child gains a better quality of life.”

OaSN, a Florida-based non-profit organization that provides autism services to people in the state, would like to educate local providers who deal with children who have autism and neuroimmune disorders and connect them to the doctors and other medical professionals who will be presenting. The conference will include question and answer time for medical professionals, and OaSN will provide one-on-one 15-minute sessions with some of the speakers for the families who attend.

“I was offered this opportunity at another conference,” says OaSN’s Executive Director, Karen Vega, parent of three children on the autism spectrum. “This helped me out tremendously with my youngest son.

He was diagnosed with PANDAS, but our doctor at the time had no idea how to treat him. One of the conference speakers, offered to discuss treatment protocol with our

family doctor at the time, and this is what helped him to go into remission. We want to give this same opportunity to other families.

This is all about helping.”

Inspiration for the conference came from a testimony from a family who traveled from Pensacola to Ocala, a six-hour drive, to hear Dr. Sri Ganeshan speak on Cerebral Folate Deficiency in autism at the OaSN multi-use facility. She took the information he presented back to her pediatrician, who was able to test her son and identify a rare autoimmune disorder which prevents folate from entering the brain properly. Her son, with severe autism, is now being treated for this disorder and is starting to communicate and learn in a way he never could before. This great testimony inspired Vega and Sossong to plan a full day conference with several speakers.

Speakers include Dr. Richard Frye, Chief of the Division of Neurodevelopmental Disorders, Phoenix Children’s Hospital and Dr. Daniel Rossignol, chairman of the Medical Academy of Pediatric Special Needs.

Other speakers are Dr. Richard Boles, a medical geneticist and a pediatrician who specializes in mitochondrial medicine; Dr. David Berger, a pediatrician with over 20 years of experience as a clinician who has developed a national reputation in wholistic

pediatric primary care; and Dr. Jerry Kartzinel, a board certified pediatrician and a fellow in the American Academy of Pediatrics who specializes in the recovery of neurodevelopmental, chronic neuro-inflammatory diseases, and hormonal dysfunctions and Kara Darling, director of The Lighthouse Complex Care clinic, which seeks to guide complex patients in neurology, immunology, genetics and metabolics to optimal health and quality of life by providing comprehensive, individualized medical care.

There are local providers in several specialties from the Ocala area speaking as well, including pediatric neurology, pediatric psychiatry, and functional medicine.

Registration for the conference is $25.

It is being held at One Health Center, 1714 SW 17th Street, Ocala, Florida. The link to register is: https://outreachautismservicesnetwork.com/oasn-neuro-medicalconference/

PHYSICIANSPOTLIGHT

Dr. Raj Kandavanam Reminds Patients on Best Use of Urgent Care vs. Emergency Room Generally, an emergency is a condition that may threaten an individual’s life or cause impairment. If your medical problem is lifethreatening, call 911 immediately and care will be provided at the nearest emergency room. However, ER visits should be reserved for true emergencies. If you are experiencing chest pain, a heart attack, severe abdominal pain, or have been in a life-threatening accident, it’s best to go to the emergency room. A visit to the ER without an actual emergency can be costly and inefficient and distract providers from providing service to individuals who truly need emergency care.

If you have a problem that is not lifethreatening, but you are concerned about your health state, visit an Urgent Care Cen25

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ter. Urgent care is meant to be used for those who cannot get in to see their regular physician when immediate medical attention is needed. The Urgent Care Center on the campus of Leesburg Regional Medical Center (LRMC) treats minor scrapes, coughs, colds, cuts, abscess boils, sore throats, poison ivy, sprained ankles, and much more.

“Keep in mind, however, if you do present to our Urgent Care Center with symptoms of abdominal or chest pains, our team will quickly evaluate whether or not you should be transferred over to the emergency room,” said Raj Kandavanam, MD, Medical Director at the LRMC Urgent Care Center. “This happens several times a day and our professional staff is here to help.”

The LRMC Urgent Care Center is conveniently located on the main campus of Leesburg Regional Medical Center so that patients have access to whatever level of care they may need. The Center is staffed with boardcertified physicians and a team of experienced clinicians. “We take pride in providing fast service and most patients are treated and released within one hour of their arrival.”

During the flu season and throughout wintertime, many patients suffering from flu-like symptoms seek urgent care. Getting a yearly influenza (flu) vaccine from the LRMC Urgent Care Center is a quick and convenient way to help protect yourself from the flu. By immunizing yourself, you also help prevent the spread of the flu.

