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PHYSICIAN SPOTLIGHT PAGE 3
Michel M. Murr, MD ON ROUNDS
Bending the Healthcare Cost Curve Florida Chamber unveils Healthcare Alliance at 2013 Forum ... 11
Transitioning Veterans USF College of Nursing receives largest of nine federal grants for veterans with healthcare skills to earn nursing degree By LyNNE JETER
The University of South Florida (USF) College of Nursing received the largest of nine federal grants funded by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HHS) to create a Veterans’ Bachelor of Science Degree in Nursing (VBSN) Program. The grants will help more than 1,000 veterans nationwide become nurses. The fully funded, four-year grant
award for USF College of Nursing is $1.25 million. For fiscal year 2013, USF College of Nursing received $349,773 of HHS grants totaling $2.78 million to provide veterans and service members a program that builds upon their military healthcare training and experience called Creating Access to Registered Nurse Education for Veterans (V-CARE). The program will facilitate a more efficient pathway from veteran, to student, to career nursing professional, awarding a
certain amount of credit for previous military training and service. The nursing college anticipates enrolling one to two dozen students next fall, and plans to enroll 120 veterans and service members, including reservists, over four years. “The V-CARE program will creatively address several critical national challenges -- a significant shortage of registered nurses, the underemployment of (CONTINUED ON PAGE 4)
POCD or Delirium?
UCF family medicine professor weighs in on controversial studies linking dementia to anesthesia and surgery Moving into Venice
SMH opens fourth urgent care center – and first in Venice ... 7
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By LyNNE JETER
A noted Orlando family medicine physician specializing in geriatrics addresses the controversy on whether elderly patients undergoing anesthesia for surgery may suffer from postoperative cognitive dysfunction (POCD), leading to early onset dementia, or delirium, a temporary state of confusion. Mariana Dangiolo, MD, assistant professor of family medicine, director of geriatrics at the UCF College of Medicine, and a geriatrician for UCF Pegasus Health, said preoperative cognitive testing for elderly
patients establishes a baseline that takes the guesswork out of determining their postoperative cognitive state. “Preoperative cognitive testing helps establish the distinction between dementia and delirium in elderly patients that become confused and disoriented after surgery,” said Dangiolo. “Delirium isn’t easy to recognize because a cluster of problems may lead to a patient’s state of deep confusion. Usually, there’s more than one underlying symptom in the presentation. A baseline status would be (CONTINUED ON PAGE 12)
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PhysicianSpotlight
Michel M. Murr, MD
Director, Bariatric Metabolic Institute, Tampa General Hospital By JEFF WEBB
TAMPA - Threads of irony and hope run through Michel Murr’s life story. As director of surgery at the Bariatric Metabolic Institute for the past 15 years, Murr has helped thousands of people survive the deleterious comorbidities of obesity. But it was his early-life lessons about survival that brought him to this opportunity in Tampa Bay. “My happy childhood was interrupted by a civil war that started in Lebanon in 1975,” said Murr, who grew up one of four sons of a travel agency owner and a stayat-home mom. “The violence besieged everyone and tore apart the civic fabric and normative values; life became very cheap and survival became a very critical skill. I learned to endure tremendous hardship and strife by keeping a positive attitude,” said Murr, 51. “We lived in one part of the city and went to school in another part of the city. We would cross war zones and road blocks. We would be picked up because we were from a different religion or of a different political persuasion,” said Murr, who was raised Catholic Christian in a predominantly Muslim region. There were “people in the streets who were zealots and carrying guns. We became targets. We did a lot of things to conceal who we were. I saw air raids, street bombs, kidnappings, slaughters and massacres,” he recalled. Murr had just finished his undergraduate studies at American University of Beirut when terrorists shocked the world by bombing the barracks of American Marines and French soldiers in October 1983. The deaths of those 299 peacekeepers made life in Beirut worse than it already was, Murr said. “It was miserable after that,” he said. Murr enrolled in medical school at American University and had a front-row seat to more carnage. “Working in the hospital, you are seeing it one day after the other. It was very stressful,” said Murr. His touchstone throughout those turbulent times was his high school sweetheart, Suzy. “We had a great romance, and it carried through to college. Time was tight so we had to make (the best) from what little time we had. It was long distance at times,” said Murr. “With the war we were not sure what was going to happen the next day. But one of the ways people dealt with it was to get out for training or studying abroad. A lot of people were doing that,” said Murr. And that is what he and Suzy, an architect and artist to whom he has now been married 27 years, did when he got his medical degree in 1986. The couple landed in Iowa City, where Murr interned in pathology and did his surgical residency. “One of the challenges that I experienced was changmedicalnews
