2019 State of Health Care in Kansas

State of

IN KANSAS JANUARY 2019

Your life. Your wellness. An in-depth exploration of health care in the Sunflower State

KANSAS

Underwriters

CEO creative in recruiting doctors PAGE 8

Rural hospitals seek alternative solutions PAGE 16

Professionals tackle opioid crisis PAGE 20

Teen pregnacy rates dropping PAGE 32

Medicaid Expansion Key Issue For Legislature Sherman Smith Staff Writer

Medicaid expansion remains one of the most talked about issues swirling through state government this year, where its prospects remain uncertain.

Democratic Gov. Laura Kelly made Medicaid expansion a cornerstone of her campaign, but conservative leaders in a Republican-controlled Legislature harbor ongoing objections to the cost of the Affordable Care Act, the reliability of expansion estimates and the concentration of funds in urban areas.

The ACA expanded eligibility of the program for disabled, pregnant and low-income residents, but a U.S. Supreme Court ruling struck down the expansion mandate, leaving the decision up to each state. For states that agree to provide coverage to those whose income is less than 138 percent of the federal poverty level — $16,000 for an individual or $34,000 for a family of four — federal funds cover 90 percent of the state’s Medicaid costs.

Led by opposition from Republican Govs.

Sam Brownback and Jeff Colyer, Kansas lawmakers rejected expansion as a government overreach, and pointed to states where costs exceeded projections. In 2017, a wave of newcomers led to passage of an expansion plan, but there wasn’t enough support to override Brownback’s veto.

That bill, which used research from the Kansas Department of Health and Environment, expected 150,000 new participants and

a $26 million impact on the general budget for fiscal year 2020, which starts in July. Other studies have reached similar conclusions.

Kelly argues that the economic benefit to the flow of federal funding would erase the state’s burden and aid struggling rural hospitals. She also sees it as a humanitarian issue.

“Health care is a critical need for all Kansans, and for too many, it’s still inaccessible and unaffordable,” Kelly said. “My administration will work on a bipartisan plan to expand Medicaid so that more Kansans have access to health care, our rural hospitals can stay open, and the tax dollars we send to Washington come back home to Kansas to help our families.”

Opponents aren’t so confident in the economic impact and highlight concerns with the state’s long-term financial outlook. If costs for Medicaid expansion exceed expectations, coupled with spending increases for schools, highways, foster care, pensions and other areas of state government, the state could be forced to raise taxes.

House Speaker Ron Ryckman, R-Olathe, said many questions remain unanswered.

Most of the federal dollars would be funneled to medical facilities in Sedgwick, Johnson and Wyandotte counties, he said.

“We’re always open to ideas,” Ryckman said. “What we don’t want to do is give false hope, especially a lot of our rural hospitals.”

For an analysis of the likelihood of Medicaid expansion, go to Page 25

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An Aspirin a Day ... or Not?

Local doctors say individual health history key to daily dose

A large study of 19,000 Australian and American patients, published in fall 2018, found that taking a lowdose aspirin is not helpful for people without other medical conditions, such as heart disease, and can be harmful. Many older people believe they should take aspirin just because they are aging. Instead, they should talk to their medical professionals before doing so. Photo by Thad Allton/Staff Photographer

By Morgan Chilson Staff Writer

A large research study published in fall 2018 caused a burst of headlines questioning whether older adults should be taking a daily aspirin, something many have embraced as an easy way to fight off significant health issues.

Taking a daily dose of aspirin has been touted as a way to reduce risks of heart disease, cancer and possibly even dementia. And while there is evidence-based research indicating aspirin can have an effect on those issues, especially cardiovascular problems, two Topeka physicians said it all depends on each patient and his or her individual health history.

“A low-dose aspirin, as harmless as it sounds, I think in the right person can cause a lot of problems,” said Stormont Vail Health cardiologist Seshu Rao, adding that it’s important for people to always talk to a doctor before adding medication to their daily regimen.

The idea of taking a daily aspirin, often a low-dose baby aspirin, has long been popular.

A 2015 study found that 47 percent of adults ages 45 to 75 were taking a daily aspirin even though they had no history of heart problems

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— the primary condition taking that pill is supposed to affect.

Stormont family medicine physician James McIntosh said the vast majority of his older patients take aspirin without getting input from medical professionals.

“I think it’s gotten to the point it’s almost like a vitamin or a supplement,” he said.

The recent study, which was published in the New England Journal of Medicine and led

by Australian researchers, examined whether taking aspirin daily was really the best medicine for about 19,000 healthy people ages 70-plus in Australia and the United States.

The study found that for healthy people, there were no benefits to taking an aspirin a day. In addition, there could be serious consequences.

Rao said most of the people he sees in his cardiology practice are taking aspirin daily, and it’s an appropriate medication for someone who has had a history of cardiovascular issues. The key in the Australian study, he said, was that people were healthy.

“It’s hard to hang your hat on one study,” he said, but added: “In the past, nothing has really shown significant benefit for aspirin as a stand-alone primary prevention. It’s great for secondary prevention.”

That secondary prevention means low doses of aspirin can be helpful not only with a history of cardiovascular disease, including high blood pressure and stroke, but also for those who have diabetes, Rao said.

The key, both he and McIntosh said, is to talk with your doctor because each situation is dependent upon the patient’s health history.

“Any medicine should be taken with caution,” Rao said. “As benign as aspirin sounds, you should talk to people who’ve had a GI (gastrointestinal) bleed — it’s life-threatening.

Even a low-dose aspirin, if you don’t have any risk factors but then you’ve got a bad bowel or a bad GI, can cause catastrophic bleeding.”

Aspirin, like other non-steroidal anti-inflammatory drugs commonly referred to as NSAIDs, can cause problems with GI bleeds and other issues.

McIntosh, who finished his residency in 2017, said the concerns about overuse of aspirin were a common topic in medical school and among medical professionals today.

“This (Australian) study kind of confirmed what we were already suspicious of,” he said, adding that the American College of Cardiology since 2015 or 2016 has had guidelines against using aspirin as a general use because of the risk of bleeding.

McIntosh said it’s critical for physicians to “tease out” from patients as they talk what medications they’re using. Low-dose aspirin has become so common that patients may forget to mention they are taking it.

As a primary care doctor, McIntosh said he’s not just concerned about the use of a daily aspirin, but also about the use of other NSAIDs like ibuprofen, Aleve and others.

“A lot of people have aches and pains,” he said. “I can’t tell you how many of my older patients will tell me ‘I take almost 400 mg of ibuprofen daily.’ When you start combining those, you’ve got the daily aspirin and you’ve got other NSAIDs, before you know it, you’ve got major risks of bleeding.”

There are dietary factors that can thin blood, too, and adding those issues all together increases risks of serious issues, McIntosh said.

He encouraged patients to bring a list of their questions to the doctor, along with a list of medications — both over-the-counter and prescribed — vitamins and anything else they regularly take.

“The No. 1 thing I tell my patients, regardless of what they’re taking ... is talk to your doctor about it,” he said. “Something that can be helpful in some populations can be harmful in other populations.”

James McIntosh, a Stormont Vail Health family medicine practitioner, says many of his older patients take an aspirin daily, believing that it helps prevent heart problems.

Advancing

healthcare in Topeka, together.

Stormont Vail Health cardiologist Sensu Rao says it is appropriate for most of his patients to be taking an aspirin daily because they tend to have pre-existing heart conditions that justify such a decision. But patients should always talk to their physician before doing so.

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January 2019

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Taking Steps to Understand, Prevent Physician Burnout

FIND A CLINIC NEAR YOU

Women particularly affected, professor says

By Katie Moore Staff Writer

A University of Kansas Health System professor has found that gender influences physician burnout and a systemic shift is needed to address the issue.

Kim Templeton, professor of orthopedic surgery, worked with the National Academy of Medicine to look at issues related to burnout.

Female physicians are more likely to suffer from emotional exhaustion. Male physicians, however, are more likely to suffer from depersonalization, where they “feel somewhat emotionally disconnected to your work and to your patients,” Templeton said.

According to the Medscape Physician Lifestyle Report, 46 percent of physicians indicated they had burnout.

Templeton said burnout isn’t surprising given the nature of the job, which may include treating critically ill or dying patients on a daily basis.

According to Templeton, there isn’t data that indicates working fewer hours has an impact on burnout.

“I think it’s less about people wanting to work fewer hours than being able to maintain their identity as a person so that they don’t become this entity that works 24/7 and doesn’t have time to do what it is that they want to do,” she said. “As we’re looking at a variety of ways of combating burnout, one of the things to address is to recognize that physicians are still people, that they have feelings, they are impacted by what they see at work, but they also have lives outside of medicine.”

While a younger generation of physicians may ask for fewer

working hours, the issue is more the support from home for what they do at work and support from work for what they do at home.

Women are particularly affected.

“Women physicians still do 70 percent of the work at home,” Templeton said.

Employers can help by acknowledging there are responsibilities outside practicing medicine, having leeway in scheduling to take time off, and providing parental and family leave.

Templeton said it is also important to understand that burnout isn’t “a defect within the physician, it’s the system.”

There can be a disconnect between a physician’s priorities and what a health system prioritizes.

“It’s turning more to a big business model,” she said. “If you think that the organization has different priorities than you do whether that’s true or not, then when you have issues like trying to take off time to do what you need to do outside of work, if that’s not accessible, then all that does is increase this feeling that you and your employer are going down different paths.”

Other ways to support female physicians include leadership training and making clear that gender bias and sexual harassment aren’t acceptable.

Addressing burnout is important because people are leaving medicine as the need for health care services grows, Templeton said.

“We are already suffering from a physician shortage, so we can’t lose additional people,” she said.

“Women also make up now more than half of the medical students in the incoming classes, and so when you’re looking at a gender issue, that’s especially going to

be an issue as these women go further along in their careers, we need to keep them in their careers.”

It’s also important from a patient standpoint to optimize care, she said.

Stormont Vail Health has taken several steps to address burnout.

“Developing a sense of belonging, a belief that you serve a noble purpose and have real positive impacts, helps to drive positive work and career engagement,” said Robert Kenagy, senior vice president and chief medical officer. “At Stormont Vail, our new physicians feel supported through a yearlong orientation, which includes a mentoring program that pairs the new physician with a more established physician within our health system. This gives them someone who will be reaching out and checking in with the new physician.

“I also personally meet with each new physician in their first year of practice, to ensure they are having a good experience, are well supported and are settling into their practice.”

Stormont Vail Health also offers a job sharing option for a flexible workweek and has added team members to their primary care setting, including social workers, mental health providers and care managers.

“This delivery model enhances the patient experience and reinforces the sense of belonging to and leading a team,” Kenagy said.

Monthly medical group meetings also help develop connections, he said.

At the University of Kansas Health System St. Francis Campus, CEO Steve Anderson and chef medical officer Jackie Hyland have open door policies and encourage

24 So. Main

SOUTH HUTCHINSON

University of Kansas Health System professor Kim Templeton worked with the National Academy of Medicine to look at issues related to gender and physician burnout. physicians “to talk with us about issues related to job satisfaction that might lead to burnout,” Anderson said.

The hospital also works with physicians to accommodate

a work-life balance, and many specialties are adding advance practice providers to relieve some of the workload from physicians, he said.

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January 2019

January 2019

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Innovative Recruiting Offers Hope Amid Doctor Shortage Commitment to community also part of cure, southwest Kansas administrator says

By Tim Carpenter Staff Writer

Small-town hospital administrator Benjamin Anderson’s introduction to the physician shortage in Kearny County was painful.

He was told in 2013 when hired to manage the county hospital in southwest Kansas that the facility was in the market to hire five doctors and was about to lose one of four physicians on staff. The remedy formulated in the tiny hospital in Lakin, a city of 2,200 people marked by economic pendulums of the agriculture and energy industries, is now being replicated to address the shortage of primary care doctors infecting Kansas and other states.

The answer at Kearny County Hospital to the uneven distribution of health care providers necessitated a culture shift at the hospital, Anderson said. Every physician had to be a full-spectrum provider in terms of working in the emergency room, delivering babies and sharing the on-call duties equally. The role of physician assistants and nurse practitioners was amplified.

Staff salaries were brought in line with industry rates.

In an unorthodox move, Anderson began recruiting doctors completing professional residency programs by offering contracts with an eight-to-10-week window each year for overseas humanitarian work. The quest was to entice people wired to serve in medically challenged countries, which often aligned new doctors with the constellation of refugees and immigrants moving to western Kansas.

“We agreed the millennial generation was full of mission-driven people. When they work with purpose, they are very, very engaged,” he said.

Anderson said the recruiting-and-retention campaign

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January 2019

blossomed into another project to fly job candidates to western Kansas for a personal introduction to communities seeking their expertise.

Kearny County Hospital filled its physician vacancies in about one year and draws about 20,000 patients annually from more than a dozen counties. That’s double the patient volume of six years ago.