“We also see many patients with sinus infections,” continues Dr. Kandavanam. “These can be painful and take time to heal. Our caring and friendly team can help determine whether or not you have a sinus infection and recommend the proper treatment so you can start feeling better.”

The LRMC Urgent Care Center offers splinting, onsite lab work, X-rays and special procedures. “In some instances, patients may be sent over to the hospital for a CT scan or an ultrasound when needed,” said Dr. Kandavanam. “Most urgent care centers do not have that capability.”

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GrandRounds Residents Encouraged to Sign Up Today for Upcoming Diabetes SelfManagement Classes

If you have diabetes, controlling it is a key part of living a healthy life. Fortunately, residents have an opportunity coming up soon to take free diabetes self-management classes that will lead them on the path to health success.

The Florida Department of Health in Marion County is holding diabetes selfmanagement classes starting now at the Belleview Public Library (13145 SE County Highway 484, Belleview). Classes will take place from 10 a.m. to noon each Tuesday through Nov. 5 at that location.

The classes will help residents learn more about diabetes and the changes they may need to make to their daily habits to ensure they can effectively control it. Class instructors will cover: understanding diabetes, risk factors, eyes, teeth, toes and feet, physical activity, meal planning, preventing complications, and medications and medical care.

People who are age 65 and older and/ or Medicare recipients are particularly encouraged to attend, but anyone is welcome to come to the sessions. Interested residents are encouraged to pre-register. To register or find out more information, contact Demi Danso at 352-644-2618 or Demi.Danso@ FLHealth.gov.

DOH-Orange Welcomes Marlene Cruz Andreoli as the Community Health Nursing Director

The Florida Department of Health in Orange County (DOH-Orange) welcomes Marlene Cruz Andreoli, RN MSN as the department’s new Community Health Nursing Director. Mrs. Andreoli comes to DOH-Orange from the private sector with over 11 years of nursing care and education and training experience.

Mrs. Andreoli will directly supervise Family Planning and Prenatal Clinics, Employee Health services, Dental Clinic, School Health and Neighborhood Center clinics, and the Healthy Start program. She will also ensure training and nursing skills competency for DOH-Orange nurses.

“A lifelong goal of mine has been to provide compassionate care to those who need it most,” said Mrs. Andreoli. “Emily Dickinson described it best in her poem ‘If I can stop one heart from breaking.’ Working with a group of caring and selfless professionals just confirms this is where I belong.

This position will allow me the opportunity to provide mentorship to public health nurses in collaboration with many wonder-

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ful public health programs. As I embark on this journey, I am excited and anticipate many positive outcomes.”

Prior to joining DOH-Orange, Mrs. Andreoli’s work experience included providing oversight and direction to Clinical Quality Data analysts and specialists as an Electronic Health Record Implementation Manager. In addition, she served as the Senior Director of Education and Training at Orlando Health and Rehab and working in the Medical Surgical Unit as a Registered Nurse at the Hunter Holmes McGuire Veterans Affairs Center in Richmond, Virginia.

Mrs. Andreoli holds a master’s degree in Nursing Informatics from Walden University and she received her Registered Nurse Diploma from the Southside Regional Medical Center School of Nursing in Petersburg, Virginia. This coming January, Mrs. Andreoli plans to pursue a Nursing Practice doctoral program at the University of Central Florida.

Ocala Health Celebrates Topping Off Ceremony at Full-Service Emergency Department in Trailwinds Village

Area residents, local officials and business leaders were present as Ocala Health leadership held a topping off ceremony on the site of the new Trailwinds Village ER, a new freestanding ER on 466A located at 6131 Seven Mile Dr., Wildwood, FL 34785.

The new, 24/7 full-service freestanding emergency department will feature 11 emergency room beds and will be capable of caring for all ages. The 11,630-squarefoot, one-story facility will front 466A. The freestanding ER is expected to serve more than 11,500 patients a year. The $13 million project will employ approximately 30 fulltime healthcare professionals.

“While continuing to expand our Ocala Regional and West Marion campuses, we saw an opportunity to bring emergency care closer to the residents of Sumter County,” says Chad Christianson, Ocala Health CEO. “Over the last few years, we have seen more patients from Sumter County and Lake County choosing Ocala Health for their healthcare services. We believe this freestanding emergency room will provide our patients a more convenient, higher level experience for emergent care. We will continue to expand healthcare services where needed for our growing community.”

As a means to improve access to local

high-quality care, this will be Ocala Health’s third freestanding emergency department.

Ocala Health opened its first freestanding emergency department in Summerfield (Summerfield ER) in October 2016 and has recently opened its second freestanding emergency department (Maricamp ER) on Maricamp Road in Ocala.