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ing from a survival mode to a successful mode,” said Murr. “I put in extraordinary effort to differentiate myself from other trainees. This included excelling in clinical work, getting high scores in national exams and publishing original scientific research reports,” he explained. A fellowship in gastrointestinal surgery at the Mayo Clinic in Rochester, Minn., was followed by a stint as the GI surgery scholar. In 1998 he was recruited by the University of South Florida College of Medicine to jumpstart its fledgling bariatric surgery program. “I was brought here with one task to be accomplished. (A program was in place), but it was not standardized or put in the context of inter-disciplinary care,” said Murr. “We started making a presence in the market with the science behind it within two years of starting. We did a lot of surgeries and took good care of a lot of patients. We did a lot of research protocols and wrote about how to take care of patients. That all pushed the program to prominence and we became nationally recognized,” he said. That “track record of credibility,” Murr said, has resulted in a hybrid collaboration between USF and Tampa General Hospital. “Tampa General and USF agreed without any questions or issues, that bariatric services were needed in the hospital and in the community. That’s why
we built a collaborative, co-branded, core-recruited center. For the first time in history you see their logos at the same level in the same place. We brought in the patients. We brought in the (resources) of the hospital and all the talent and expertise from USF and put it all in one place,” he said. The inter-disciplinary approach at the Bariatric Institute includes “an exercise physiologist, a dietician, a psychologist, and everyone else needed for day-to-day care,” said Murr. “Everyone reads from the same page. It’s one-stop for the patients,” many of whom “feel guilty to be alive,” he said. “It took the AMA 15 years to come to the conclusion (that obesity was a disease),” Murr said. “We started that conversation very early at Tampa General,” which he said is one of the busiest bariatric treatment centers in the southeastern U.S. The institute, Murr predicts, will perform about 500 operations next year. “We are the safety net for this region. Complicated cases come here from
all over the state,” said Murr, who compared his bariatrics clinical and research programs to the Cleveland Clinic and the University of California at Irvine. “We get applications from one-third of the applicants in the U.S. (trying to match fellowships). We are competing at that level for the training pool. That makes me very happy,” said Murr, who takes great pride in being a mentor. “Mentoring is either something you have or you don’t. I didn’t know I had it until I did it and realized I should nurture it,” he said. “The ability for a person to take another person and educate them about to care for a patient is awesome. And the feedback you get from those who say ‘You helped me. You opened doors for me. I learned from what you did,’ makes your day,” said Murr, who brings in two fellows a year, in addition to residents, medical school students and nurses who do specialty rotations there. Murr said that striking balance (CONTINUED ON PAGE 9)
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Transitioning Veterans, continued from page 1 veterans, and increased patient demand for access to care,” said project director Rita F. D’Aoust, PhD, ANP-BC, associate dean for academic affairs and director for interprofessional initiatives at the USF College of Nursing. These challenges are particularly pressing in Florida, a state projected to have the greatest shortage of RNs, Dr. Rita F. accounting for nearly D’Aoust 130,000 jobs, in the eastern United States by 2030, according to the U.S. Registered Nurse Workforce Report Card and Shortage Forecast. Award recipients like USF School of Nursing are charged with recruiting veterans and preparing VBSN undergraduates for practice and employment in local communities, and also developing career ladders that include academic and social supports, career counseling, mentors and linkages with veteran service organizations and community health systems. “The VBSN program recognizes the valuable skills and experience of our veterans, while addressing the nation’s nursing workforce needs,” said HHS Secretary Kathleen Sebelius, when the program was announced mid-September. “The education and training they receive helps qualify them for civilian nursing positions, while expanding Americans’ access to high-quality care.” Veterans know the value of working
VBSN Grants Awarded Nationwide for FY 2013: Florida schools received nearly one-third of total VBSN grant funding for FY2013, accounting for $890,459 of $2.78 million. The breakdown nationwide for schools receiving VBSN grants is listed by grant amount, highest to lowest. • University of South Florida in Tampa: $349,773 • Hampton University in Hampton, Va.: $349,689 • Florida International University in Miami: $335,420 • Davenport University in Grand Rapids, Mich.: $327,284 • University of Alabama at Birmingham: $315,969 • Shenandoah University in Winchester, Va.: $312,025 • State University of New York at Stony Brook: $296,763 • University of Texas at Arlington: $291,408 • Jacksonville University in Jacksonville: $205,266 SOURCE: HHS.
in teams and have a strong commitment to service, said Health Resources and Services Administration (HRSA) Administrator Mary Wakefield, PhD, RN. “These are just the skills and talents our healthcare delivery system needs right now,” she elaborated. “We want to tap the expertise of a growing supply of medically-trained veterans to help address the nation’s nursing workforce needs while expanding Americans access to high-quality care,” said D’Aoust. “USF’s V-CARE model will help fill important gaps for highly skilled registered professional nurses in Florida and our nation by capitalizing on the valuable skills and experiences that veterans can bring to our healthcare delivery system.”