Surveys and studies have documented the decades-old problem with placement of primary care physicians in Kansas. Health professionals, not just primary care physicians, persist in gravitating to jobs in urban locales, which they believe provide solid career opportunities and a quality of life for their families.

United Health Foundation, through America’s Health Rankings, ranked Kansas as the 27th healthiest state in 2018. Colorado was eighth, while Missouri was 38th. In terms of primary care doctors for every 100,000 residents, Kansas ranked 31st in the nation for the third consecutive year. That headcount included doctors in general practice, family practice, obstetrics and gynecology, pediatrics, geriatrics and internal medicine.

“Like many states, Kansas is facing a physician shortage,” said Michael Kennedy, associate dean of rural health education at The University of Kansas Medical Center in Kansas City, Kan. “What makes the situation acute is that there is an uneven distribution of physicians, which leaves underserved areas with critical shortages.”

BY THE NUMBERS The Robert Wood Johnson Foundation ran numbers based on 2015 data that offered insight into the range of coverage by primary care physicians from county to county

Benjamin Anderson is shown outside the Kearny County Hospital in Lakin. Anderson is the hospital’s CEO and has prioritized innovative recruiting efforts for doctors.

Brad Nading/Staff Photographer

Garold Minns, dean of KU School of Medicine-Wichita

in Kansas. The population-to-doctor ratio in Kansas averaged 1,320 residents for every doctor. Nationally, the 90th percentile benchmark was 1,030:1.

Here is a sampling of the diversity in patient-to-doctor coverage among counties in Kansas: Johnson County, 830:1; Brown County, 890:1; Sedgwick County, 1,150:1; Douglas County, 1,180:1; Saline County, 1,270:1; Shawnee County, 1,390:1; Ellis County 1,610:1; Finney County, 1,860:1; Ford County, 2,030:1; Wyandotte County, 2,550:1; Kingman County, 7,690:1; and Linn County, 9,540:1.

More than two dozen Kansas counties have been declared frontier areas in medical terms, because there are two or fewer primary care doctors in each.

The three medical schools in Kansas are affiliated with The University of Kansas and operate on branch campuses in Wichita and Salina,

Michael Kennedy associate dean of rural health education at The University of Kansas Medical Center in Kansas City, Kan.

as well as the original complex in Kansas City, Kan. The Salina campus, founded in 2011, was conceived with the understanding it would focus on addressing the ever-growing need for primary care doctors in rural areas. With eight students per class, KU Medical Center officials said the Salina campus was suited for self-starters who could be a better fit at health facilities in rural communities, where resources may differ from larger hospitals or clinics.

The Wichita campus was born in 1971 out of the need for hands-on clinical training for students in their final two years of medical school. It grew to become an integral part of the training of primary care physicians practicing throughout the state. The Wichita program, which expanded to four years in 2011, is a community-based enterprise with more than

1,000 volunteer faculty located at three partner hospitals. As a result, KUMC said, students benefit from exposure to a wide variety of clinical experiences, especially family medicine.

The American Association of Medical Colleges ranked the KU School of Medicine in the 96th percentile in producing doctors working in rural settings 10 years to 15 years after graduation.

Garold Minns, dean of KU School of Medicine-Wichita, said the ranking meant the university’s graduates were working with underserved populations from the urban core in Kansas City, Kan., to sparsely populated areas along the Colorado border. However, he said, more should be done to deal with the shortfall of primary care doctors.

The gaps can be geographic, given the distances between clinics and

Doctor Shortage

go a long way.”

continued from page 8

WELCOMING NEW DOCTORS

patients, or demographic, resulting from a concentration of low-income residents.

“We need more primary care physicians in Kansas. Primary care physicians are the foundation of medical care systems,” he said.

Tom Bell, executive director of the Kansas Hospital Association, said academic scholarships and college loan repayment programs had produced more medical school graduates in Kansas. There remains a shortage of post-graduate training residency opportunities across the state, he said.

“We are graduating physicians,” Bell said. “We really could use more residency slots. That would

Anderson, who began developing his novel approach to doctor recruitment while working for a hospital in Ashland, said the key to retention of medical professionals in underserved regions involved development of a sense of community sought by new arrivals. The loneliness felt by a Texas-trained doctor living in Lakin resembles the separation experienced by immigrants to Kansas, Anderson said.

The ongoing work, he said, was to demonstrate that a cure to doctor shortages required building upon an educational foundation with professional opportunities and a commitment to community.

Anderson said one of the most

important duties he and his wife performed recently was serving as babysitter for a 2-year-old child so a physician and his wife could go on a date. On a recent evening, Anderson and some of his immigrant friends hosted a gathering for prospective hires.

“We have the answers,” Anderson said. “Raising two fingers off a steering wheel is not hospitality.

The question is: Will we share our dinner tables?”

He said rural Kansans are among America’s best-kept secrets.

If they let newcomers into the circle of trust, he said, people find hardworking, honest, faith-driven people who can form “friendships for life.”

About 18 months ago, Anderson was in Texas to help recruit a physician to the Kansas communi-

ty of Tribune. He asked a group of residents — doctors finishing their training and ready for the marketplace — if they would be willing to visit southwest Kansas if flown there by charter.

Eventually, 20 agreed to explore Kansas. That initial group had a steak dinner in Garden City. Gov. Jeff Colyer, a surgeon, spoke to the group. Some of the recruits signed contracts to work in Kansas.

The fourth such recruiting flight bringing health professional prospects to Kansas is scheduled for Feb. 1.

Interest is high enough that job applicants have been referred to other Kansas hospitals with management that subscribes to the recruitment framework piloted at Kearny County Hospital.

Anderson, raised on the West

Coast and educated on the East Coast, said the hospital in Lakin had proven quality prospects were hungry for careers in locations that offered professionally and culturally safe environments for constructing a medical career and raising a family. While doctors and nurses audition for jobs in Kansas, he said, so must residents of communities in demand for those medical services.

“There are more mission-driven, well-trained millennial family physicians interested in practicing in rural Kansas than there are safe places to hire them,” Anderson said.

He said he believes a reasonable 10-year goal should be: One primary care physician within a 30-minute drive of every Kansan.

continued on page 9

January 2019

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How Do I Feel Today?

How Do I Feel Today? continued from page 10

Social-emotional learning teaches youths how to manage emotions

By Gary Demuth Staff Writer

Each morning, students at Salina’s Heusner Elementary School pick a “zone” on which they attach a clothespin bearing their name.

If the student attaches their clothespin to the green zone, it means they feel happy, calm, focused and ready to learn. The yellow zone indicates frustration, worry or feeling some loss of control. The blue zone reflects sadness, sickness, tiredness or boredom, while the red zone means the student is feeling angry, mean, terrified or out of control.

Each morning, individual teachers call “morning meetings,” where the kids greet each other, talk about how they feel that day and perform a group team-building activity before starting the day’s lessons.

“The morning meeting is all about community building and establishing a relationship between the staff and the kids,” said Julie Clayson, a family support worker at Huesner.

“By talking about what ‘zone’ they’re in, it gives children the ability to talk about emotions, that it’s not bad to feel sad or mad because they can get the emotional support they need and learn coping skills.”

If a child is feeling angry or out of control, they might go to a “peace zone,” a designated area in classrooms where the fluorescent lights are muted, and they can relax and relieve their stress through therapy putty, a stress ball, sensory bottles or a Hoberman sphere.

“When it comes to behavioral issues, early intervention makes a big difference,” said Lori Munsell, principal of Heusner Elementary School.

Early intervention is the goal of social-emotional learning, one of the talking points of KansansCan, a vision for education spearheaded by the Kansas State Board of Education in Topeka. Social-emotional learning is the process through which students acquire the knowledge, attitudes and skills necessary to understand and manage emotions, set and achieve positive goals, feel and show empathy for others, establish and maintain positive relationships, and make

10 January 2019

Students at Salina’s Heusner Elementary School can play with therapy putty, a stress ball, sensory bottles or a Hoberman sphere in the peace zone, a designated area in each classroom where students can go to release stress.

Photos by Aaron Anders / Salina Journal

responsible decisions.

INTEGRATED APPROACH KSDE is collaborating with the University of Kansas to provide implementation of a statewide, integrated tiered approach for social-emotional support.

“It’s become a renewed focus for the state of Kansas,” said Shanna Rector, executive director of administration and student support services for Unified School District 305 in Salina. “It’s a lot more than focusing on students with trauma. We want to make sure all students have the skills they need to be successful, productive citizens. It’s about giving students a skill set they can use whenever problems come their way, whether perceived or real.”

Programs being explored to integrate into classes, beginning in elementary school, include focusing on developing students’ core values and their applications to everyday life decisions; connecting service in the community with academic coursework; training students to help guide other students in resolving conflicts peacefully; addressing matters relating to bullying and harassment; developing strategies to help

Julie Clayson, family support worker for Unified School District 305 in Salina, holds a sensory bottle next to one of the peace zones at Heusner Elementary School. Clayson said she has seen a major improvement in the mental health of boys and girls after two years of having special areas designated as peace zones where the fluorescent lights are muted and children can relax to get their minds off their problems. students understand and manage their anger; teaching students the dangers of drug, alcohol and tobacco use and abuse; and developing skills for managing conflicts, building positive social skills and practicing the importance of acceptance, respect and empathy.

By focusing on character development and coping skills from an early age, Rector said students will more easily be able to navigate positive and negative social situations, avoid falling into isolation or depression and be able to better handle academic pressure in middle or high school.

“Anything we can do to help give students the opportunity to feel successful is important,” she said. “That’s why we’ve increased the number of elementary school counselors over the last couple of years, as well as in middle schools, and increased the number of social workers we have.”

SOCIAL-EMOTIONAL SPECIALIST The Salina school district also has hired a full-time social-emotional specialist, Sarah Lancaster, who has been in place about a year and a half. Lancaster said her role is to help schools create time in their day for intentional relationship building with students, including those with behavioral or trauma issues.

“In an effort to create behavioral change and not just enforce a punishment, mediation can be utilized when there are issues between students, or between a student and teacher, to help process the problem,” she said. “Creating time for intentional relationship building with all students builds the foundation for students to feel safe at school, to know they have adults who genuinely care about them and to have a connection with their peers. Having these elements in place is critical in order for academic learning to take place at its highest potential.”

Integrating social-emotional and character building skills into the classroom might be done through written expression of feelings through journals, poetry and essay writing; reading and identifying how certain passages reflect emotions; using art or computer-generated models to convey emotions; or building skills through games, videos and role playing in group formats.

“There’s no one program or solution to such a diverse, complex issue,” Rector said.

“One school’s need may be very different than another’s. But we’re moving away from a more reactive approach to a more proactive approach to social-emotional support.”

performance, based on students’ brain development and developmental trauma.

The district also has partnered with the University of Kansas to develop a Comprehensive, Integrated, Three-Tiered (Ci3T) model of prevention, constructed to address academic, behavioral and social issues by maximizing available expertise through professional collaborations among school personnel.

“All of our schools have had training, with a focus on behavioral, academic and emotional support,” Anderson said.

Anderson said curriculum materials also are being introduced into the classrooms by counselors that address social-emotional issues that include anti-bullying and suicide prevention, which Anderson said is the second leading cause of death for children ages 10 through 14 in Kansas.

There also are 15 therapy dogs available in the district’s middle schools for student use, she said, as well as mental health rooms that allow students to excuse themselves from class and “let off some steam” to regulate their emotions with the assistance of available counselors.

“We’re giving a strong message that (mental health) is of the greatest priority,” Anderson said. “You look nationally at school shootings and find individuals with mental health issues from an early age.

Kansas has a high rate of teen suicide, and that is often related to depression. That’s why we’ve approved adding student mental health as part of our strategic plan.”

Anderson said she hopes the mental health strategies that Topeka is piloting will expand statewide.

“We hope the state can use this to further implement quality mental health services for students in Kansas,” she said.

Elementary students at Heusner Elementary School can choose their mood based on how they are feeling and share it with their teacher and classmates. Photos by Aaron Anders / Staff Photographer

ADDRESSING MENTAL HEALTH

Kindergarteners pick a stuffed animal, depending on what kind of mood they are in each day, at the beginning of class at Heusner Elementary School in Salina. continued on page 11

But what about students who have experienced trauma or have mental health issues that might need stronger proactive intervention?

Tiffany Anderson, superintendent of USD 501 in Topeka, has spearheaded a tiered level of support to address mental health services in her school system. A mental health committee that she chairs provides support and training that addresses acute and chronic traumatic events involving students and staff.

To support staff in developing a deeper understanding of trauma, Topeka Public Schools has partnered with the Houston-based Child Trauma Academy to offer Neurosequential Model in Education (NME) training. The academy has developed a set of training courses to help school counselors, administrators, teachers and support staff understand student behavior and

Students pick a color, depending on how they feel that day, and share it with the teacher and their classmates during morning meetings at Heusner Elementary School in Salina.