Florida Heart and Lung Institute Earns 3-Star Rating From STS

Ocala Health in partnership with Florida Heart and Lung Institute of Ocala (formerly Ocala Health Heart and Lung) and its Cardiothoracic Surgical program has earned a distinguished three-star rating from The Society of Thoracic Surgeons (STS) for its patient care and outcomes in isolated coronary artery bypass grafting (CABG) and aortic valve replacement and coronary artery bypass grafting (AVR/CABG) procedures. The three-star rating, which denotes the highest category of quality, places Omeni Osian, MD among the elite for heart bypass surgery and aortic valve replacement in the United States and Canada.

The STS star rating system is one of the most sophisticated and highly regarded overall measures of quality in health care, rating the benchmarked outcomes of cardiothoracic surgery programs across the United States and Canada. The star rating is calculated using a combination of quality measures for specific procedures performed by an STS Adult Cardiac Surgery Database participant.

The latest analysis of data for CABG surgery covers a one-year period, from January 2018 to December 2018, while the AVR/CABG surgery covers a three-year period from January 2016 to December 2018.

Historically, only approximately 10%-12% of participants receive the three-star rating for isolated CABG surgery and less than 5% of participants receive the three-star rating for AVR/CABG. This data ranks Ocala Health’s program as second highest among 87 HCA Healthcare open heart programs.

“Ocala Regional Medical Center achieved the highest rating in heart surgery compared to other cardiac programs nationwide. This achievement is a demonstration of the patient-focused approach adopted by our multi-disciplinary team in the care of patients and families in need of heart surgery. We are motivated to continue the pursuit of excellence on behalf of our patients.” says Omeni Osian, MD, Cardiothoracic Surgery Medical Director, Ocala Health.

“The Society of Thoracic Surgeons congratulates STS National Database par-

ticipants who have received three-star ratings,” said David M. Shahian, MD, Chair of the STS Council on Quality, Research, and Patient Safety. “Participation in the Database and public reporting demonstrates a commitment to quality improvement in health care delivery and helps provide patients and their families with meaningful information to help them make informed decisions about health care.”

The STS National Database was established in 1989 as an initiative for quality improvement and patient safety among cardiothoracic surgeons. The Database includes four components: the Adult Cardiac Surgery Database (ACSD), the Congenital Heart Surgery Database (CHSD), the General Thoracic Surgery Database (GTSD), and the mechanical circulatory support database (Intermacs).

The STS ACSD houses approximately 6.8 million surgical records and gathers information from more than 3,800 participating physicians, including surgeons and anesthesiologists from more than 90% of groups that perform heart surgery in the US. STS Public Reporting Online enables STS ACSD participants to voluntarily report to each other and the public their heart surgery scores and star ratings.

AdventHealth Ocala Lights Up for Cancer

AdventHealth Ocala is going pink to help raise awareness and provide education for Breast Cancer Awareness Month. The hospital will be lit pink for the month of October to honor patients diagnosed with breast cancer. Additionally, the hospital is the Survivor Sponsor of the Making Strides Against Breast Cancer Walk later in the month and will host a free Breast Health Symposium to educate the community on the latest in diagnosis and treatment for breast cancer.

Current statistics show 1 in 8 women will develop breast cancer in their lifetime.

AdventHealth is focused on early detection, diagnosis and treatment of all women who need care. The hospital is currently the only facility in Marion County offering SCOUT® technology for patients with small breast cancer tumors. The technology replaces the traditional process of marking extremely small tumors with a hooked wire inserted into the breast. SCOUT® allows physicians to precisely locate and remove cancerous tissue during a lumpectomy or surgical biopsy without a wire accidentally being moved or dislodged prior to a procedure.

WHEN:

OCT 1-30 AdventHealth Ocala goes pink OCT 19 Making Strides Against Breast Cancer Walk OCT 23 Breast Health Symposium

WHERE:

AdventHealth Ocala Goes Pink 1500 SW 1st Ave, Ocala, FL 34471 Making Strides Against Breast Cancer Walk Marion County Veterans Park, 2601 E Fort King Str AdventHealth Ocala Breast Health Symposium Auxiliary Conference Center 1542 SW 1st Ave, Ocala, FL 34471 orlandomedicalnews

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October 2019

New Round of Medicare Readmission Penalties Hits 2,583 Hospitals Facilities in Volusia and Brevard Counties included

By Jordan Rau, Kaiser Health News

Medicare cut payments to 2,583 hospitals Tuesday, continuing the Affordable Care Act’s eight-year campaign to financially pressure hospitals into reducing the number of patients who return for a second stay within a month.