The USF College of Nursing was selected because of its long history of supporting the nation’s service members, veterans and their families with innovative educational programs and partnerships tailored to meet the complex needs of this population, said Dianne Morrison-Beedy, PhD, RN, senior associate vice president of USF Health and dean of the College of Nursing. USF ranks fourth among the country’s most veteran-friendly four-year colleges by Military Times magazine, and was recently named by GI Jobs magazine in the top 15 percent of all colleges, universities and trade schools nationwide as a Military Friendly School. “This new program will build upon the strengths of our existing links with the
USF Office of Veterans’ Affairs, our clinical collaborations with leading healthcare and VA agencies, our partnerships with key personnel at military bases, and our strategic focus on military and veterans’ health,” she said. V-CARE supplements the USF College of Nursing’s ongoing strategic priority known as RESTORE LIVES, which focuses on evidence-based research and education programs to train a nursing workforce that can help veterans and service members overcome psychological stress and other combat-related health problems. “USF is clearly one of the best colleges in the nation for students who are veterans or serving in the military,” said Larry Braue, EdD, director of veterans services at USF. “The College of Nursing is building an educational ladder that will contribute to the success of USF’s student veterans’ by providing those rich in life experiences and military medical service with the opportunity to pursue their dream of becoming a nurse.” For more information on V-CARE, contact Alicia Gill Rossiter, MSN, ARNP, military liaison for the USF College of Nursing, at arossite@health.usf.edu
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PROUDLY SERVING FLORIDA’S CULTURAL COAST
Moving into Venice SMH opens fourth urgent care center – and first in Venice By LyNNE JETER
VENICE – While dodging controversy over a long-planned urgent care center on Laurel Road in Venice, Sarasota Memorial Health Care System opened its fourth urgent care center – and first in Venice – on the Venice Bypass in mid-October. Open seven days a week from 8 a.m. to 8 p.m. except Thanksgiving and Christmas, the new urgent care center is located near the prominent intersection of the U.S. 41 Bypass and Tamiami Trail in Venice. Sarasota Memorial board-certified emergency, family and internal medicine physicians treat patients daily with non-life threatening illnesses and injuries. The new facility also features an outpatient imaging center and lab on the first floor to accommodate mammogram, CT, X-ray, bone density testing, blood draws and other testing services. Pediatric care will also be a component of the new center. Family medicine physicians Veronica Voloshinov, (CONTINUED ON PAGE 13)
Gaining Perspective on the Reimbursement Landscape: Glass Half Empty … or Half Full By CINDy SANDERS
To see something in a different light often requires a shift in perspective. David A. Williams, CPA, MPH, FHFMA, leader of healthcare reDavid A. Williams imbursement and advisory services for HORNE LLP, believes this certainly holds true for practices and facilities facing ever-increasing budget pressures. Glass Half Empty Williams, a partner in HORNE’s Ridgeland, Miss. office, noted for many healthcare providers, any incremental increase in revenue is eaten up by rising costs — from increased wages to higher prices for supplies to hikes in rent and utilities. He pointed out that for hospitals, medicalnews
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the largest revenue stream is for inpatient stays, and the largest single payer is Medicare, which can represent from the low 40s to the high 60s in terms of percentage of patients. “There has been a market basket update, but for the last couple of years, it’s been less than 2 percent,” he said. Williams noted the government puts in the full market basket update but then begins reducing the rate by looking at adjustments tied to value-based purchasing, readmission rates and acquired conditions, in addition to other factors. “Normally you’re seeing very minimal increases. It’s caused a flattening of revenue per patient,” he said. Then, Williams
continued, after payment increases are netted out, “Medicare is subject to a 2 percent reduction to fulfill the sequestration order.” He added that Medicaid, which typically covers anywhere from 5-15 percent of patients … or higher depending on location and a hospital’s safety net status, is not currently subjected to sequestration. Yet, he said, hospitals are faced with mounting concerns about Medicaid expansion, uncompensated care, and cuts to disproportionate share hospital payments. For hospitals in states that didn’t opt to expand Medicaid rolls, administrators are worried about rising levels of uncom-
pensated care for those that fall into the gap in the Affordable Care Act between traditional Medicaid eligibility and qualifying for federal subsidies on the healthcare exchange. Even for providers who are in states that did expand Medicaid, Williams said uncertainty still exists about how reimbursement will actually net out. Traditionally, Medicaid has reimbursed providers at a set match rate for direct patient services and a 50 percent rate for the administrative portion of the episode of care. Although the ACA Medicaid expansion plan covers 100 percent of patient services for three years and then rolls down incrementally to 90 percent over subsequent years, the administrative match remains at 50 percent so the state does incur additional cost by expanding rolls. Additionally, Williams said certain provisions of the ACA require mandatory (CONTINUED ON PAGE 9)
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The Evolution of HIPAA Compliance By LINDA RODRIGUE AND LyN SAVOIE
Because the increasing prevalence of technology, mobile devices in the workplace and online health records, as well as the risk of making patient information more public, HIPAA, or the Health Insurance Portability and Accountability Act, recently instituted new safeguards and restrictions. HIPAA was established in 1996 to safeguard protected health information. In 2009, the United States Congress signed the Health Information Technology for Economic and Clinical Health Act into law to promote the proper use of health information technologies. The HITECH Act works to ensure healthcare providers learn the proper methods and are given the resources to transmit Electronic Health Records of patients. The new “Final Rule,” effective on March 26, 2013, through the HITECH Act added several changes to the privacy and security policies in HIPAA. Of the many additions and regulations enacted by this new rule, three carry the most weight: new Business Associate Agreements; new breach notification rules and enforcement; and new notice of privacy
practices requirements. A business associate, as it pertains to the new rule, is any person or entity who creates, receives, maintains or transmits protected health information (PHI) for a covered function or activity, or provides other work that requires them to use or disclose PHI. Under new regulations, this now includes subcontractors, requiring covered entities to make new agreements with their business associates and the business associates to make agreements with their subcontractors. Simply speaking, anyone who touches medical records may need to sign a new agreement. There’s a single exception – if a business associate agreement was made prior to March 26, 2013, the contracts can be used until they expire or on Sept. 23, 2014, whichever comes first. New, stricter rules addressing breach notification have gone into effect, transferring the burden of proof to covered entities and business associates. Previously, covered entities were not presumed to have breached unless a significant risk was present. Now, all entities have to prove there was no compromise of PHI based on a
thorough risk assessment. Three exceptions to breaches have also been maintained – an entity is not held accountable if an in-house use was unintentional; if PHI was disclosed to an unauthorized person under the assumption they won’t retain the information, or if one authorized person inadvertently discloses the information to another authorized person in-house. Finally, healthcare privacy has evolved dramatically since HIPAA was first signed into effect, and updated regu-
lations require entities to address these changes. Staffs should be retrained on PHI, how to use a mobile device in the work environment and protecting shared data. Regulations also strongly recommend entities preemptively address the use of social media. Health care providers must also give a notice explaining to the patient how they can use and share their health information and how they can exercise their health privacy rights; the notice must explain how they use and disclose PHI, as well as the fact that the entity must get a patient’s permission before using their health records for various uses or disclosures. The task of staying compliant with HIPAA policy changes is evolving as quickly as the medical field itself, and the rise of mobile technology has only served to increase complications. But becoming and staying compliant should be a huge priority for businesses and individuals, to prevent significant public perception and financial losses. Linda Rodrigue is a partner with Kean Miller, LLP in Baton Rouge. Lyn Savoie is an associate at the same location.