January 2019

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Three-time Magnet® recognition

“We provide quality care with kindness and respect...everyone deserves that.”

— Emily Padilla, BSN, RN

Nurse Practitioners Eye Change of Law

By Mary Clarkin Staff Writer

When Miranda Lewis goes to work, she can’t predict whether she’ll treat a patient with a sliced-open finger or one experiencing chest pain.

“People always need something when they come here,” said Lewis, an Advanced Practice Registered Nurse and family nurse practitioner at PrairieStar Health Center, Hutchinson.

They say they see patients from “womb to tomb” at the walk-in federally qualified health center, with a cross-section of patients ranging from the homeless to CEOs. “You just never know what your day’s going to be like,” Lewis said. “I like the face-to-face interactions, getting to know their story.”

Patients request physicals for work or school, or they seek relief from an infection or they are concerned about their baby’s health. Putting casts on fractured bones is rare, but she’s done that. She writes drug prescriptions and educates people about dealing with hypertension or diabetes. The educational piece is one of her favorite aspects of the job, she said.

Lewis is a graduate of Hutchinson High School, and she and her husband, Will Lewis, decided to raise their children near family. She did her clinicals at PrairieStar and “really just kind of fell for the place.”

She doesn’t have the years of schooling and training of a medical doctor, but her advanced degree studies and training qualify her to deliver a range of care. Particularly in rural areas of Kansas where physicians are in short supply, such nurse practitioners as Lewis could help fill in some gaps. But they’re in short supply, too.

Some think Kansas statute is contributing to the problem.

SHORT BY ANY MEASURE

Every moment matters.

Stormont Vail Health received Magnet® recognition – nursing’s top achievement – for the third time. Only two health systems in Kansas are recognized by Magnet®, and Stormont Vail is noted for its superb quality care, nurses who lead both in the organization and in the community, and improved outcomes for patients.

stormontvail.org 12 January 2019

Most counties in Kansas fit under the Health Professional Shortage Area umbrella for primary care providers. More than half of the counties with an undesirable HPSA score of 15 or higher are located west of Reno County, according to federal Health Resources and Services Administration data in March 2018.

Under a scoring system where higher means worse, Reno County fell in a category of counties medically underserved but not as drastically underserved as some other counties.

In August 2018, the Kansas Governor Certified Counties list for counties designated as medically underserved areas for the purposes of developing rural health clinics, numbered more than half the counties in Kansas.

In September 2018, US. Department of Health and Human Services workforce statistics suggested the percentage of primary medical care needs that are being met in Kansas at about 45 percent. The number of additional primary care health professionals required to meet the needs would be

142. By comparison, Missouri, Colorado and Oklahoma had even greater needs for health professionals than Kansas, and Nebraska had a smaller demand.

The Kansas State Board of Nursing’s latest available annual report, for fiscal year 2017, revealed an increase during the year in the total numbers of all categories of APRNs, rising from 5,167 to 5,362. However, the report also showed that some rural counties had one or none active APRN licensees living there. That data does not account for nurse practitioners who live in one county in western Kansas and work in another county and that occurs, according to Merilyn Douglass, an APRN in Garden City.

SUPPLY AND DEMAND At the end of December, ads pitched nurse practitioner job openings in a number of places, including Wichita and Overland Park — and Dodge City.

Western Plains Medical Center in Dodge City was looking for a nurse practitioner to establish an outpatient clinic near two manufacturing plants.

“There is a very strong compensation package in an economically healthy community with a low cost of living.

Sign on bonus, relocation, loan repayment, and marketing allowance, plus a full benefits package,” the ad said.

State Sen. Mary Jo Taylor, R-Stafford, who serves on the Senate Public Health and Welfare Committee and whose husband, Todd Taylor, is the administrator at Stafford County Hospital, said a lot of times communities are taking the initiative to attract those professionals. “Our hospital will pay a certain percentage of your education if you come here,” she said.

Salaries for APRNs have climbed and some can earn in the six figures, depending on experience and skills, specialty, and location.

“Fortunately, that has started to become a little more commensurate with the responsibilities,” said Sally Maliski, dean of the School of Nursing at the University of Kansas Medical Center.

Maliski oversees campuses in Kansas City and Salina. The University of Kansas School of Nursing partnered with Salina Regional Health Center to open the latter campus in 2017.

The “great need in western Kansas” for nurses spurred the creation of the Salina campus, Maliski said in 2017.

The University of Kansas’ School of Nursing also is part of a consortium with Kansas State University and Pittsburg State University and has partnerships with community colleges. It and other schools of nursing in Kansas offer online classes, making it easier for students to pursue advanced studies.

Another effort to help boost health care delivery in rural areas is a federally funded grant project through ANEW (Advanced Nursing Education Workforce).

The purpose of the project is to provide advanced practice nurses with clinical education experiences in rural and

Miranda Lewis is a nurse practitioner at PrairieStar Health Center in Hutchinson.

underserved communities in Kansas. “So far, we have supported 28 APRN students. These students are enrolled in our Family Nurse Practitioner, Adult/Gerontology Primary Care Nurse Practitioner, and Nurse Midwifery programs,” according to Kay Hawes, associate director of News and Media Relations at the University of Kansas Medical Center.

The hope, said Maliski, is that as participating students experience and become familiar with working in a rural setting, they’ll desire to choose that option.

“Rural areas have their appeal,” Maliski said, for nurses.

“They are part of the community, they are taking care of their neighbors and friends.”

The current grant runs through June 2019, and the School of Nursing is applying for another grant that would be larger and would run for four years, according to Hawes.

SCOPE OF AUTHORITY In January 2015, the Henry J. Kaiser Family Foundation published a report titled “Tapping Nurse Practitioners to Meet Rising Demand for Primary Care” by Amanda Van Vleet and Julia Paradise.

Nurse practitioners have completed master’s degrees continued on page 14

January 2019

13

associations oppose it.

In 2015, Hays APRN Michelle Knowles wrote in her testimony for Senate Bill 69 that, “Advanced practice nurses are searching farther and father, many times from 30 to 200 miles away to get an agreement signed. It is unnecessary.”

Gregory Beck, Leavenworth, described in his testimony how the search for a collaborating physician affected his wife, Judith Beck. She had tried to launch two different health care businesses but was stymied by the challenge of securing a written physician agreement. One obstacle included how much compensation a physician expected for the amount of work performed.

The Kansas Medical Society’s testimony against the bill in 2015 stated, in part: “The fundamental premise of this bill is that APRNs and physicians are essentially interchangeable and that the two professions have a body of knowledge and clinical skills that are equivalent. That is not the case.”

An accompanying chart showed over 10,000 hours of supervised clinical education and training for a physician compared to 500 to 750 total patient care hours required through training for APRNs, based on an Institute of Medicine report.

“We do not allow MD students who graduate and do not match with a residency to practice independently, so why would we allow someone with less experience in making medical diagnoses to practice without collaboration?” Lynn Fisher, a physician from Rooks County and vice president of the Kansas Academy of Family Physicians, wrote in testimony against the bill.

NEW LEGISLATION

Nurse practitioner Miranda Lewis talks about an X-ray on her computer at PrairieStar Health Center. Jesse Brothers/Staff Photographer

Nurse Practitioners continued from page 13

or higher level nursing degrees and close to 90 percent of all nurse practitioners are prepared in primary care, the report said.

They can manage 80 percent to 90 percent of care provided by primary care physicians, it stated.

It takes much less time to produce a nurse practitioner than a physician — an average of six years of education and training versus 11 or 12 years for a physician’s training and residency — so nurse practitioners could be key to answering the expanding need for primary care providers, the report said.

The authors also pointed to a hurdle: More than half the states — including Kansas —

14 January 2019

have statutes reducing or restricting the full practice authority of nurse practitioners.

Removing barriers for a nurse practitioner’s “full deployment” is a step states can take, the study noted.

Less than 10 days after that report was published, the Kansas Senate Committee on Public Health and Welfare conducted a hearing on Senate Bill 69. It would have removed the requirement that APRNs have a collaborative agreement with a physician — one of the barriers cited in the “Tapping Nurse Practitioners” report.

Ultimately, the bill died in the committee.

Merilyn Douglass, of Garden City, president of the 3-year-old Kansas Advanced Practice Nurses Association, said in December 2018 that a new bill is being drafted to remove the barrier and it likely will be intro-

duced in February in the state Legislature.

DEBATE Kansas is not the only state mandating APRNs have a written collaborative agreement with a physician. Other states require an even bigger role for the physician, while slightly more than 20 states give APRNs full scope of practice authority.

KU’s Maliski said the required collaborative agreement restricts the ability of APRNs to practice at the full scope of their education and training, fully using their “knowledge,” “skill” and “judgment.” She would like the Legislature to pass full scope of practice authority legislation “not only for our graduates but for the health of Kansas.”

Generally, nurses and nurse associations also favor that, but physicians and medical

Douglass said in late December that the bill being readied for 2019 likely would have four components: • Remove the collaborative agreement requirement.

• Allow APRNs to prescribe drugs without the current protocol language.

• Require APRNs to carry malpractice insurance.

• Require APRNs to have a national certification.

Nearly all APRNs already work for an employer providing malpractice insurance or they carry their own policy, and those currently practicing without national certification would be grandfathered in, Douglass said.

“If our bill passes, collaboration doesn’t go away. There is no intention to practice independently or as a silo,” Douglass said. The teamwork concept will continue, she said. continued on page 15

Nurse Practitioners continued from page 14

Douglass has worked as a family nurse practitioner in Garden City for the past 21 years. For the past three years, she has worked in a privately owned clinic and has her physician agreement with a local doctor.

“I’ve called him probably three times in 2018,” she said, to ask a question.

Douglass said if she moved to Hutchinson to establish a clinic, she couldn’t open it until she had a signed agreement with a physician. If the agreement was not required and she came here to establish a clinic, still one of the first things she would do would be to introduce herself to physicians and other health care professionals here to establish relations, she said.

Nurse practitioners seeking a physician face the obstacle of large entities that prohibit their affiliated physicians from entering into an agreement with an APRN, she pointed out.

Lobbyists are assisting nurse practitioners on this new bill and will advise whether to start it through the House and its Health and Human Services Committee or through the Senate and its Public Health and Welfare Committee, according to Douglass.

“We’re trying to garner more business support and support from patients,” Douglass said.

NEW DEBATE State Sen, Barbara Bollier, D-Mission Hills, is a retired anesthesiologist, and her husband, Rene Bollier, is a family practice physician. She is the ranking Democrat on the Senate Public Health and Welfare Committee.

“We have huge discussions on this,” Bollier said of conversations with her husband. Nurse practitioner Miranda Lewis examines an X-ray on her computer at PrairieStar Health Center. Jesse Brothers/Staff Photographer Both have personal experience as physicians with collaborative agreements.

“We need to work on ways to get nurse PrairieStar’s Lewis said she doesn’t have United Methodist Health Ministry Fund.

“I will tell you it was the right thing to do practitioners to areas that are underserved,” a strong opinion on the issue. She likes her He said it would be good to be able to try and it was the best for the patent, “ Bollier Bollier said. She would support telehealth’s current agreement with supervisor and test approaches for tackling the primary said. role, but that only underscores the need to PrairieStar chief medical officer Rogena care provider shortage that don’t require She would oppose abolishing the requirefocus on improving broadband access in Johnson. “I’ve never seen it that I don’t going through the Legislature. ment, citing the different levels of education rural areas, she said. have independence,” Lewis said, and she The state of California established an infor physicians and APRNs as one factor. She Douglass said some nurse practitioners likes “having the comfort” of a physician to novation office within the California Health further noted that nurse practitioners are now rely on distant physicians, but she contact. and Human Services Agency to encourage schooled in a collaborative practice arena, questioned the practicality of looking to pilot programs, he said. and existing statute fosters continuation of telehealth as the solution. A nurse practiANOTHER AVENUE “It’s an exciting innovation that would be that approach. tioner is “not going to jump on her computer helpful for Kansas and any state with a rural Bollier said she does not think the statute screen for each patient,” she said. “I revere Scope of authority debates pit trade population,” Jordan said. is the reason rural areas cannot attract their educational path, they worked hard to associations against each other and what Colby hasn’t been able to fill a behavioral nurse practitioners. They aren’t going there become doctors, and none of us want to be sometimes gets dropped in the debate health position in five years, he said, adding, because they don’t want to live there, she a doctor. We just want to take care of the is what is good for the public, said David “We need to be able to innovate.” said. population we were trained to care for.”

Jordan, president of the Hutchinson-based

January 2019

15

Alternative Solutions Sought In Rural Kansas

By John Green Staff Writer

The announcement earlier this year that Mercy Hospital in Fort Scott would close by the end of the year was a surprise and shock to the community, which will lose several hundred jobs and more than a century of community health care legacy.

But it was not necessarily unexpected to those in the industry.

Many hospitals across Kansas, as around the country, have struggled the past decade with declining patient numbers amid rising costs.