The severity and broad application of the penalties, which Medicare estimates will cost hospitals $563 million over a year, follows the trend of the past few years. Of the 3,129 general hospitals evaluated in the Hospital Readmission Reduction Program, 83 percent received a penalty, which will be deducted from each payment for a Medicare patient stay over the fiscal year that begins today.

Although Medicare began applying the penalties in 2012, disagreements continue about whether they have improved patient safety. On the positive side, they have encouraged hospitals to focus on how their patients recuperate, and some now assist them in procuring medications and follow-up appointments.

But the hospital industry and some academics have raised concerns that some hospitals may be avoiding readmitting patients who require additional inpatient care out of fear of the financial repercussions, while others have said the program is not showing major benefits.

Click here to find reports on other facilities in Florida and around the country.

“A lot of hard work has gone into trying to reduce readmissions, and the needle has not moved very far,” said Dr. Karen Joynt Maddox, co-director of the Center for Health Economics and Policy at Washington University in St. Louis, who has been skeptical of the initiative. “It’s been a huge investment by hospitals but not very much in outcomes, but some good things have come out of it.”

A few studies have even found an increase in mortality since the penalties took effect, but other studies, including a recent one by the Medicare Payment Advisory Commission (MedPAC), an independent body that helped devise the approach for Congress, identified no such link.

“I don’t believe the HRRP kills people,” David Grabowski, a commission member and health policy professor at Harvard Medical School, said at the commission’s meeting last month, using the acronym for the penalty program.

The MedPAC staff’s preliminary analysis, made public last month, found that the frequency of Medicare patients being readmitted within 30 days of discharge dropped from 16.7 percent in 2010 to 15.7 percent in 2017. However, the analysis said the decrease was more significant once it took into consideration that the average patient was

frailer in 2017 than in 2010 and thus more likely to end up back in the hospital, with all other things being equal.

“On a risk-adjusted basis, it appears that readmissions have declined in 2010 to 2018 without causing a material increase in mortality,” Jeff Stensland, a MedPAC analyst, told the commission.

The penalties are based on the frequency of readmissions of Medicare patients who had originally been treated for heart failure, heart attack, pneumonia, chronic lung disease, hip and knee replacement or coronary artery bypass graft surgery. Readmissions that were scheduled to occur are not counted.

Medicare counts the readmission of patients who returned to a hospital within 30 days even if that hospital is not the one that originally treated them. In those cases, the penalty is applied to the first hospital. This year’s penalties are based on discharges from July 1, 2015, to June 30, 2018.

“This is like driving your car by looking in the rearview mirror of the car three cars behind you,” Dr. Jonathan Perlin, the chief medical officer of HCA Healthcare in Nashville and a MedPAC commission member, said at last month’s meeting. “It’s very difficult to operationalize.”

BREVARD MEDICARE READMISSION PENALTIES BY PERCENTAGES

2019 2020

VOLUSIA MEDICARE READMISSION PENALTIES

BY PERCENTAGES

2019 2020

Steward Melbourne Hospital

1.00

Adventhealth Fish Memorial

1.04

1.41

Adventhealth Deland

.85

1.26

Adventhealth New Smyrna Beach

.64

.99

Adventhealth Daytona Beach

.31

.64

Halifax Health Medical Center

.15

.24

MELBOURNE, FL

Steward Rockledge Hospital ROCKLEDGE, FL

Holmes Regional Medical Center MELBOURNE, FL

Parrish Medical Center TITUSVILLE, FL

Viera Hospital MELBOURNE, FL

2.27

ORANGE CITY, FL

.93

.94

DELAND, FL

.77

.72

NEW SMYRNA BEACH, FL

1.00 1.79

.63 .49

Palm Bay Hospital

1.25

.28

Cape Canaveral Hospital

.36

.06

PALM BAY, FL

COCOA BEACH, FL

1 Brevard facility penalized by 1 percent in 2019 for excessive hospital acquired conditions

DAYTONA BEACH, FL DAYTONA BEACH, FL

Volusia Facilities Penalized By 1 Percent In 2019 For Excessive Hospital Acquired Conditions Adventhealth New Smyrna Beach, New Smyrna Beach, Fl

Holmes Regional Medical Center, Melbourne, FL

Halifax Health Medical Center, Daytona Beach, Fl

Source: KHN analysis of hospital data from the centers for medicare & medicaid services

Source: KHN analysis of hospital data from the Centers for Medicare & Medicaid Services

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The average penalty will be a 0.71 percent decrease in payment for each Medicare patient who leaves the hospital over the next year, according to a Kaiser Health News analysis. The KHN analysis also found: 1,177 hospitals received a higher penalty than they did last year. 1,148 hospitals received a lower one than last year. 64 hospitals received the same penalty as last year. 194 hospitals that had not been penalized last year are being punished this year. The maximum penalty — a 3 percent reduction in payments — was assessed against 56 hospitals. 372 hospitals avoided penalties in both years.