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Gaining Perspective, continued from page 7 changes for states regardless of expansion, including: welcome mat population or those who were eligible for Medicaid but had not enrolled previously, foster children expansion to age 26, expanded eligibility for children, primary care physician fee increase, and health insurer fee. In Mississippi, a non-expansion state, the estimated amount of the mandatory changes is between a $272 - $436 million increase in spending. With this amount of growth, the state is not expected to increase the reimbursement rate for a full episode of care. Medicare DSH payments also are causing administrators to lose sleep at night. Initially, the ACA plan called for a 75 percent reduction in Medicare DSH payments. However, Williams said part of the final regulation that went into effect Oct. 1 of this year moderated that number a bit by moving to an empirical DSH payment for uncompensated costs … a complex, calculated cut that softens the blow some by looking at a hospital’s relative share of Medicaid inpatient utilization as a proxy for uncompensated patients. Williams said that for one hospital in the Mississippi Delta, the original Medicare DSH reduction would have meant a loss of $5.6 million. “But,” he continued,
“because of the additional payment to fund the uncompensated cost, it was actually a reduction of $2 million.” While that is still a significant loss, “It could have been worse,” Williams noted. Still, he continued, “You’re faced with the fact your revenue isn’t growing as fast as your expenses. It’s very concerning to most every healthcare organization around.” Glass Half Full So if revenue isn’t going up, the logical place to increase margins is to decrease costs. Yet, healthcare providers want to make sure they provide the best care possible without sacrificing a patient’s well being simply to save a few dollars. “A lot of people equate higher quality with higher cost, but that’s not necessarily true,” Williams pointed out. In fact, he said, doing the right thing in the right way is often significantly more cost efficient. “A major cost in providing care to patients is variation in the clinical process of care,” Williams said. He added it is easy to find real world examples of this type of variation where one hospital’s cost for an average hip replacement is $45,000, yet another one might have an average cost of $22,000. “What’s the disconnect?” he
asked of the two cost scenarios. “A lack of standardization of using evidence-based protocols,” he answered. By using data available through electronic health records coupled with a partnership with technology company Health Catalyst, Williams said HORNE is able to mine the available information to look at clinical pathways and search out deviation from standard protocols that adds to the cost of care. He was quick to add that the technology doesn’t seek to stop physicians from exercising their medical judgment but does highlight where there are outliers when it comes to following clinical protocols. “Best practices and evidencebased medicine say that these are the best protocols out there,” he pointed out. Following those protocols not only saves money, but also should optimize quality. With increased transparency, payers and patients will have access to information regarding those positive outcomes and lower costs, which could ultimately drive volume. A Foot in Both Boats Administrators and chief financial officers are caught between the fee-forservice and value-based payment worlds (CONTINUED ON PAGE 11)
PhysicianSpotlight Michel Murr, MD, continued from page 3 between his professional and personal lives is an ongoing challenge and he is making progress. One way he does that is gardening. “I have one-way conversations with my plants. They don’t have complaints and they don’t tell you how their day was,” he joked. “I call it the Garden of Redemption … I de-stress and reflect on many issues,” he said, and he often is joined by his children, Hana, 22, and Ramsey, 20. But Murr has another creative outlet, one he has nurtured since he was in Lebanon; he’s a creative writer. “I’ve kept a diary since I was 14. It’s a place where you can express yourself without feeling that anyone is going to judge you,” he said. But his literary outlets are not limited to a diary. He writes poetry and has almost finished a fictional period book about the Ottoman Empire. “I am very pragmatic … you could never tell that I have an ounce of romanticism,” said Murr. “I keep it to myself (and) read to very few people.”