According to the Kansas Hospital Association, of the state’s 127 hospitals spread across 91 counties, more than two-thirds had negative operating margins in a recent national study.

Most were reporting increases in bad debt, more charity cases and increases in the use of emergency care at the same time there were cuts in state and federal health care reimbursements.

As a result, hospital owners, other health providers and health care organizations for the past several years have been exploring alternatives to traditional systems for providing care, particularly in the state’s rural areas, which face some of the most significant challenges.

A MOVE TO PRIMARY CARE One example is the response to the decision in Fort Scott, which was similar to that in Independence when another Mercy Hospital closed there in 2015.

Community Health Centers of Southeast Kansas (CHCSK), a federally qualified health care center headquartered in Pittsburg, will take on providing primary care services to patients in the Fort Scott region once the hospital closes.

The nonprofit organization will assume the operation of four free-standing care facilities that were also operated by Mercy. The

16 January 2019

An artist’s drawing shows what the proposed $41 million, 62,500-square-foot Patterson Health Center for Harper County will look like. Photo Submitted Gould Evans facilities include primary care and urgent care facilities in Fort Scott, and clinics in Arma and Pleasanton, said Jason Wesco, CHCSK CEO. United Methodist Health Ministry Funds is supporting the shift by adding two more “patient navigators” to help coordinate care for new patients, said David Jordan, president of UMHMF. Community Health Centers, which started with a clinic in Pittsburg in 1997 as an outreach of Mt. Carmel Regional Medical Center and then became a separate nonprofit in 2003, will grow to 17 sites with the Mercy transfers, which also include Olathe Health in Mound City.

“What we provide is integrated primary care, which is a different model” than the current services offered by Mercy,” Wesco said.

“We’re not only primary care but offer behavioral health, dental services and pharmacy.”

Their services also are offered on a sliding scale for the uninsured.

“So you can access care for as little as $15, including medical and vision,” he said. “So, in many ways, access to primary care in Fort Scott will improve. We’re focused on helping people access care but at the appropriate level at the right time.”

A significant concern with the loss of a hospital is the loss of its emergency room.

Though the hospital closed Dec. 31, Mercy has agreed to keep the emergency room operating through at least January, and it is in talks with the Ascension Health, owner of the Via Christi hospitals, to take over the ER after that.

“Via Christi has shown strong interest in operating the ER,” Wesco said. “Hopefully there will be no interruption in ER service.”

Notably, a Kaiser Family Foundation study following the closure of Mercy Hospital in Independence found as many as 90 percent of visits to the emergency department there were for non-emergencies.

The local ambulance service, meanwhile, which had contracted with Mercy, will also continue to be run locally, with patient transfers “dictated by location and patient preference,” Wesco said.

NOT SUSTAINABLE Two Sisters of Mercy nuns founded Fort Scott’s Mercy Hospital in 1885 as a 10-bed hospital. A new 45-bed hospital opened at its current location in 2002.

A significant part of the hospital’s issue was the small percentage of the population using the hospital.

“Their market share, the last time I talked to someone at Mercy, was somewhere around 20 percent of the people were using the hospital locally,” Wesco said. “They were going to Kansas City. Some were coming to Pittsburg, some over to Nevada, Mo.” A study on patient migration by the Kansas Hospital Association in

2017 found 20 Kansas counties had hospitals that retained 25 percent or less of their county discharges, accounting for about a fifth of hospitals in the state.

It was easy to drive the hour north or east to a much larger hospital that offered more specialists and services, Wesco said. Mercy was even drawing patients away from its own hospital after it built a new one in Joplin, Mo., to replace a facility destroyed by a tornado.

The Fort Scott hospital also was not a “critical access hospital,” a designation from the Center for Medicare and Medicaid Services, which provides additional operating subsidies for hospitals with no more than 25 beds and that keeps patients four days or fewer.

There are 85 so designated hospitals in the state, according to a list from Flex Monitoring, a service-monitoring team formed by a group of universities.

“Any hospital that is not in a major urban area that is not a critical access hospital is at risk,” Wesco said. “You never want to see a hospital close, which brings with it that loss of jobs and often some of the highest wages in a community. But people should understand, the majority of health care they received in Fort Scott will still be there. And when you look to the future, what you’re going to see is what Mercy has done in Oklahoma. You don’t build a full-blown hospital; you build an emergency department or a surgery center that can do outpatient, and you do primary care.”

ANOTHER SERVICE OPTION The Kansas Hospital Association, with significant input from stakeholders over a four-year process, developed a proposed new health care model for rural communities called a Primary Health Center.

The model is designed to fill the gap between a rural clinic or continued on page 17

Alternative Solutions continued from page 16

federally qualified health care center and full-service hospitals, according to a report on the KHA website.

Core functions of a Primary Health Center include emergency room and urgent care services; primary health care; emergency and non-emergency transportation; patient observation as part of transitional care; care coordination; and telemedicine.

The model, officials said, also allows for optional services to be determined by each community. Those could include dentistry, rehab, mental or behavioral health, specialty care via telemedicine and more transitional care.

There have been numerous discussions at the state and national levels since a large Rural Health Visioning Technical Advisory Group formed by the KHA unveiled the Primary Health Center idea in 2015.

The model includes both 12- and 24-hour facilities that would provide assessment and interventional services for however many hours in the day the center is open.

A critical part of such a venture, the study noted, is a relationship with a partnering organization that could handle patients referred from the health center. Medical transportation is also vital.

“We’ve done a lot of education with our members about the changing landscape, and many are starting to see the ways Desiree Ortiz loads a box of meals in to the backseat of a car at St. Catherine Hospital as she prepares to deliver meals for the Finney County Meals on these new models can benefit a community, Wheels program in Garden City. The meals are prepared in the hospital’s food service. Brad Nading/Staff Photographer based on their needs,” said Jennifer Sindley, Kansas Hospital Association vice president.

“We have not been successful, however, in “We’ve had conversations with a division two hospitals just 10 miles apart in the spring of 2019. getting a demonstration to test this model to to do a project like we want, but we’ve not same county faced possible closures, board The 62,500-square-foot complex will see how it would work in the real world.” been invited to formally apply,” Sindley said. members from both organizations “came to consolidate services offered in Harper and The association did a “paper test” using “It’s a very thoughtful and long process to a brave decision,” said Jordan, at the United Anthony under one roof, including a 15-bed detailed data from a group of five hospitals get through the approval to get something Methodist Health Ministry Fund — “merge.” critical access hospital, neighboring health around the state that indicated it could like this. From turning in an application to Harper Hospital District No. 5 and the Anclinic, physical therapy and rehab center, work, but they’ve not received approval going live can take a year or two.” thony Medical Center agreed to do so in Noand a wellness center. from the Centers for Medicare and Medicaid The organization has also been talking to vember 2017, creating Hospital District No. 6, The campus will also feature a public cafe Services to try it. lawmakers at the state and federal levels, and representing “one of only a few hospital that will also serve the hospital, as well as “to get it on their radar screens,” Sindley district mergers in Kansas,” Jordan said. an open community center, public green LENGTHY PROCESS said.

The decision, however, was significantly space for community events, a community “We’ve been working all avenues,” she helped along by Neal Patterson, the late CEO garden and various trails.

“There are a couple of different ways we said. “We’re talking to anyone willing to talk of Cerner and former Harper County resiOfficials estimate cost savings from the can get a demonstration project,” Sindley to us.” dent, who challenged the two communities consolidation will be $2.1 million a year once said. “One is to have legislation to direct That’s included Kansas health officials and before his death last year to join and come the new facility is fully completed by 2021.

CMS to create a model that looks like this care providers. up with a new more comprehensive health “As a result of the merger, the provider one. Another is for CMS to decide they want “We had three hospitals step forward and care approach. clinic patient experience will be improved to test something new. They’ve done that say they were interested in doing a demonHis estate and Family Foundation pledged using recommendations of the Oklahoma from time to time, and put out the opportustration,” Sindley said. “One of the three, $35 million toward construction and equipState University Innovation Center,” Jordan nity for those interested in a demonstration interestingly, was Fort Scott, which is off the ping costs of the new Patterson Health noted. “Senior behavioral health, rehabilitaproject.” list now.”

Center. UMHMF provided the first outside tion, diabetic and telemetry programs will The third, she said, is through the CMS She declined to identify the others but said dollars to support the planning and develop- be enhanced.”

Innovation Center, an agency that’s part of they are proactive organizations in smaller ment activities for the project, Jordan said.

“Our hope is that this experience of two CMS created through the Affordable Care communities.

A groundbreaking for a new $41 million communities coming together create a Act, which develops its own models based joint campus located between the two health system that makes sense for the size on stakeholder input and then solicits orgaDISTRICT MERGER communities was Dec. 10, 2017. Officials of their communities will serve as a model nizations to do pilot projects using grants previously projected the first phase of the through a competitive process.

When confronted with the reality their multiphase development would open in the continued on page 18

January 2019

17

Boards for Harper Hospital District No. 5 and the Anthony Medical Center decided to merge their operations into one, the proposed Patterson Health Center, shown here in an artist’s rendering. Photo Submitted Gould Evans

Alternative Solutions continued from page 17

for other communities,” he added.

PRE-EMPTIVE HEALTH MEASURES Besides looking at alternative operating models, many hospitals and health organizations are working to improve community health proactively, said Tatiana Y. Lin, a senior analyst and strategy team leader at the Kansas Health Institute.

“We’re seeing a movement toward trying to avoid readmission and avoid utilization of emergency rooms,” Lin said. “Hospitals have started engaging more in population health, looking at both clinical and non-clinical approaches to address issues in the community, such as housing and transportation.”

“With that movement the hospital becomes a very important champion in the community, impacting population health,” she said.

The effort was prompted by requirements in the Affordable Care Act for non-profits to do community needs assessments, to address some of the issues that contribute to poorer health, and it expanded from there.

The KHA recently highlighted things eight hospitals around the state are doing, including helping in trail development and assisting restaurants and schools in offer-

18 January 2019

ing healthier food choices.

At Wilson Medical Center in Neodesha, for example, they’re working with the city to form a transportation advisory board to make the city more pedestrian and bike friendly and hired an athletic trainer to help improve student health in the local school district.

At St. Catherine Hospital in Garden City, they’ve supported transportation needs of patients and worked to address food insecurity, while Kearny County Hospital, among its numerous measures, has built greenhouses for year-round produce and helped launch a free bike-share program with the city. The hospital in Lakin is also encouraging the development of new moderate-income housing by partnering with developers to guarantee units are rented for the first year.

Housing is an issue because people in homeless populations, or those with unstable housing, are more likely to end up in emergency rooms or come back within 30 days of release from a hospital because they don’t adhere to treatment plans, Lin said.

“Some hospitals are looking at how to connect a patient who presents with certain issues with social services in the community that can help with those needs,” she said.

It’s also important for hospitals to recognize changing demographics and add or change service delivery for those popula-

tions.

NETWORKING Several small, rural hospitals in the state have formed a sharing network called the Kansas Frontier Community Health Improvement Network.

The group’s goal, UMHMF’s Jordan said, is to create a way for small, rural hospitals to share best practices and lessons learned, to discuss how they can improve quality and to report on projects.

“Ultimately, we see this partnership as creating an opportunity to improve how care is delivered with an eye towards sustainability and patient experience,” Jordan said. “The group is refocusing its attention on a potential shared quality measurement project.”

At Minneola District Hospital, CEO Debbie Brunner said the network helped it integrate behavioral health services into its primary care practices and to set up a process for transitional care management, both of which they’d not been able to explore without the network and support of the United Methodist Health Ministry Fund.

“We routinely email each other and do conference calls,” Brunner said. “We’re getting ready to embark on a new Frontier Network project through a workshop at the Dallas School of Medicine in Austin on redefining how we measure the value of our operations to patient and taxpayers.”

“It’s really a paradigm shift in thought processes as leaders and providers in health care, designing processes with a much better understanding of what patients hope and pray are going to be their experience at the end of care process,” she said.

Hospital leaders attended sessions in Dallas for a week in September and in October and are now working to develop partnerships with programs at the Dallas School of Medicine.

“Together we’ll work on one project, so it’s a learning and teaching experience,” Brunner said. “And then we’ll each have resources to keep going in our individual organizations.”

Other frontier network participants include hospitals in Lakin, Tribune, Phillipsburg, Oakley, St. Francis and Ashland, as well as a couple of others recently joining, Brunner said.

The group formed six years ago and generated a lot of ideas, but only in the past year or two have they been able to translate into changes at her hospital, Brunner said.

“It’s given us tools and resources to be able to do things internally, to make performance improvement part of our everyday work and get it going well,” she said. “In larger hospitals, they’ve been doing this a long time, but it’s more difficult in small, critical access hospitals.”

“I wouldn’t say it has kept us from closing, but in Minneola we want to be an example for rural health care,” she said. “We’re always looking for new opportunities and ways to do things better, to work more efficiently.”