These figures do not include 2,142 hospitals that Medicare exempted from the program this year, either because they had too few cases to judge; were veterans hospitals, children’s hospitals, psychiatric hospitals or were critical-access hospitals, which are the only hospitals within reach of some patients.

Also, Maryland hospitals were excluded because Congress lets that state set its own rules on how to distribute Medicare money and handle readmissions.

The Centers for Medicare & Medicaid Services determines its penalties by looking at national averages for each of the conditions, so hospitals that have reduced their readmissions from previous years can still take a hit. The hospital industry argues it may be approaching the limits of how much it can do to prevent readmissions. A repeat stay, hospitals say, is sometimes necessary no matter what precautions are taken.

Akin Demehin, director of policy at the American Hospital Association, said: “It raises the question: Is the value of the program to improve care or just to enact penalties on hospitals?”

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GrandRounds Parrish Medical Center is Healing in Every Sense

A growing body of research attests that music therapy is more than a nice perk. It can improve medical outcomes and quality of life in a variety of ways,” according to Beverly Merz, Executive Editor, Harvard Women’s Health Watch.

Understanding and believing in music’s healing affects, Parrish Medical Center (PMC) has made music a regular part of its healing environment for nearly two decades.

Live weekly music performances are held in the medical center’s atrium near the central seating area for outpatient services and the atrium cafe. Community volunteer musicians as well as professional musicians play weekly. A beautiful baby grand piano, donated by the PMC Auxiliary, has a prominent place as well in the atrium.

“Whether it is a scheduled outpatient surgery, MRI or mammogram, having access to healing music helps to ease feelings of stress or anxiety,” said PMC Vice President, Communications, Community and Corporate Services Natalie Sellers.

“We have hosted the Brevard Symphony Orchestra small groups, volunteer pianists and other musicians,” Sellers said.

“We also have witnessed couples dancing in the atrium, people singing along to a familiar song, or simply listening and enjoying the respite the music provides.”

Healing Experiences For Everyone All The Time® is PMC’s mission and the system has served to fulfill that mission in part by the evidence-based healing environment it has designed and created for the people and community served. To view PMC’s weekly music schedule visit, parrishhealthcare.com/musicschedule. If you are interested in being a volunteer musician please contact 321-268-6110.

Parrish Medical Center Primary Stroke Center Re-certified by The Joint Commission

Parrish Medical Center (PMC) has earned The Joint Commission’s Gold Seal of Approval® and the American Heart Association and American Stroke Association’s Heart-Check mark for primary stroke care.

PMC’s recertification as a Primary Stroke Center extends its first-in-Brevard County achievement for area patients endangered by stroke’s potentially debilitating effects.

“Primary Stroke Center Certification recognizes health care organizations committed to fostering continuous quality improvement in patient safety and quality of care,” says Mark Pelletier, RN, MS, chief operating officer, Accreditation and Certification Operations, and chief nursing executive, The Joint Commission. “We commend Parrish Medical Center for using certification to reduce variation in its clinical processes and to strengthen its program structure and management framework for stroke patients.”

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“We congratulate Parrish Medical Center for this outstanding achievement,” says Nancy Brown, chief executive officer, the American Heart/Stroke Association. “This certification reflects its commitment to providing the highest quality of care for stroke patients.”

Stroke is a leading cause of death in Florida. Growing research shows, however, that stroke patients’ outcomes can be significantly improved when they receive treatment from an organized stroke system of care.

“The Joint Commission established the Primary Stroke Center program to set a care standard to protect and saves lives,” said George Mikitarian, PMC president & CEO. “Meeting that standard takes tremendous commitment, resources, and work, but we have long dedicated ourselves to providing the highest levels of patient safety, clinical quality, and healing patient experiences on behalf of the people and communities we serve.”

“This Joint Commission’s Gold Seal affirmation of PMC’s quality stroke care means that patients and families can have confidence in the objective measurement, accomplishment, and results, of PMC’s treatment program,” Mikitarian added.