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Bending the Healthcare Cost Curve Florida Chamber unveils Healthcare Alliance at 2013 Forum By LyNNE JETER
During the Florida Chamber Foundation’s 2013 Future of Florida Forum in mid-October, state chamber leaders unveiled a new tool for “bending the healthcare cost curve.” The chamber’s Florida Business Alliance for Competitive Healthcare Solutions (Healthcare Alliance) will focus on innovations occurring across Florida’s healthcare industry to control costs, increase access to care, and improve the quality of care. Job creators, technology leaders and healthcare providers comprise the Healthcare Alliance. “As job creators across Florida are preparing for the implementation of the Affordable Care Act, the Florida Chamber’s Healthcare Alliance will provide employers a strong platform to share ideas on what’s working to improve the quality of care and reduce health costs,” said Steve Payment, healthcare executive for IBM and chair of the Florida Chamber’s Healthcare Alliance. By 2030, an estimated two-thirds of Florida’s population, the nation’s fourth largest state, is expected to be 65 and older. By focusing attention toward programs that can be used as statewide models, Florida’s leaders plan to balance the future of medicine with the needs of an evergrowing and ever-aging population. Following the announcement of the Florida Chamber’s Healthcare Alliance, delegates attending the Florida Chamber Foundation’s Future of Florida Forum participated in a Health-
care Summit. Discussions included: • Legislative Panel – The Policy Vision of the Future • Healthcare Innovation – Bending the Cost Curve, Securing the Future • Healthcare Scorecard • Preparing the Healthcare Workforce of the Future Key speakers included: • Florida Surgeon General John Armstrong. • Florida Rep. Matt Hudson (R-Naples), chair of the Health Care Appropriations Subcommittee. • Florida Rep. Cary Pigman (R-Avon Park), vice chair of the Select Committee on Health Care Workforce Innovation. • Connie Barden, director of telehealth initiatives for Baptist Health South Florida • Michael Good, MD, dean of the University of Florida College of Medicine. • Steve Payment, healthcare executive for IBM. • Tom Enders, senior managing director for Manatt Health Solutions (MHS), the interdisciplinary policy and business advisory practice of Manatt, Phelps & Phillips LLP. • Belinda Keiser, vice chancellor of Keiser University. The 2013 summit was held at Disney’s Contemporary Resort in Lake Buena Vista on Monday, Oct. 14. The Florida Chamber of Commerce represents the state’s first organized business advocacy group, now the state’s largest federation of employers.
Gaining Perspective, continued from page 9 right now. Williams said they are trying to keep their heads above water in the current payment system … and now reimbursement experts want them to shift their focus to population management. Although making the move is understandably frustrating, Williams believes it is also the best option to ultimately improve the bottom line. “There has to be a change in culture from what it’s been in the past,” he noted. “We tell them, ‘Let’s prepare for
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it by being the most efficient, effective deliverer of care and eliminating patient waste.’ That puts you in a competitive advantage over those providers that have a higher cost structure.” It is a different mindset, Williams continued, to stop attacking reimbursement from the top and instead improve revenue by cutting costs. “If you deliver high quality at a lower cost, then your margins are going to be greater. We see opportunities,” he concluded. NOVEMBER 2013
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POCD or Delirium?, continued from page 1 needed to validate dementia.” Unfortunately, preoperative cognitive testing isn’t standard procedure. In fact, it’s rarely done, with some anesthesiologists saying it takes too much time and health insurance won’t cover it. “A mental status exam to evaluate different areas of the brain can be quickly given by the physician who’s performing pre-operative clinical evaluation of a paMariana tient,” said Dangiolo, Dangiolo, MD who includes it as a routine part of physical exams with geriatric patients. “Other cognitive baseline tests, especially comprehensive ones, may take several hours. Those typically aren’t covered by insurers, and aren’t usually what you need to establish a baseline status. Something simple, such as asking patient and/or family about patient’s daily level of functioning before surgery, can certainly provide a lot of information.” Many times, when Dangiolo is conducting an initial geriatric assessment and cannot administer a complete mental status exam, she’ll use a mini cognitive test to provide a baseline reference. “The Mini Cog test has three components and takes about five minutes to complete,” she said. “It tests orientation, short term three-word recall, and planning and execution function by asking patients to draw a clock. If there’s a problem in any of those areas, there are grounds to proceed to a longer baseline test.” Postoperative Difference
When assessing the patient’s postoperative mental state, it’s important for healthcare providers to discern the distinction between dementia and delirium, said Dangiolo, pointing to various recent studies that suggest a certain link to dementia and anesthesia in elderly patients. A recent Duke clinical study published in the Journal of Anesthesiology confirms earlier findings from an important 1998 Lancet publication, showing significant numbers of elderly patients experiencing changes in higher order brain function after anesthesia and surgery. • At discharge from the hospital, signs of POCD were present in roughly one in three patients. • At the 3-month mark, 12.7 percent of patients over the age of 50 still showed cognitive impairment. • Elderly patients are at risk of POCD, but the study doesn’t specify whether it’s due to anesthesia, surgery, or postsurgery recovery aspects, such as pain, pain medication, other medications, infection, inflammation, sleep disruption. A study by French doctors released earlier this year at a European Society of Anesthesiology congress in Barcelona, Spain, said general anesthesia for the elderly boosts the risks of dementia by more than a third. • Researchers led by Francois Sztark at the University of Bordeaux in France analyzed data from a long-term study into cognitive decline covering 9,300 elderly people in three French cities. The volunteers – average age 75 – were interviewed when they were recruited into the study and then two, four, seven and 10 years post-surgery. • The data showed a link between the
onset of dementia and a general anesthetic that had been administered two or three years earlier. • Some experiments suggest that various anesthetics inflame neural tissues, causing protein plaques and tangles to develop that are precursors of Alzheimer’s disease. Another recent study examining the incidence of POCD after major non lifethreatening procedures shows how certain risk factors have been identified and demonstrated a number of correlates and risk factors, even though much remains to be clarified about the true incidence, etiology, prevention, and treatment. • In the study of 200 patients age 60 and older undergoing hip surgery, postoperative delirium was a strong independent predictor of the development of subsequent cognitive impairment, subjective memory decline, and the need for longterm care. • Interestingly, the correlation with the development of POCD isn’t shown whether the patients had regional or general anesthesia. Several theories have been posed to anesthesiologists regarding the possible link between dementia and anesthesia and surgery in patients 85 and older: • In the traditional view, anesthetic agents are rapidly metabolized and/or excreted from the body, and therefore are unlikely to cause neurologic injury long term. Also, certain anesthetic agents appear to protect, not injure, the brain. Recent research challenges the belief that a well-done anesthetic and complication-free surgical procedure is totally neurologically benign.