CARE COORDINATION Besides funding two patient navigator positions for CHC SK in Fort Scott, the United Methodist Health Fund supported Kearney County Hospital in expanding its care coordination team to provide services to the refugee and immigrant population that in the region.

The care coordinator makes in-home visits, participates in patient rounding for acute care hospital patients and visits with emergency room patients who are triaged as non-emergent by medical providers, Jordan explained.

“All of these activities help reduce non-emergent ED use while increasing appropriate clinic use,” he said. “Additionally, the care coordinator assists patients with Medicaid applications and accessing patient assistance funds so patients can receive medications that are otherwise unaffordable.’

The care coordination team makes referrals to community-based services and provides some transportation services for patients having difficulty attending behavioral or other social services.

“This work played a significant part in reducing non-emergent visits to the hospital’s emergency room by 88 percent in a single year — from a monthly high of 110 visits down to 14 — by following up with each patient to provide education about more appropriate health care resources,” Jordan said.

KANSAS HAS GIVEN UP MORE THAN

$3 BILLION IN FEDERAL FUNDS SINCE 2014

BY NOT EXPANDING KANCARE

THAT MONEY COULD BUY:

500

MILES OF RURAL

4-LANE HIGHWAY

66

REBUILT OR NEW

HIGH SCHOOLS

15

NEW WICHITA

AIRPORT

TERMINAL & PARKING STRUCTURES

9

SPRINT

CENTERS

IT’S NOT TOO LATE TO BRING OUR TAX DOLLARS BACK TO KANSAS

To expand KanCare to 150,000 working Kansans

Create jobs and boost our economy

Help our community hospitals

Kansas Legislature:

The time is NOW. Expand KanCare in 2019.

Paid for by the Alliance for a Healthy Kansas. www.ExpandKanCare.com 700 SW Jackson Street, Suite 600 Topeka, KS 66603

January 2019

19

Kansas Health Professionals Address Opioid Crisis

Report: More than 1,500 Kansans have died from overdoses since 2012

By Jonna Lorenz Staff Writer

The battle over the nationwide opioid crisis is a matter of life and death for Jim Wolfe.

The 60-year-old Canton man lost his job as a welder, his wife of 30 years kicked him out, and an overdose in June nearly cost him his life.

“I had a good life, but the opiates snuck in and attacked me, and I guess I chose to do nothing about it,” Wolfe said. “I became everything I despised.”

His longtime struggle with addiction started with drinking at age 18 and meth at 28. He got clean and spent a decade sober before knee surgery set off a downward spiral from Percocet to heroin and crystal meth.

“I didn’t think I had a problem with pills until I got hooked on it, and it’s just been a battle,” Wolfe said. “Opiate withdrawal sucks.

It’s painful. You’re sick. You’ve got diarrhea. It’s miserable. It’s one of those things where you’d sooner use than be sick.”

Wolfe’s brush with death landed him in the hospital for a week, followed by a stay at an inpatient treatment facility in Dodge City and on to outpatient services at CKF Addiction Treatment. Clean for six months, Wolfe receives treatment, including counseling and the medication Suboxone, from a grant through the Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration.

Today, Wolfe is engaged to be married, has a relationship with his two adult daughters and four grandchildren, and helps others with their treatment at CKF Addiction Treatment.

“I don’t even think about opiates. I don’t hurt like I used to,” he said.

20 January 2019

A chalk wall lets patients release what’s on their minds while staying at the CKF Addiction Treatment building in Salina. The CKF Addiction Treatment offers evaluations, individual therapy, cognitive-behavioral therapy, treatment services, social detoxification, prevention, education and anger management.

Photos by Aaron Anders/ Staff Photographer

Jim Wolfe

PUBLIC HEALTH EMERGENCY More than 1,500 Kansans have died from opioid or heroin overdoses since 2012, according to the Governor’s Substance Use Disorder Task Force, which released a report in September. Drug poisoning killed more than 300 Kansans in 2016 alone, and prescription drugs were involved in 80 percent of drug poisonings from 2012 to 2016.

Nationwide, opioid-involved overdoses killed 42,249 people in 2016, according to the Kansas Prescription Drug and Opioid Misuse and Overdose Strategic Plan released in July.

A number of factors contributed to the rise of opioids, starting with a focus on eliminating pain, according to Greg Lakin, chief medical officer for the Kansas Department of Health and Environment and chair of the Governor’s Substance Use Disorder Task Force.

The medical community also was led to believe that opioids weren’t addictive by pharmaceutical comcontinued on page 21

Opioid Crisis continued from page 20

panies that aggressively marketed the drugs, he said.

In 2016, the CDC issued guidelines for prescribing opioids for chronic pain that aimed to reduce the risk of opioid use disorder. In 2017, the Trump administration declared a nationwide public health emergency regarding the opioid crisis.

While Kansas hasn’t seen the extent of problems that other states have, “We’ve still been hit hard. It truly is a crisis,” Lakin said.

As far who is affected, “It’s not who you think,” Lakin said, pointing out that many who struggle with opioids are middle-aged professionals.

“Oftentimes these are very good people, but they’re having to steal, they’ve having to burglarize, they’re having to take money out of their mother’s purse, they’re having to do things they would never have done,” he said.

While attention is on prescrip-

tion drugs, many overdoses can be traced to illegal drugs, such as heroin laced with fentanyl that makes its way here from China, Lakin said.

The opioid crisis has evolved in three waves, said Karan Braman, senior vice president of the Kansas Hospital Association and a member of the task force. The first wave, starting in the 1990s, was prescription opioids, driven by overmarketing of OxyContin, she said. That was followed by a wave of heroin overdoses after Mexican drug cartels targeted areas where OxyContin was being abused. The third wave is fentanyl addiction.

“I think everything we’re doing for opioids — because that’s where the attention and the money is — is certainly going to help with treating other substances as well,” Lakin said.

SEEKING SOLUTIONS The state has received about $30 million in federal grant funding, which has supported prevention, awareness, education and treatment to combat the opioid

crisis. But funding, which comes in “somewhat haphazardly,” has been a source of frustration for treatment providers, Lakin said.

The Governor’s Task Force made 34 recommendations in five focus areas: provider education, prevention, treatment and recovery, law enforcement, and Neonatal Abstinence Syndrome. Recommendations include establishing permanent funding sources for various programs, increasing awareness and use of the state’s prescription drug monitoring program, expanding medication-assisted treatment and promoting the use of naloxone, an overdose antidote.

Lakin signed a standing prescription allowing anyone in the state to go into a pharmacy and get naloxone. Now he is working to spread awareness about the potentially lifesaving drug, which is marketed as Narcan, hoping to get it in the hands of more police and emergency medical service workers, along with friends and family members of those with the potential to be at risk continued on page 22

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21

Treatment

Teresa DeMeritt is director of Labette Health Quality.

Photos by Stephanie Potter/Staff Photographer

Perioperative team drives the pain management protocols with other multidisciplinary teams at Labette Health in Parsons. Photos by Stephanie Potter/Staff Photographer

Opioid Crisis continued from page 22

Labette Health Quality director Teresa DeMeritt displays a poster she created for a Leader Fellowship Report. Labette Health has received national attention for reducing opioid administration by 47 percent and has spoken to hospitals throughout the state to share the story.

Opioid Crisis continued from page 21

of overdose.

“It’s just a safe way to save lives,” he said, noting that the nasal spray is harmless if administered unnecessarily.

“I have had many patients that had a wake-up call to their addiction, realized they were on the brink of death … realized it was time to get treatment,” Lakin said.

LOCAL EFFORTS Work to address the opioid crisis on the local level has included efforts to reduce opioid doses and prescriptions, use alternatives for managing pain and assess patients’

22 January 2019

ability to function rather than use a traditional pain scale.

“Every community is different, and solutions that work the best are local solutions,” said Braman, with the Kansas Hospital Association.

Labette Health in Parsons has been a leader in combating the opioid crisis, receiving national attention for its efforts to improve patient safety and participating in national presentations to share success stories with other hospitals.

In 2014, the organization set out to reduce adverse drug events, with a goal of cutting the number of naloxone administrations for patients receiving opioids within the hospital by 40 percent by September 2016, said Tereasa DeMeritt, director or quality.

The organization took a multimodal approach that involved peri-operative, pharmacy, orthopedic and frontline staff. Some measures that were adopted included giving smaller doses of opioids incrementally and using alterna-

tives to opioids, such as regional blocks, IV acetaminophen and gabapentin.

Labette Health surpassed its goal, reducing naloxone administration by 73.2 percent, reducing opioid administration by 44 percent and increasing its pain management scores to the 90th percentile, DeMeritt said.

“Overall, we did not make significant system changes,” she said. “We made small, incremental changes that made a significant impact. Being transparent with our data and sharing it to educate and engage our team was key.”

PRESCRIPTION MONITORING One of the state’s most successful tools in fighting the opioid crisis has been the prescription drug monitoring system K-TRACS. Established in 2010, K-TRACS alerts prescribcontinued on page 23

ers and pharmacists when patients reach a threshold of getting at least five controlled substance prescriptions from prescribers and visiting at least five pharmacies to fill those prescriptions in a 90-day period.

Lori Haskett, assistant director of the Kansas Board of Pharmacy, pointed out one such patient who received 15 controlled substance prescriptions from 14 different prescribers, which were filled at 15 different pharmacies in Kansas and noted that grant-funded enhancements to K-TRACS have helped significantly curb such suspicious patient behavior.

The number of threshold patients dropped from a high of 300 in September 2013 to 118 in December 2017, according to the Kansas Board of Pharmacy.

The Kansas Board of Pharmacy and KDHE are partnering on a CDC grant-funded effort to integrate K-TRACS into health care providers’ electronic medical records. Integration saves an average of four minutes per patient because providers don’t have to log in to separate systems. Thirty hospitals and 127 pharmacies are integrated.

Eric Voth, vice president of primary care at Stormont Vail Health, said combating the opioid crisis requires a balance between conflicting demands. On one hand, there are those who have a legitimate need for opioids. But the consequences can be severe when the drugs are misused.

Stormont Vail is participating in a national research project with the Centers for Disease Control and Prevention to study the effect of using electronic medical records to track opioid prescriptions.

The organization has integrated K-TRACS into its electronic medical record, allowing health care providers to easily access a patient’s prescription history. Stormont Vail also screens patients with detailed questions, administers drug tests and obtains informed consent agreements before prescribing opioids.

“You can’t just withhold opiates,” Voth said, “but by the same token, if there looks to be a clear pattern of drug abuse, it’s really not wise to put the opiates in on top of it.”

The problem is far more complex than careless doctors overprescribing opioids, Voth said, cautioning against overreactions that might vilify physicians or lead to changes that might somehow harm providers.

“There are some providers that are looser

than others, no doubt, and there’s been a lot of marketing, of course, but I’ve always sensed that the providers I’ve been around have been really careful and are trying to do what’s best for patients,” he said.

The opioid crisis requires a holistic approach to solving it, one that considers policies, funding, education, social factors and traumatic childhood experiences, with three major steps: diminishing supply of opioids, diminishing demand and saving lives, said Gianfranco Pezzino, senior fellow and strategy team leader at the Kansas Health Institute.

“There is really no doubt at this point that it is a brain disease and needs to be treated as such. It’s not the result of poor personal choices,” he said.

Braman, with the Kansas Hospital Association, emphasized the need to increase access to addiction treatment services.

“Addiction is a disease. It’s not a moral failing,” she said.

Based in Salina, CKF Addiction Treatment treats about 2,000 Kansans a year at its outpatient treatment facilities in Salina, McPherson, Abilene and Junction City and sees an additional 5,500 through a screening program at Stormont Vail and Salina Regional hospitals. Treatment includes doctors’ appointments, counseling and medication, and the CDC grant covers all of it for qualifying low-income Kansans.

Lindsey Ray and Shilo Redger are two such Kansans receiving treatment through CKF Addiction Treatment.

Ray had been addicted to opioids for about 10 years, having gotten hooked after receiving treatment for chronic back pain.

A longtime addict who was introduced to cocaine by her father at age 14, Ray had tried to quit using drugs many times when she sought help after the birth of her fourth continued on page 24

A lab technician prepares an intravenous bag at Labette Health in Parsons.

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23

Research Solidifies Estimates for Medicaid Expansion

By Sherman Smith Staff Writer

Kylie Sotelo, addiction recovery coach, meets with Shaina Laskowski and Theresa Henderson in the CKF Addiction Treatment building in Salina.

Shane Hudson is president and CEO of CKF Addiction Treatment, which serves 65 Kansas counties and helps treat almost 2,000 people a year. Photos by Aaron Anders/Staff Photographer

Opioid Crisis continued from page 23

child in 2013.

“After she was born, I realized I didn’t want to live like this anymore,” the 33-year-old Stockton woman said. “I didn’t know there was a way out. I didn’t think I was ever going to get better.”