In 2010, PMC became the first hospital in Florida to participate in the Mayo Clinic telestroke program. Via a remote presence robot that stands five feet tall, neurologists at Mayo Clinic’s Comprehensive Stroke Center in Jacksonville can remotely evaluate acute stroke patients and assist with diagnosis and treatment.

Quick administration of a drug called tPA to dissolve a stroke-causing blood clot and restore blood flow is part of The Joint Commission’s standards followed by PMC, said Gregory P. Cuculino, MD, FACEP, emergency department medical director.

“In many cases the drug results in the patient having minimal or no neurological damage from the stroke,” said Dr. Cuculino, “It’s one aspect of our approach to stroke care, which includes prevention, treatment and rehabilitation while always working as a team.”

Hospitals began to apply voluntarily for PSC certification from the Joint Commission in 2003 in response to proposed organized stroke system of care by the Brain Attack Coalition in 2000. The proposed stroke system of care promotes EMS routing acute patients to Primary Stroke Centers (PSCs), and Comprehensive Stroke Centers able to provide proven stroke care reliably and rapidly.

In 2004 PMC became the first health system in Brevard and third in the state of Florida to earn The Joint Commission’s PSC certification. And, every two years since 2004, The Joint Commission has evaluated and recertified PMC’s PSC. The most recent evaluation, in 2019, resulted in the latest recertification.

Effective July 1, 2019, Senate Bill 1460 mandates hospitals to be stroke certified by a nationally recognized certifying organization that is approved by AHCA by July 1, 2021. The Joint Commission PSC certification meets this requirement.

Three Dog Night Drummer Finds His Rhythm Again

At the height of his acid reflux, Pat would find himself waking up choking and hacking at night, despite sleeping at a 45-degree angle to alleviate symptoms. Not to mention the horrible heartburn that plagued him daily while traveling as a drummer for the band Three Dog Night.

But after finding himself in Health First’s Viera Hospital for emergency gallbladder surgery, a conversation with surgeon Dr. Kenneth Tieu made Pat realize maybe he didn’t have to live in such misery anymore.

“He said he could fix that easy,” Pat said, adding that his Gastroesophageal Reflux Disease (GERD) likely affected his singing. “I was not feeling rested, and I am sure it affected my voice.”

After undergoing surgery for the LINX Reflux Management System, Pat’s GERD cleared up immediately. The bracelet-shaped system of flexible, magnetic titanium beads, placed around the esophagus, restores the body’s barrier to acid and bile reflux. The magnetic attraction of the titanium beads allows the esophagus to open and close to let food in or out, should it need to.

“I mean, when you have acid reflux, you just learn to live with it, and you don’t know how bad it was until it’s gone,” Pat said. “The symptoms were completely gone after the surgery.”

The procedure, done laparoscopically under general anesthesia, is used for treating acid reflux when medication no longer provides relief or if patients are seeking an alternative to using acid-suppression medications long-term, which can come with risks.

“It hasn’t slowed me down one bit,” Pat said of the surgery. “And with all the terrible choices for food on the run, I used to get a bad bout of heartburn and acid reflux.

That’s all in the past. I have zero symptoms now and feel better than ever.”

Parrish Medical Center Board Votes No Taxes for 25th year in a Row

For the 25th straight year, no taxes will be assessed to support operations of the North Brevard County Hospital District d/b/a Parrish Medical Center (PMC).

PMC’s board of directors voted unanimously during public hearings on Sept. 23 to establish the millage rate and budget for fiscal year 2020.

PMC is an independent, public, notfor-profit hospital, and state law gives the North Brevard Hospital District (d/b/a Parrish Medical Center) the authority to set a tax rate to support hospital operations.

However, unlike most public hospitals, the PMC Board of Directors has for 25 years chosen not to use tax dollars as a means of funding the hospital.

“PMC serves the community’s health

through compassionate and exceptional care and is recognized as one of the nation’s best in clinical care, patient safety and patient experience,” said PMC Board Chairman Herman A. Cole, Jr. “We are pleased to continue to take this position on behalf of the community we serve while also investing tens of millions of dollars back into North Brevard each year in charity care and services.”

“As long as the community continues to support PMC – PMC will be able to continue to support the community,” concluded Cole.

AdventHealth Names Director of Strategic Program Management

Katie Palacios has been selected to serve as the director of strategic program management for the AdventHealth facilities in Flagler, Lake and Volusia counties.

In this new role, Palacios is responsible for organizing and driving leadership strategies forward and ensuring alignment for strategic priorities across the AdventHealth Central Florida Division.