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• Researchers suggest that, in patients who develop POCD, limited brain “reserve” has been somehow “unmasked” by anesthesia and surgery, or that anesthesia and surgery somehow accelerates the aging process in the brain. Inflammation might be the culprit. Previous research has shown signs of inflammation in cerebrospinal fluid after surgery, but it’s not clear whether this is the cause or the result of POCD. • A significant limitation of POCD studies is exclusion of a standardized preoperative neurological examination, in addition to the neuropsychological testing, making it very difficult to separate the relationship between surgery and anesthesia and subsequent cognitive decline and death from the cognitive decline and death that occur among older adults without surgery. Difference Makers “We (healthcare providers) can prevent a lot of confusion in the hospital not only with the preoperative cognitive evaluation, but also with some very simple modifications in postoperative care,” she said. “For example, we know hospitals can be very noisy, yet the patient needs to maintain uninterrupted sleep while there. Nurses go into the room every two hours or so, along with other interruptions such as blood tests that hinder a patient’s rest.” The unfamiliar environment also breeds confusion for some patients, Dangiolo said. “Having family photos, a clock, or other items from home to orient the patient will help,” she said. “Keeping the lights on from 7 a.m. to 7 p.m. will help regulate the sleep cycle.” Many times, physicians busy making their rounds may forget to ask patients whether they wear glasses or use hearing aids, resulting in perceived patient confusion. “Also, anything that restrains patient activity in the hospital, such as being connected to an IV or catheter, adds to confusion,” she said. “If the patient has a catheter, it should be removed as soon as possible. Otherwise, it could lead to infection, which could lead to confusion and more.” Pain affects patients in a way that creates temporary confusion, and unnecessary guests create an environment not conducive to rest, Dangiolo said. “Elderly people take an average of six prescription drugs or more, plus overthe-counter drugs and supplements,” she said, noting that all medications should be carefully reviewed, with special attention to those that affect the brain such as sedatives, antidepressants, hypnotics and antispasmodics. “When you combine all these elements, it’s easy to see how elderly patients could become confused,” she said. “These simple modifications after surgery can make a big difference in the assessment of a patient’s postoperative cognitive state.”
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Wellness Programs’ Impact on the Medical Field By JENNIFER PATEL
With rising healthcare costs companies are searching for ways to not only reduce costs, but also create healthier employees. Stats highlighting a decrease in used sick days and reductions in overall healthcare costs have many employers looking into health and wellness initiatives to encourage employees to live healthier lives. As more companies begin to incorporate wellness programs, the time for healthcare providers to become directly involved is now. While today’s employers are beginning to see the benefits of wellness programs and preventive care, they didn’t always. In the past, employees have been left to worry that taking time off for doctors appointments or tending to other preventative care issues will result in a negative reaction from management. Because of this, employers have to find ways to encourage employee participation in wellness programs. One successful method of encouragement that employers have discovered is to have direct participation from healthcare professionals. The following are ways healthcare professionals can, and are beginning get involved with health and wellness plans. Encourage Preventive Care The Centers for Disease Control and Prevention (CDC) estimate that 68 percent of adults and 33 percent of youth are
currently overweight or obese. Chronic obesity-related conditions, including heart disease and diabetes, have a big impact on health and wellness. In addition, chronic diseases reduce the overall quality of life with half of all chronic disease-related deaths occurring in people under the age of 70. Healthcare professionals are in an ideal position to offer tools for employees to be healthy. In an effort to combat employees’ reluctance to leave work for such care, employers are beginning to bring in healthcare professionals to offer biometric and preventative screenings in the workplace. This is beneficial for both parties as less time is spent away from work. Offer Expertise Generally speaking, most employers
are not healthcare experts, which gives physicians extra advantages. When putting together a wellness program, employers look at screenings, physical activity and incentives for positive results. But what constitutes positive results and what is the best way to get there? Not only can the healthcare industry provide valuable insight when designing these programs, but it can assist in educating employees on what they should be doing, why it’s important, and then monitoring to ensure that no issues arise. Inviting additional healthcare professionals to implement a wellness program will provide extra validation to the importance of a healthy workplace. Build Relationships One of the biggest obstacles that employers face when encouraging employees to take part in health and wellness programs is a desire to not be the squeaky wheel. Whether or not it is admitted, employees still feel that taking time off work is seen as something that can affect their growth within the company. The way businesses address this issue is by building positive relationships with their employees and letting them know it’s more beneficial for the entire team if one employee is too sick and needs to stay home and get well. By encouraging preventative care, as well as offering educational opportunities, employees build positive relationships with both their
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with no obstacles or challenges, according to hospital spokesperson Kim Savage. Construction of the $8 million project took about a year to complete. The hospital’s venture further south, on its 65-acre Laurel Road medical campus at the southeast corner of Laurel and Pinebrook roads near Interstate 75, remains tied up in a nearly seven-year-old challenge issued by Venice Regional Medical Center. In 2006, a year after Sarasota Memorial acquired land for the project for $25 million, hospital executives approached Venice city leaders with plans for a medical complex. The Venice Planning Commission approved the Laurel Road project. When city officials determined that two or three pages of documents outlining zoning requirements were accidentally omitted, Venice Regional protested, saying that with more information, the planning commission might have made a different decision. After the planning commission ruled that Venice Regional lacked the legal standing to challenge the decision, Venice City Council voted 4-3 to grant it to the local hospital. In July, after Sarasota
Invest in Your Employees As the healthcare industry’s role within workplace health and wellness plans increases, it’s important to turn the looking glass upon itself. While providers may have the closest access to the care, it can be difficult to find time to care for themselves. With high rates of smoking, stress levels and long hours, the healthcare industry suffers from many of the same ailments it attempts to rectify. By implementing a health and wellness plan of their own, healthcare professionals are able to practice what they preach. By providing the necessary time to take part in the program, determining what programs are needed, as well as offering incentives, healthcare professionals can not only be a part of others’ programs, but their own. Invest in employee enrichment and see how a wellness program positively impacts a company’s bottom line. Hallmark Business Connections, the businessrelationships unit of Hallmark Cards, helps businesses build and strengthen relationships that help them thrive. One valuable service the company provides is corporate wellness program development. For guidance on strategic wellness program implementation, email Jennifer Patel at Jennifer.Patel@hallmarkbusinessconnections.com or visit www.hallmarkbusinessconnections.com.