She said she used drugs throughout her pregnancy and lucked out that her baby didn’t suffer any withdrawals.

“It’s not something I’m proud of, but it’s part of my story,” she said.

In October 2014, she started taking Suboxone, which combines an opioid and opioid blocker. She said she was doing well with her recovery until relapsing after she missed an appointment and stopped taking the medicine.

She is back in recovery and has been taking Suboxone for about a year.

“For me it’s a miracle drug. It has enabled me to live a normal life and be a good mother to my children and be a good wife,” said Ray, whose children are now ages 17, 15, 9 and 4.

Medication-assisted treatment is controversial, with critics saying it amounts to replacing one drug with another. Ray said two of her siblings, who also have struggled with addiction, were skeptical. Since seeing her get sober, they have started treatment, she said.

Shane Hudson, CEO of CKF Addiction Treatment, said that while patients on Suboxone are physically dependent on the medicine, it allows them to move past the chaos and negative effects of addiction and find balance and stability in their lives.

“I’m not using it to get high,” Ray said. “I want to feel

24 January 2019

normal, and people don’t understand that. I had already done so much damage to my brain from being an opioid addict.”

Opioid addiction also ran through Shilo Redger’s family, including her grandparents, parents, aunt and uncles.

The 29-year-old Plains woman said she began struggling with opioid addiction in her teens after a surgery and has been in and out of treatment. She also has struggled with addiction to meth.

Redger said traumatic experiences contribute to addiction, and she’s had her share, including a series of health concerns, the sudden death of her fiancé of carbon monoxide poisoning, and losing and regaining custody of her two sons, ages 10 and 7.

She has little trust in doctors, who she says “were handing (opioids) out like candy.” Redger credits Suboxone with saving her life, but she said she hopes to get off the medicine eventually.

“I do not like the fact that I am still feeding into this monster of pharmaceutical companies,” Redger said. “It’s ridiculous. They’ve got their hand in the pocket of each and every American in this country.”

She points to two needs that she sees as downfalls of addiction and keys to recovery: a spiritual connection with God or a higher power, and strong social connections, particularly with family.

“Nobody wants to talk about addiction. Everybody has it, but nobody wants to talk about it. Nobody wants to deal with it,” Redger said. “Almost every family that I know of has been affected by these drugs in some way, shape or form.”

Jonna Lorenz is a freelance writer. She can be reached at jonnalorenz@gmail.com.

Thirty beds house those going through recovery at the CKF Addiction Treatment building in Salina. The CKF Addiction Treatment facility serves 65 Kansas counties and helps treat almost 2,000 people a year.

Justin Fields and Theresa Henderson play a game of pool in the game room in the CKF Addiction Treatment facility in Salina. The game room aims to help patients keep their mind off their addictions while in recovery.

Suzan Emmons couldn’t afford to purchase her own health insurance plan anymore.

Premiums spiked following implementation of the Affordable Care Act, and she didn’t qualify for a plan through the marketplace with just $14,000 in annual income from her housecleaning business in Allen County.

Emmons, who is raising two grandchildren, made too much money to qualify for Medicaid in Kansas, where funds for adults are reserved for those who are pregnant, disabled or barely making money.

The ACA, also known as Obamacare, expanded Medicaid eligibility to protect individuals like Emmons who were caught in the coverage gap, but a U.S. Supreme Court ruling made expansion optional. The idea met resistance in Kansas as unsettled cost projections spooked lawmakers. Mounting evidence suggests a massive influx of federal cash and subsequent economic growth would neutralize the state’s burden and cushion weakened rural hospitals, but the idea faces ongoing opposition from skeptical lawmakers.

In 2017, Emmons testified before legislative committees, hoping her personal story would convince those lawmakers to look beyond the numbers on their policy briefs and see a labored caregiver. The Legislature that year passed a Medicaid expansion bill but didn’t have enough votes to override the veto of former Gov. Sam Brownback, hardening Emmons’ view of the political process.

“They have their heads up their rears,” Emmons said. “It’s just look at numbers on a paper and what makes sense to them. I don’t understand why they want to turn their head the other way. They are ignoring what Kansans need.”

Lawmakers who stiff-armed Medicaid proposals in 2018 entered this year’s session with the urging of Gov. Laura Kelly to expand coverage, a relatively stable budget outlook and research from a litany of sources

who independently report amenable costs for providing insurance to another 150,000 individuals.

‘HARDWORKING AMERICANS’ Emmons now earns enough to qualify for a marketplace plan and enjoyed health insurance in 2018 for the first time in several years.

She also received her first mammogram in several years, which revealed a concerning spot.

Mercifully, further examination determined the mark wasn’t malignant. She wouldn’t have been able to afford those tests without coverage, though, and the consequences of abandoning preventative care are startling for someone with a family history of cancer. She felt like opponents to expansion believe people who are poor deserve to die.

“There’s a stigma about welfare — you know, just laying around doing nothing,” she said. “It’s not. It’s hardworking Americans who are just trying to make a living. And it makes me angry that they let all this money go.”

Under expansion, the state would pay for 10 percent of the cost of medical service while the federal government absorbs the rest. That amounts to an increase of $1.8 million in federal funds that would flow through Kansas health care providers every day.

Kansas is among 14 states yet to embrace expansion, and five years of resistance already has cost the state more than $3 billion in federal assistance, according to figures tracked by the Alliance for a Healthy Kansas, a coalition of doctors, hospitals, social service providers and faith leaders that lobbies for Medicaid expansion.

“All we’re doing,” said alliance director April Holman, “is sending our taxpayer money to those states who have made this policy a part of their state makeup.”

The Kansas Policy Institute is a driving force behind the naysayers who object to any advancement of Obamacare and dispute prevailing cost analysis. KPI policy director

James Franko asserts that costs always exceed expectations when states deploy Medicaid expansion, a common objections by opponents.

“People of good faith can simply come to different conclusions on this or any other policy question,” Franko said. “We should also be able to agree that a program should be measured on results.”

‘A FOCAL ISSUE’ The ACA offers the carrot of higher compensation to states that expand coverage to individuals whose yearly income is less than 138 percent of the federal poverty level — $16,000 for an individual or $34,000 for a family of four.

Studies by the Kansas Department of Health and Environment, Kansas Health Institute, Kansas Hospitals Association and Harvard researchers show 145,000 to 152,000 individuals would sign up following expansion. That includes people who already have coverage through another source, as well as people who don’t realize they already are eligible — sometimes referenced as the “woodwork” effect, and a source of bitterness by expansion critics who fear Kansas enrollment will soar beyond prediction.

Robin Rudowitz, the associate director for Kaiser Family Foundation’s program on Medicaid and the uninsured, said many states initially discovered more people than anticipated were taking advantage of newly available coverage, but in the long run, the estimates were met. As more states embraced expansion, forecasters are able to better calibrate their expectations, she said.

The 2017 expansion bill expected 150,000 new participants and a $26 million impact on the state budget for fiscal year 2020, which starts in July. That is consistent with a KHI study that shows the state’s gross cost would be about $110 million and the KHA assessment that savings would lessen the burden. For exam-

Medicaid expansion advocate Suzan Emmons, a selfemployed housecleaner who cares for two children in Allen County, doesn’t understand why lawmakers turned the heads away from hardworking Americans like herself.

Tom Bell, president and CEO of the Kansas Hospitals Association, said Medicaid expansion isn’t the only factor for the financial health of medical providers, but it is a contributing factor to those that decide to close.

continued on page 26

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KU Med School Making Efforts to Place Doctors in Rural Areas, Small Towns

Medicaid expansion continued from page 25

ple, the state currently pays 45 percent of the medical costs for an uninsured pregnant woman but would be responsible for just 10 percent after Medicaid expansion.

The hospitals group also contends that improved tax collections would eliminate the state’s burden entirely. The estimate assumes a modest 5 percent return on federal funds, where other states have seen a 13 percent to 18 percent return.

Based on those figures, KHA president and CEO Tom Bell said he doesn’t understand why some remain so adamantly opposed to expansion.

“Why we are apparently trying to become the last state to do this is beyond me,” Bell said. “I can understand the politics of it, but continuing to make this such a focal issue year in and year out, I don’t understand.”

Varied and various programs aim to attract med students to practice in Kansas

‘FISCALLY RESPONSIBLE’ Late last year, Mercy Hospital in Fort Scott became the most recent Kansas hospital to shut its doors.

Medicaid expansion isn’t the only reason hospitals struggle financially, but it is a contributing factor. Without Medicaid expansion, Bell said, more Kansas hospitals could cease to exist.

“I think the answer probably is yes,” Bell said, “but I can’t tell you which ones those are, and I can’t tell you that the closure of any particular hospital is 100 percent because of Medicaid expansion. I can tell you that if Fort Scott had been able to count on an extra million bucks from Medicaid expansion, they’d have thought a lot more seriously about whether to close.”

Commercial health insurance carriers traditionally subsidized the cost of caring for patients without insurance, but those carriers no longer see that as their responsibility.

In some rural areas, hospitals operated by city and county governments have turned instead to local taxpayers to make up for the lack of coverage, Bell said.

A study released in September by Harvard fellow Anna Goldman and associate professor Benjamin Sommers concluded the uninsured rate of low-income Kansas adults is significantly worse than in other Midwest states that adopted Medicaid insurance.

As a result, Kansans report more frequent delays of care, greater difficulty in paying medical bills and worse quality of care.

Scott Taylor, president and CEO of St. Catherine Hospital in Garden City, said his hospital, as a ministry of the Catholic church, has a calling to provide for patients regardless.

But many rural facilities are losing money, he said. By unlocking federal funding,

26 January 2019

Michael Kennedy is the associate dean for rural health education at The University of Kansas School of Medicine in Kansas City, Kan.

those payments would make a difference in communities where medical providers would be able to hire another practitioner or purchase equipment.

Through the Centura Health network, Taylor works with 600 employees at facilities that serve a 20-county area in rural western Kansas. Expansion would provide them with $3 million in annual revenue, Taylor said, all of which would be invested in new jobs or devices.

He said he believes opposition to expansion is purely political spite for Obamacare.

If he could whisper in the ear of lawmakers as they prepare to vote on the issue, he would tell them expansion is the right thing to do for hardworking, low-income Kansans.

“It’s fiscally responsible, and it will improve the health of all of Kansas,” Taylor said.

‘THEY’LL DRAG IT OUT’ Franko cautions that economic projections ignore an unseen impact in the form of reg-

ulatory distortion and taxes paid by private business.

“Being given a Medicaid card does not guarantee better health outcomes,” Franko said. “We should also keep in mind the other ways to increase access and lower health care costs that do not bring more folks onto government insurance — short-term or association health plans are but two things we’ll be working on in 2019.”

Franko embraces the Foundation for Government Accountability, source of many of the counter-expansion arguments, as a “great partner.” FGA analysis is widely disparaged, however, in by the academic realm.

Assessment of FGA findings by journalists, legislators and a federal judge, as documented by the Brookings Institute, describe FGA information as incompetent, misleading, fundamentally flawed, oversimplistic, exaggerated and irresponsible.

Officials from Indiana, North Dakota and Ohio have contradicted the FGA narrative that every state that expands Medicaid faces a higher-than-expected surge in enroll-

ment. A peer-reviewed study by Sommers found state budget projections to be reasonably accurate.

Franko dismisses the criticism as robust policy discussion between groups with different perspectives.

Despite those differences, Holman, the Alliance for a Healthy Kansas director, remains cautiously optimistic that lawmakers will pass expansion this session. She is leaning on a network of people across the state to educate and engage on a grassroots level.

“I think that their personal stories about why this is important to them are going to be, in the end, the most powerful work that is done for expansion,” Holman said.

Emmons, the Allen County grandmother, has a more jaded view. She wonders if the governor will follow through on her talk of expanding Medicaid, or if the Legislature will even send her a bill.

“I’m sure they’ll drag it out as long as they can because that’s what they do,” Emmons said.

The University of Kansas School of Medicine’s main campus is in Kansas City, Kan. Photo Submitted

By Phil Anderson Staff Writer

Kansas is among the top states in the nation when it comes to placing its medical school students in rural areas and small towns.

Even more impressive are the number of students who remain in those areas after getting their start there.

But the future of medicine in sparsely populated areas of Kansas is somewhat in jeopardy, experts warn, as the state wrestles with Medicaid reimbursements that allow doctors and hospitals to remain solvent.

Michael Kennedy, a family practice doctor and associate dean for rural health education at The University of Kansas School of Medicine in Kansas City, Kan., is the caretaker of a number of programs that have proven highly successful at plugging students into some of the state’s least populated areas.

Kennedy noted some of the programs

started more than 50 years ago and continue to this day.

The KU Medical School has an enrollment of around 800 students. Students who commit to serving in a rural area or small town after their graduation can benefit from tuition assistance and stipends that can drastically reduce their debt.

Kennedy said the KU Medical School places a high priority on Kansas students filling its slots each year. More than 85 percent of the medical school’s 211 incoming students each year are from Kansas.