Palacios has five years of experience and began her career at AdventHealth Hendersonville in North Carolina.

She most recently served as the senior manager for CREATION Life at AdventHealth’s corporate offices. In this role, she was responsible for aligning employee wellness efforts across the entire AdventHealth organization using the framework of CREATION Life, a lifestyle transformation program that was created to help people improve their overall wellbeing, reach their goals, and live a full and complete life. As one of the nation’s largest faith-based health care systems, this role impacted AdventHealth’s 80,000 employees at nearly 50 hospitals within about a dozen states.

A Longwood resident, Palacios earned a Bachelor of Science in corporate/community wellness management from Southern Adventist University, as well as a master’s degree in public health from Andrews University.

About AdventHealth Central Florida Division - North Region Encompassing six AdventHealth hospitals in Flagler, Lake and Volusia counties, the AdventHealth Central Florida Division - North Region is the largest hospital system in the area with 1,196 beds and more than 8,000 team members. The North Region includes facilities in Daytona Beach, DeLand, Orange City, New Smyrna Beach, Palm Coast and Tavares. Formerly known as Florida Hospital, the organization’s parent company changed the name of all whollyowned entities to AdventHealth on Jan. 2, 2019. Based in Altamonte Springs, AdventHealth is a connected system of care. With more than 80,000 team members, AdventHealth is one of the nation’s largest faithbased health care systems with nearly 50

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GrandRounds hospitals and hundreds of care sites in nearly a dozen states.

Parrish Healthcare Leads North Brevard Community Health Needs Assessment

Parrish Medical Center | Parrish Healthcare Board of Directors, during a special meeting of the Board of Directors held on Monday, Sept. 23, approved the 2019-2021 North Brevard County Community Health Needs Assessment (CHNA) and recommended health needs prioritization.

Parrish Healthcare engaged Professional Research Consultants (PRC), national experts, to conduct the needs assessment effort for North Brevard.

“A Community Health Needs Assessment is a systematic, data-driven approach used to study the health status, behaviors and needs of residents served by Parrish Healthcare,” said Parrish Medical Center President/CEO George Mikitarian.

“Through the Community Health Needs Assessment, Parrish Healthcare’s leadership are able to make informed decisions about resource allocation and strategic priorities to address and/or to close healthcare gaps, while fulfilling our mission, vision and values on behalf of the communities we have the honor to serve,” added Mikitarian.

A random sample of 300 north Brevard residents and 75 members of Parrish Healthcare’s Community Health Partnership participated in the needs assessment and prioritization of unmet needs process.

The Community Health Partnership represents a diverse cross-section of the county’s health and human services, social services, civic and faith-based organizations, among other community stakeholders.

The following represent the top 10 priorities approved to be developed into a three-year implementation plan: 1. Mental Health 2. Heart Disease & Stroke 3. Diabetes 4. Nutrition, Physical Activity/Weight 5. Substance Abuse 6. Access to Healthcare 7. Cancer 8. Respiratory Diseases 9. Tobacco Use 10. Potentially Disabling Conditions In addition to providing safe and highquality care to the community, Parrish Medical Center also provides more than $30 million annually in community benefit investment including uncompensated and charity care.

Parrish Medical Center Designated a Breast Imaging Center of Excellence

Parrish Medical Center (PMC) has been designated a Breast Imaging Center of Excellence by the American College of 29

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Radiology (ACR). The award is presented only to breast imaging centers that have demonstrated excellence by earning ACR accreditation in all the college’s voluntary, breast-imaging accreditation programs and components, in addition to the mandatory Mammography Accreditation Program.

This means PMC’s mammography, stereotactic breast biopsy, breast ultrasound and ultrasound-guided breast biopsy imaging services are all fully accredited. Accreditation is determined through peer-review evaluations by board-certified physicians and medical physicists who are experts in the field. PMC achieved high practice standards in image quality, personnel qualifications, facility equipment, quality control procedures, and quality assurance programs.

PMC is proud to be one of only two breast imaging centers in Brevard County to be designated a Breast Imaging Center of Excellence, and the only one in North Brevard.

PMC voluntarily went through ACR’s rigorous review process to ensure it met nationally accepted standards. This process certifies that PMC care partners, through education and certification, are well qualified to perform and interpret medical images and administer radiation therapy treatments.

It also means PMC has the appropriate equipment for a patient’s prescribed test or treatment, and that quality assurance and safety guidelines are always met or exceeded.