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Moving into Venice, continued from page 7 MD, and Christopher Jefferson, MD, share office space on the second floor as part of Sarasota Memorial’s First Physicians Group (FPG). The practice relocated from FPG’s Venice location at Lakeside Medicine. Other specialists are expected to move into the second floor by year end. “As a public hospital, Sarasota Memorial is accountable to and committed to serving residents throughout the county – 44 percent of Sarasota County’s residents live south of Osprey – and more than 18,000 patients are cared for by our First Physicians Group primary care physicians in South County,” said Sarasota Memorial COO David Verinder. “Our new urgent care and healthcare center will help fill a gap in the network of outpatient care we provide in that region.” The Sarasota County Public Hospital Board approved the purchase of the Venice Bypass property for $1 million last year. A desolate two-story, 12,000-square-foot building on the property had housed several unsuccessful restaurants. Planning and permitting progressed smoothly for the newly opened Venice urgent care clinic,
bosses and the healthcare professionals. Through relationships with employers, healthcare professionals are given access to a wealth of potential new clients at no cost to them.
Memorial sued the city over the matter, Circuit Judge Charles Williams ruled that Venice Regional had not exhausted other options before appealing to the court. That same month, Community Health Systems acquired Venice Regional and other HMA hospitals in a $7.6 billion deal. Sarasota Memorial CEO Gwen MacKenzie has pointed out that Venice taxpayers also support the public hospital, and should have access to its services, and that urgent care centers don’t compete with ERs for business. The newly opened urgent care center is located less than two miles from Venice Regional. Sarasota Memorial’s three urgent care centers already open: Heritage Harbour in Bradenton, and University Parkway and Stickney Point in Sarasota. Other off-site centers include a sleep disorder clinic in Osprey and a freestanding emergency room in North Port. On the drawing board: an urgent care clinic to be located one-half mile from Doctors Hospital of Sarasota, an HCA facility.
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GrandRounds Florida Cancer Specialists & Research Institute Announces Executive Team Promotions Florida Cancer Specialists & Research Institute (FCS) is pleased to announce the addition of Sarah Cevallos and Christina Sievert to the Executive Leadership team. Sarah Cevallos has been named Vice PresiSarah Cevallos dent Revenue Cycle. Sarah has led the effort to reduce inefficiencies and maximize revenue by improving the insurance billing and collections functions. She will continue to oversee these Christina areas, and in addition, Sievert she will be responsible for the strategic direction of payer contracting and credentialing. Sarah has an MBA in Healthcare Management and has been with FCS for five Sharon Dill years. Christina Sievert has been named Vice President of Clinic Financial Services. Ms. Sievert directed the overall performance of the managed care and patient Shelly Glenn collections departments. She led these departments and has been directly re-
sponsible for improved front- end patient collections, core values, customer service, patient advocacy with various foundations and pharmaceutical companies. A member of the FCS team for 10 years, Ms. Sievert has held numerous positions within the organization and brings more than 25 years of experience in the healthcare industry to her current position. FCS is also pleased to announce two additional promotions within the Executive Leadership team. Sharon Dill has been named Chief Human Resources Officer;Shelly Glenn has been named Chief Marketing & Sales Officer. The promotions reflect the roles that Ms. Dill and Ms. Glenn have had in successfully managing the significant growth of the organization, as well as their leadership and contributions to the communities in which they live and work.
Largo Medical Center Earns an “A” Safety Rating Largo Medical Center has earned the top “A” Safe Hospital Score from the Leapfrog Group. The score is derived from Leapfrog’s key questions and publicly reported data, allowing for the comparison of hospital safety performance. A blue ribbon panel of the nation’s top patient safety experts provides guidance to The Leapfrog Group, an independent national nonprofit run by employers and other large purchasers of health benefits, to develop the Hos-
pital Safety Score. The Hospital Safety Score is calculated using publicly available data on patient injuries, medical and medication errors, and infections. “A” scores were awarded to for-profit hospitals, not-for-profits and public hospitals throughout the nation. Not all hospitals earned an “A. The Hospital Safety Score exclusively measures safety – meaning errors, accidents, and infections. To see the full report go to www.HospitalSafetyScore.org. Largo Medical Center earned its first “A” Safe Hospital Score in 2012.
Tim Burkhart Named Florida Hospital Association Trustee Jim Burkhart, President & CEO of Tampa General Hospital was selected to serve on the Board of Trustees of the Florida Hospital Association. The term is for two years. The Florida Hospital Association installed its 2013-2014 executive officers and trustees at its Annual Meeting held in Orlando last week. The officers and trustees were nominated by the executive committee which included past board chairmen. They were then elected by their peers. The FHA has a membership of 238.