“We want most of our students to have their homes in Kansas,” Kennedy said, “because we know students from Kansas are more like to return to Kansas.”

The medical school — which has campuses in Wichita and Salina in addition to its home base in Kansas City, Kan. — divides the state into six regions, said Kennedy, who also serves as assistant dean for student affairs at the medical school.

Those regions are northeast, southeast, north-central, south-central, northwest and southwest. Each one of those areas has its own director from the KU Medical School’s faculty, Kennedy said.

Students are plugged into the various regions during their time at the KU Medical School. Some students spend a few weeks in a particular region, while others spend several months.

A key component to the program’s success, Kennedy said, is the participation of some 250 rural preceptors who are “spread across Kansas.”

The medical school students are assigned a preceptor to serve as a mentor while the students serve in one of the rural areas or small towns of Kansas. Some of the preceptors may take a single student under their wing during a given year, while others may work with as many as 10.

The students take on almost a rock-star status when they serve in one of the practic-

es in a rural area of the state.

“The communities house the students,” Kennedy said, “and many will feed the students.”

The biggest benefit to the students, Kennedy said, is the opportunity for the medical school students to work one-on-one with the practicing physician. In many cases, those physicians have primary care practices.

“It’s an extremely valuable learning experience for the students,” Kennedy said.

One of the most successful initiatives sponsored by the KU Medical School’s rural health education program is the Scholars in Rural Health program. Kennedy said this program is open to juniors in college who have applied for entrance into the KU Medical School. Students accepted as a Scholar in Rural Health gain 200 or more hours of “shadowing” a doctor in a rural area or small town.

The program started in 1999 with six students, Kennedy said. In the past two years, 16 students have taken part.

The success of the program shows up in the retention rates, Kennedy said. Some 80 percent of the program’s graduates remain in Kansas, and two-thirds become primary care doctors. Even more impressive, some continued on page 28

January 2019

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Ku Med School continued from page 27

The University of Kansas School of Medicine also has a campus in Salina, in addition to one in Wichita and its main campus in Kansas City, Kan. Photos Submitted

60 percent of graduates elect to serve in rural areas following their graduation from medical school.

Another program that has proven dividends is the Summer Training Option in Rural Medicine — or STORM — which has been in existence for 26 years. It had its 699th participant last year and attracts roughly 30 students per year, Kennedy said.

Students participate in the program in the summer between their first and second years of medical school. The students receive hands-on experience, including everything from working in the emergency department to assisting with surgeries.

Kennedy said 16 students have gone back to practice at the sites where they did their STORM programs, and now are serving as preceptors for KU Medical School students.

Students in their third year of medical school can take part in the Rural Options Clerkships in Kansas — or ROCK — which takes them off-campus to work in a rural setting. The program started in 1997 and has had 490 students participate during its 21-year history.

Like some of the other rural programs offered by the KU Medical School, ROCK offers students a chance to take part in family medicine practices, as well as in obstetrics, surgery and pediatrics.

28 January 2019

“The students love it,” Kennedy said. “They get a fantastic experience.”

The Rural Preceptorship program, targeting rural medicine, was started by Franklin Murphy as part of the Kansas Plan that was signed into law in 1949 by Gov. Frank Carlson.

Kennedy said The University of Kansas School of Medicine has

been one of only two medical schools in the nation to have a required rural preceptorship program lasting at least four weeks.

The program has seen more than 17,000 participants since it started 70 years ago.

Kennedy said the intentional efforts of the three-campus system of the KU Medical School to address medical needs in Kansas have paid off in a big way. He noted the KU Medical School is in the 99th percentile of all medical schools in the nation in terms of placing students in family medicine, a vital specialty for rural areas and small towns in Kansas. The KU Medical School also ranks in the 94th percentile of graduates choosing to locate in rural settings.

Speaking for himself as a physician, and not as a representative of the KU Medical School, Kennedy said there are concerns regarding rural hospitals and access to care.

According to America’s Health Rankings from the United Health Foundation Report, Kansas has slipped in medical ratings over the past couple decades, listed at 25th in 2017 compared to eighth in 1990, “which disturbs us greatly,” Kennedy said.

The most important thing the state of Kansas can do, Kennedy said, is “expand Medicaid.”

Such a move not only will lend stability to rural and smalltown hospitals — some of which have closed and others on the brink of closure — but also show medical school students they will be able to set up “financially viable” practices in such areas.

“If they don’t see a viable practice in rural Kansas,” Kennedy said, “we’ve shot ourselves in the foot.”

Telemedicine Enables Providers to Reach Rural Patients Lower costs of delivering services also a benefit, health center director says

By Jonna Lorenz Special to GateHouse Kansas

A shortage of mental health providers, coupled with rising demand for services, is pushing many Kansans to turn to telemedicine for treatment.

The tools are being used for everything from medication management to talk therapy and crisis intervention, and new legislation going into effect this year could expand services to Kansans.

Outgoing Gov. Jeff Colyer signed the Kansas Telemedicine Act, providing parity for telemedicine, defining what telemedicine is, who can provide it and prohibiting insurance providers from excluding telemedicine services.

“It’ll be interesting to see what kind of ef-

fect it has,” said Kari Bruffett, vice president for policy at the Kansas Health Institute. “It certainly opens up telemedicine to more payer reimbursement.”

Telemedicine enables patients to get mental health services quickly and allows providers to reach those in rural areas. It also lowers the costs of delivering services, said Walter Hill, executive director of High Plains Mental Health Center, which has been reaching out to patients via teleconferencing for about 15 years and continues to expand its use of technology.

He said the Kansas Telemedicine Act won’t bring any huge changes to High Plains.

“We’re just hoping that will set the stage that more payers will be willing to reimburse for services,” he said.

The University of Kansas School of Medicine has a campus in Wichita. Photo Submitted Walter Hill, executive director of High Plains Mental Health Center, turns on a monitor for the center’s telemedicine system at the office in Hays. Jolie Green/Staff Photographer

Shane Hudson, president and CEO of CKF Addiction Treatment, points to the 65 counties (shown with dark purple) served by the organization with telemedicine. Aaron Anders/Staff Photographer Based in Hays, with branch offices in Goodland, Colby, Norton, Phillipsburg and Osborne, High Plains Mental Health Center covers 20 counties in northwest Kansas, providing services to about 5,500 patients each year, with about 2,200 patients receiving services via telemedicine.

High Plains currently has about 50 telemedicine units at county jails, hospital emergency departments, doctors’ offices and clinics throughout the region. The organization also has a fleet of cars that travel about 750,000 miles a year to serve clients, Hill said. Without telemedicine, the organization’s fleet would have needed to travel 1.25 million miles to provide the services it did in 2017.

High Plains recently started doing almost all of its consultations and emergency work with Hays Medical Center via telemedicine.

“It increases how quickly we can get people seen,” Hill said. “They can roll the cart into the emergency room or up onto the medical floor.”

High Plains also is turning to telemedicine to deal with staffing shortages, with plans to contract with a nationwide telepsychiatry network called innovaTel to hire a part-time psychiatrist to treat patients via telemedicine, Hill said. The psychiatrist must have a Kansas license but may be located in Texas or Florida.

Hill said hiring contract mental health

providers living and working remotely is a fairly recent development in telemedicine, which is continually evolving.

While telemedicine has been around for years, the new legislation may help tear down barriers some providers have faced in adopting the technology more widely.

CKF Addiction Treatment serves patients in 65 counties in Kansas, and many of those patients are in small, rural communities with limited access to services. The organization currently uses telemedicine for assessments and for support groups paid for by a federal grant to treat substance use disorder, CEO Shane Hudson said. The organization hasn’t developed programs for counselor-led treatment via telemedicine.

Hudson said he was excited to see the Kansas Telemedicine Act pass, but he said the legislation still leaves some questions to be resolved.

“I feel like that’s got to be changed,” he said. “I’m hopeful about that.”

Hudson is concerned about limitations to originating sites, where patients are located when receiving services. The law doesn’t specify whether patients can access services from home. KanCare requires patients to log on from an approved site, such as a hospital or clinic. continued on page 30

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Telemedicine continued from page 31

Walter Hill, executive director of High Plains Mental Health Center, and Stephen Kuhl, director of IT for HPMHC, demonstrate how communication works through HPMHC’s telemedicine system at the office in Hays. Photos by Jolie Green/Staff Photographer

Walter Hill, below, executive director of High Plains Mental Health Center, talks with Stephen Kuhl, director of IT for HPMHC, using their telemedicine system at the offices in Hays. High Plains Mental Health Center has more than 50 telemedicine stations throughout its 20-county region to assist in giving care to those in rural communities.

High Plains Mental Health Center is currently working to deploy new iPads for its telemedicine system that will replace older PC units. Photo by Jolie Green/Hays Daily News

Telemedicine continued from page 30

“You’re really cutting the legs off of something that could really be great,” he said. “You’re not really doing telehealth if people can’t get on and access the services.”

Many providers wanted the law to include payment parity requiring insurance providers to reimburse telemedicine services at the same rate as in-person services.

Shawna Wright, associate director of the KU Center for Telemedicine and Telehealth, said keeping the law open and broad is a good thing.

“Sometimes if you’re too specific in your law, then you limit yourself for how telemedicine grows,” she said.

Wright founded a telepsychology practice, Wright Psychological Services, and began working with patients at skilled nursing facilities in southeast Kansas in 2012. She said she was surprised at how accepting patients were of

30 January 2019

the technology and how quickly her client load grew.

She learned to adjust her approach, asking patients more questions to assess their needs and requesting assistance from workers on site at the nursing facilities when necessary.

“I had to grow as a professional to really evaluate what the patient needs and adapt to that,” she said. “There are limitations, but most of them can be overcome if you can become comfortable with asking questions or even requesting assistance.”

Now working for the KU Center for Telemedicine and Telehealth, Wright has gone from learning and studying about telemedicine to doing quite a bit of training on the subject.

“It’s booming now,” Wright said of telemedicine. “Technology has taken off, so it’s a lot more convenient, a lot more specific and a lot more affordable than it has been before. But it’s not new.”

In addition to direct-to-patient services, telehealth

also connects providers to education and mentoring. The University of Kansas Medical Center’s Project ECHO (Extension for Community Healthcare Outcomes), connects provides across the state through video conferencing, building specialty teams to address topics ranging from pediatric psychiatry to pain management and the opioid crisis.

“Everybody learns from it,” Wright said.

Project ECHO gives primary care providers in rural communities access to mentoring from specialists that allows them to better manage complex cases locally.

“Having the ability to use technology to not just have an office visit but also really connect a system of health providers in the state so that where you live doesn’t have to determine your outcome I think is a real huge promise for telehealth,” said the Kansas Health Institute’s Bruffett.

Jonna Lorenz is a freelance writer. She can be reached at jonnalorenz@gmail.com.

January 2019

31

Kansas Teen Pregnancy Rates Dropping

By Jonna Lorenz Special to GateHouse Kansas

Kansas saw another year of improvement in teen pregnancy rates, which have fallen dramatically since 2008, according to a report released in December.

“We are encouraged by the continued decline in the teen pregnancy rates for several Kansas counties and the state overall,” Rachel Sisson, director of the KDHE Bureau of Family Health said in a statement. “KDHE remains committed to working closely with local partners and communities to identify, support and spread strategies and interventions that are making a difference.”

While the state’s pregnancy rates have dropped more than 50 percent since 2008, national teen pregnancy rates also have improved during that time, keeping Kansas slightly above the national rate. In 2017, pregnancy rates dropped among females ages 10-19, 10-17 and 15-17. But those ages 18-19 saw a 3.2 percent increase in pregnancy rates, according to the 2017 Kansas Adolescent and Teenage Pregnancy Report released in December by the Kansas Department of Health and Environment’s Bureau of Epidemiology and Public Health Informatics.

The rate of pregnancies among teens ages 15 to 19 in Kansas, including live births, stillbirths and abortions, was 25.3 per 1,000 female age-group population, down from 25.7 in 2016.

The state recorded a total of 2,446 pregnancies among teens ages 15 to 19 in 2017, and 2,469 counting girls as young as 10. Teen pregnancies in the state have fallen every year since 2008, when there were 5,309 pregnancies among Kansas teens ages 15 to 19, and 5,371 among those 10 to 19.

PREGNANCY PROGRAMS The Kansas Department of Health and Environment has several programs geared toward supporting pregnant teens and teen parents.

The Teen Pregnancy Targeted Case Management (TPTCM) program serves teens enrolled in Kan-Care with support to increase self-sufficiency and delay subsequent pregnancies until education goals are met.

The Lifting Young Families Towards Excellence (LYFTE) program helps teens and young families develop life skills, with a focus on health, education and employment.

The Abstinence Education Grant Program (AEGP) promotes abstinence, helps teens

32 January 2019

Teen Pregnancy continued from page 32

Jill Nelson is the program poordinator for Delivering Change in Junction City. resist peer pressure and provides education about sexually transmitted diseases.