The ACR, headquartered in Reston, Va., is a national organization serving more than 32,000 diagnostic/interventional radiologists, radiation oncologists, nuclear medicine physicians, and medical physicists with programs focusing on the practice of medical imaging and radiation oncology, as well as the delivery of comprehensive healthcare services.

Parrish Medical Center is an awardwinning 210-bed, acute care, not-for-profit medical center that has served North Brevard for over 50 years. PMC is nationally recognized as one of America’s finest healing environments. It has earned a gold seal for excellence and quality in Breast Health from the Joint Commission, the premier accrediting organization for healthcare systems in the nation, plus six other disease-specific gold seals. For more information visit parrishmed.com or call 321-268-6110.

AdventHealth to Build Freestanding ER and Medical Plaza in Port Orange

AdventHealth announced plans today to build a 18,400-square foot, 24-bed hospital-based emergency department in Port Orange to care for both adults and children.

Situated on seven acres directly south of the Port Orange Pavilion at 5811 Williamson Blvd., the AdventHealth Port Orange ER will house the same services found in hospital emergency rooms, including imaging and laboratory services. It will operate as a department of AdventHealth Daytona Beach.

“Port Orange has experienced growth

at a rapid pace,” said Ed Noseworthy, AdventHealth Daytona Beach President and CEO. “We looked at several properties in the Port Orange area, but none had the ease of access and visibility of this specific location. This is a convenient access point for the community and is in close proximity to the popular Port Orange Pavilion.”

Construction on this approximately $17 million project is expected to begin in March 2020 and open in early 2021.

“We believe in investing in the community. Not only is this new emergency department an investment in the community’s health care, but we are also striving to bring jobs and economic growth to the area,” Noseworthy said. “We will use as many local vendors as we can for this construction project. Once completed, we will hire additional physicians and staff, and are looking to add about 40 full-time employees.”

The location is strategically located halfway between AdventHealth Daytona Beach and AdventHealth New Smyrna Beach, giving residents from Port Orange and surrounding communities more convenient access to care. In addition to the ER, AdventHealth plans to expand on the property in the future and add a two-story medical office building for a variety of physicians and specialized care.

“A number of our physicians and specialists are already serving patients in the Port Orange area,” said Dr. Dennis Hernandez, AdventHealth New Smyrna Beach President and CEO. “The new medical plaza will allow us to bring even more specialists and primary care providers to the area, further growing our comprehensive network of services.”

In the next few months, AdventHealth will host a groundbreaking ceremony to celebrate the start of construction on the new emergency department.

The architect is Orlando-based HuntonBrady.

Halifax Health Receives Patient-Centered Medical Home Recognition

especially proud of our family and sports medicine team’s unwavering commitment to providing the highest quality of care to all of our patients,” says Carrie Vey, M.D., program director for the Family Medicine Residency Program at Halifax Health.

The American Academy of Pediatrics introduced the medical home concept in 1967. Leading primary care-oriented medical professional societies released the Joint Principles of the Patient-Centered Medical Home (PCMH) in 2007. NCQA released its PCMH Recognition program – the first evaluation program in the country based on the PCMH model – in 2008. Today, NCQA’s PCMH Recognition program has evolved to feature a set of six concepts that make up a medical home.

The program’s six concept areas include: Team-Based Care and Practice Organization: Helps structure a practice’s leadership, care team responsibilities and how the practice partners with patients, families and caregivers.

Knowing and Managing Your Patients: Sets standards for data collection, medication reconciliation, evidence-based clinical decision support and other activities.

Patient-Centered Access and Continuity: Guides practices to provide patients with convenient access to clinical advice and helps ensure continuity of care.

Care Management and Support: Helps clinicians set up care management protocols to identify patients who need more closely-managed care.

Care Coordination and Care Transitions: Ensures that primary and specialty care clinicians are effectively sharing information and managing patient referrals to minimize cost, confusion and inappropriate care.

Performance Measurement and Quality Improvement: Improvement helps practices develop ways to measure performance, set goals and develop activities that will improve performance.

Halifax Health - Center for Family and Sports Medicine has provided quality primary care to adults and children for more than 35 years. The practice includes eight board-certified family medicine physicians, one board-certified pediatrician, a Ph.D.level psychologist and 24 family medicine resident physicians. Sports medicine services are provided by four board-certified sports medicine physicians and a sports medicine fellow.

Halifax Health-Center for Family and Sports Medicine has been awarded recognition by the National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home Program. This re-certification is evidence of Halifax Health’s commitment to continuous quality improvement and patient-centered approach to care.

“Halifax Health is extremely proud to once again receive this recognition. We are orlandomedicalnews

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