Largo Medical Center Physician Receives Highest Award from the American Osteopathic Association A Largo Medical Center physician is recognized with one of the highest awards presented by the American Os-
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GrandRounds teopathic Association (AOA). Anthony Ottaviani, DO, MPH, MACOI, FCCP, Chief Academic & Designated Institutional Officer, is one of three 2013 recipients of the Distinguished Service Certificate awarded by the AOA. This award is made in recognition of a physician’s outstanding accomplishments in scientific or professional affairs according to Michael Murphy, DO, Chairman of the AOA Committee on Awards. Dr. Ottaviani is recognized for furthering the osteopathic medical profession, particularly his leadership at the Nova Southeastern University College of Osteopathic Medicine and his assistance in the expansion of graduate medical education in Florida. Dr. Ottaviani became the full time Chief Academic & Designated Institutional Officer at Largo Medical Center earlier this year overseeing 125 interns, residents and fellows in 13 specialized programs. He was a Pulmonary Medicine/Critical Care Specialist in private practice for more than three decades, was a leader in academic medicine for almost four decades having served as the Director of Medical Education for both Sun Coast Hospital and Largo Medical Center and Regional Dean for Nova Southeastern University. The American Osteopathic Association supports the leadership of osteopathic physicians and medical students in helping to shape health policy in the federal government.
It was the first note I ever got in crayon. “Thank you for making my daddy feel better.” I keep it on my desk, where I pore over patient records and cash flow statements. Because even if the medical field seems to be changing by the day, the reasons I practice never do.
HCA West Florida Finalizes Purchase Of Three Iasis Hospitals Today HCA West Florida finalized the acquisition of three Tampa Bay hospitals—Palms of Pasadena Hospital, Memorial Hospital of Tampa and Town & Country Hospital— from IASIS Healthcare® LLC (“IASIS”). Palms of Pasadena Hospital is a 307bed facility in St. Petersburg. Memorial Hospital of Tampa and Town & Country Hospital are located in Tampa and have 183 and 201 beds, respectively. Last year, HCA West Florida hospitals provided care to 1.2 million patients. With this acquisition, HCA West Florida expands to include 19 hospitals, 16 ambulatory surgery centers, and more than 19,000 employees in West and Central Florida. IASIS and HCA leadership worked closely since July to prepare for a smooth transition for the hospital employees, patients and communities served by these three hospitals. Terms of the agreement were not disclosed. Medical News is pleased to provide space for press releases by providers in our Grand Rounds section. Content and accuracy of the releases is the sole responsibility of the issuer.
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Our Medical Specialty Group provides a dedicated team with tailored solutions to meet the unique financial needs of physicians and their practices. Visit suntrust.com/medicine to find an advisor near you. Securities and Insurance Products and Services: Are not FDIC or any other Government Agency Insured • Are not Bank Guaranteed • May Lose Value. SunTrust Private Wealth Management Medical Specialty Group is a marketing name used by SunTrust Banks, Inc., and the following affiliates: Banking and trust products and services, including investment advisory products and services, are provided by SunTrust Bank. Securities, insurance (including annuities) and other investment products and services are offered by SunTrust Investment Services, Inc., an SEC registered investment adviser and broker-dealer, member FINRA, SIPC, and a licensed insurance agency. SunTrust Bank, Member FDIC. © 2013 SunTrust Banks, Inc. SunTrust is a federally registered service mark of SunTrust Banks, Inc. How Can We Help You Shine Today? is a service mark of SunTrust Banks, Inc.
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World Class Medicine. Hometown Care.
Recognized nationally. tRusted locally. Caring for patients in 16 Greater Tampa Bay Area communities Tampa Bay Area Physicians Patrick Acevedo, MD
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Jose Alemar, MD
Larry Gandle, MD
Jeffrey L. Paonessa, MD
Rand W. Altemose, MD
Christopher B. George, MD
Janelle Park, MD
Thyag Ananthakrishnan, MD
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Y. K. Peter Park, MD
Jorge Ayub, MD
Andrew E. Hano, DO
Hitesh Patel, MD
Jennifer L. Ball, DO
Vu Tran Ho, MD
J. Andrew Peterson, MD
Gregoire Bergier, MD
Nuruddin Jooma, MD, MPH
Raju V. Rao, MD
Sawsan G. Bishay, MD
Geetha J. Kamath, MD
V. Upender Rao, MD, FACP
Rafael W. Blanco, MD
Craig S. Kitchens, MD
Mark S. Robbins, MD
Kerry E. Chamberlain, DO
Richard A. Knipe, MD
Joseph Sennabaum, MD
Hafeez T. Chatoor, MD
Gajanan A. Kulkarni, MD
Ramesh K. Shah, MD, PA
Marion T. Chirayath, MD
K. S. Kumar, MD, FACP
Shalin R. Shah, DO
Mamta T. Choksi, MD
Julio Lautersztain, MD
Gerald H. Sokol, MD, MSc, FCP
Julia Cogburn, MD
Mary M. Li, MD, PhD
Thomas H. Tang, MD
Jennifer L. Cultrera, MD
Don D. Luong, MD
R. Waide Weaver, MD
Michael Diaz, MD
Joseph R. Mace, MD
David Wenk, MD
Robert L. Drapkin, MD
Vikas Malhotra, MD
David D. Wright, MD
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