KDHE also promotes Power to Decide, a national campaign to reduce unplanned pregnancy that provides research-based information on sexual health and contraception.

“I do feel like the teen pregnancy management programs do help,” said Lisa Goins, a registered nurse at the Crawford County Health Department, noting efforts to prevent or delay subsequent pregnancies among those who become parents as teens. “There are going to be some people who will get pregnant again, but the majority of them get their life together.”

Programs to address teen pregnancy are affected by the controversy surrounding the topic, with political and religious beliefs and family expectations playing a role in how it is addressed.

“I think knowledge is power. It really is. It would be great if parents would share that, but if they don’t feel comfortable, then have somebody else do it for them,” Goins said.

DELIVERING CHANGE Pregnancy rates vary throughout the state, with females ages 10 to 19 averaging 12.7 per 1,000 peer group population in Kansas. The highest rates are in Geary County (39.4), Greeley County (34.1) and Morton County (31.7). Several countries reported no teen pregnancies in 2017: Chase, Cheyenne,

Gove, Graham, Hodgeman, Jewell, Lane, Lincoln, Ness, Ottawa and Wallace.

In Geary County, the pregnancy rate rose in 2017 from a five-year average of 33.8 per 1,000 peer group population. Jill Nelson, program director for Delivering Change: Healthy Families-Healthy, pointed to demographics as a contributing factor to the county’s high rate of teen pregnancies.

“Geary County is actually one of the youngest counties in the state of Kansas because we have the Fort Riley military installation that sits in Geary County,” she said. “We have a very young population just in general because of that.”

Delivering Change receives about $70,000 a year in grant funding to administer the TPTCM program there, said program director Jill Nelson.

A case manager works with pregnant teens from the time of their first OB-GYN appointment through the first year of their baby’s life, assessing their social and emotional needs and pointing them toward resources such as prenatal education and federal funding for food through Women Infants and Children (WIC). A case manager meets with a teen mother at least once a month, offering guidance on goals related to education, housing and work.

Geary County also receives $122,000 in federal funding through the LYFTE program, which supports young adults to age 24 and reaches young men as well as women, Nelson said.

She said the programs have been successful in helping young parents reach their goals and become stable.

“I think that building that relationship between the navigator and the participant helps them to know that somebody’s on their side,” she said.

Nelson also refers clients to the Konza Prairie Community Health Center for access to contraception and counseling on abstinence and natural family planning.

“Even if you have a pregnancy early on before you had intended, it should not become a stumbling block or something that prevents you from your long-term goals,” Nelson said. “Sometimes those are the most motivated individuals because they want to do well.”

Delivering Change was established in 2012 in response to high infant mortality rates in the county. During the past five years, the county’s infant mortality rate has dropped 50 percent, Nelson said.

“I think everybody would like to see that trend continue going down,” she said. “We want to make sure that women are ready and as prepared as you can be to become a parent.”

CONTRIBUTING FACTORS Christie Appelhanz, executive director of Children’s Alliance of Kansas and a board continued on page 33

member for Seaman USD 345, said improvements in teen pregnancy rates reflect shifts in sexuality education, which are changing to become more broadly focused on healthy relationships.

“The goal of most sexuality education programs in the U.S. is to decrease negative consequences of sexual activity — to stop the spread of sexually transmitted infections and decrease rates of teen pregnancy,” she said. “These are worthy goals, but we don’t believe they go far enough.”

For the past seven years, the Children’s Alliance of Kansas has received federal funding through KDHE for its Healthy Life Choices program, focusing on reducing pregnancy among teens in the welfare system. Funding for that program ended in September.

“It’s hard to imagine that we wouldn’t have an impact as a result of that,” Appelhanz said.

Jason Wesco, executive vice president of Community Health Center of Southeast Kansas, said that while he would like to think improvements in teen pregnancy rates are a result of educational programs, he suspects contraception has played a bigger role in the decrease.

“We’ve done a lot of work to make contraception more easy to access, so I think that has to be a factor in all of this,” Wesco said. “I would suspect it’s a national factor.”

Community Health Center of Southeast Kansas provides comprehensive teen pregnancy services in Crawford, Cherokee and Labette counties, with funding from the LYFTE and TPTCM programs and a

Maternal and Child Health grant. In 2017, those counties saw teen birth rates of 12.5, 15 and 17.2 respectively, down from averages of 17.2, 19.9 and 19.1 during the past five years.

The organization has been providing prenatal care since it was founded in 2003.

Among the services it provides, CHCSEK has incorporated digital badging, which uses mobile apps to track goals and earn points and incentives like diapers.

“It’s gamifying learning,” Wesco said.

Along with education and access to contraception, Vanessa Sanburn, executive director of Let’s Talk, said social factors also play a role in pregnancy rates.

“Sex among teenagers is declining,” she said. “Some people attribute that to kids being more on their phones and texting rather than being in the same room as partners.”

Based in Lawrence, Let’s Talk provides comprehensive sex education and support to school districts and parents and runs a text message-based support line for questions about sexual health or relationships.

The organization tackles difficult topics, helping parents address such issues as consent and pornography with their teens, Sanburn said.

“I think the more comfortable people are talking about sexual health, the more critical thinking goes into decisions,” she said. “The amount of critical thought and rational thinking that young people are using to make deliberate decisions about sex and relationships seems to have increased from my perspective.”

Jonna Lorenz is a freelance writer. She can be reached at jonnalorenz@gmail.com.

Delivering Change Healthy Families-Healthy Communities held Luke’s Community Baby Shower in November 2018. Delivering Change was established in 2012 in response to high infant mortality rates in the county. Photos Submitted

Delivering Change Healthy Families-Healthy Communities held Luke’s Community Baby Shower in November 2018.

January 2019

33

Pros and Cons of Internet In Health Care

By Linda Ditch Special to GateHouse Kansas

When a car or appliance breaks down, people commonly click on their favorite search engine to find out the problem and how to fix it.

Unfortunately, that method is not necessarily a good idea with it comes to the human body. While the internet may be a good source of medical information, it is the proverbial double-edged sword when it comes to reliable facts and solutions.

George Wright, physician, who practices family medicine at Cotton O’Neil Garfield in Topeka, said: “There are a lot of conflicting things on the internet.

However, it also creates an opportunity to connect with folks and discuss their medical conditions.”

Hutchinson cardiologist Costy Mattar is a fan of the Internet.

Mattar said, “I highly advise my patients to research their problems online, to take notes and bring their questions to our next visit so I can help them understand their problems. Also, I’ve found that they will adhere more to their treatment regimen once they see what is needed to be done online.”

However, the worldwide web can cause issues when patients look up their symptoms before seeking medical care.

Sara Patry, internal medicine physician at the Hutchinson Clinic, said, “Patients are absolutely looking up their symptoms before they come in, and it’s hard to convince some patients that they may not have what they found online.”

Hutchinson pediatrician Chad Issinghoff agreed, saying: “Many times a patient comes into the office with a self-diagnosis. Given a choice between two diagnoses, a patient will often focus on the more serious diagnosis, or they’re absolutely convinced that the diagnosis they have determined is correct. When the physician gives them a different diagnosis, they become upset.”

Issinghoff said physicians spend years honing their diagnostic skills based on such numerous factors as history, physical examination, appropriate lab testing and subspecialty consultation.

34 January 2019

“An internet session to try to diagnose oneself may be more harmful by preventing the timely seeking of medical care if the patient is incorrect in their diagnosis,” he said.

Patry said the internet can benefit the doctor-patient relationship.

“Anytime a patient is taking an interest in their own health, I think that is great,” she said. “The goal is finding the right information when searching the web. Ideally, patients would use reputable sites as a platform to learn more about a disease process they already have and not as a diagnostic tool based on the symptoms they enter.”

Having been in practice for over 30 years, Hutchinson Clinic family medicine physician Tim Pauly refers to the Internet as the new Reader’s Digest.

Pauly urged people to separate out the good from the bad online.

“You can’t believe everything you read and you should always ask your doctor before deciding to do something on your own,” he said. “Google is convenient and fast and can provide quick answers to our pressing health concerns, but it cannot bring 30-plus years of experience in treating patients and conditions. And it cannot know the difference between what is presenting as a common cold and what may be a symptom of a much larger problem.

“Or, as is most often the case with the internet, it cannot properly diagnose a common cold without also bringing up some scary and life-threatening options. Please, always check with your family doctor who knows you and your health history.”

Since people have such easy access to all the information available online, most doctors are taking a “can’t beat them, join them” approach by trying to direct their clients to reputable sites. For example, Wright recommends articles on the Stormont-Vail Health website, Mayo Clinic site and Medscape, adding, “I warn people way from information on blogs and online support groups that tends to not be a reliable.”

Hutchinson Clinic family medicine physician Kay Hart said, “We often try to redirect patients to valid sites, like the Mayo Clinic, or we print information from our EMR (Electronic Medical continued on page 36

Doctors at Stormont Vail-Cotton O’Neil use the internet as a way to open up dialog with patients about their health care options. Photos Submitted

Cardiologist Costy Mattar talks with a patient through Telemed. He can listen to heart sounds and share his thoughts to both he patient and a nurse at the other end of the computer connection.

January 2019

35

Rural Communities Face Critical Issues In Caring for Elderly Scarcity of services a major problem, official says

By Morgan Chilson Staff Writer

Doctors at the Hutchinson Clinic use the internet to facilitate informative dialog with patients.

Photos Submitted

Pros and Cons continued from page 35

Records). With today’s technology, we can also send well-researched and reliable information to our patients through our patient portal. For example, if a patient calls with complaints of back pain, we can immediately send information on back exercises they can try before they come in for their appointment.”

For Stormont Vail Health patients who are connected through My Chart, E-Visits are available. For such non-emergency conditions as colds, flu, diarrhea and skin rashes, this can be a way to get a doctor’s advice without going into the office. A patient fills out an online questionnaire, and a doctor will respond through MyChart within an hour if submitted between 8 a.m. and 7 p.m. weekdays, and 8 a.m. to 2 p.m. weekends and holidays. Cost is $45.

Linda Ditch is a freelance writer in Topeka. She can be reached at lindaaditch@gmail.com.

36 January 2019

Taking care of the elderly in rural Kansas communities is complicated by an already stressed environment challenged with a decreasing population and scarce resources.

Already stretched services are being pulled further to take care of people 65 years old and up who in 2012 made up nearly 14 percent of the country’s population.

That same population was responsible for 34 percent of health care-related spending in 2012, according to the Centers for Medicare and Medicaid. Personal health care spending per person for those 65 and older was $18,988 in 2012, which is more than five times higher than spending per child at $3,552 and about three times the spending per working-age person at $6,632.

Elder care isn’t just about addressing health issues, although those become more extensive as people age. Brock Slabach, spokesman for the National Rural Health Association, said considering the needs of elderly citizens is part and parcel of the work his organization supports in rural communities.

“We like to say that rural communities are older, poorer and sicker,” he said. “As you compare the average percentage of the elderly in rural areas against urban, we have a much higher percentage. One statistic I think that’s fascinating is every day, more than 10,000 Americans turn 65 years old, and one in four of those American seniors live in small towns or rural areas.”

An easy way to encapsulate the challenges meeting the needs and the challenges meeting those needs of the elderly in rural areas doesn’t exist.

Rachel Monger, vice president of government affairs for LeadingAge Kansas, an organization that represents nonprofit aging service providers statewide, understands those problems well. Sixty percent of LeadingAge’s members are in communities with populations below 4,000.

When asked if problems are at a critical stage, she was blunt.

“Frankly, unless we do something drastic very soon, yes it will be because it’s our rural parts of the state that are aging the most and the most rapidly,” Monger said.

“The staffing issues that we’re seeing, the closures that we’re seeing of nursing

homes, all of those issues are accelerating and will continue to.”

Some communities aren’t well-fortified to address needs, Monger said. Nearly all LeadingAge members provide long-term care along with other services, such as assisted living, home care, meals and transportation. One way to address scarcity of services is to diversify and provide many of them through one organization, she said.

Slabach said NHRA breaks concerns about care into several categories. One of those is social isolation.

“Statistics show this can afflict up to 43 percent of older adults,” he said. “This is also directly linked to obesity, and smoking, that often lead to heart disease, stroke, dementia and disability. Social isolation is one of those root causes, if you will, that can cascade into those other areas.”

A second area is infrastructure, which speaks to a wide array of issues, including hospitals, safe and affordable housing, transportation and broadband internet.

“The lack of these things can make it difficult to remain at home,” Slabach said.

“A lot of elderly want to age in place. They don’t want to leave their rural community.

They don’t want to have to move to Wichita or Topeka or Hutchinson.

“Deinstitutionalization has been a goal of many Medicaid and some Medicare programs now, which we understand in the long run may be cheaper than putting people in a nursing home,” he said.

The structure in place to care for seniors and others in a rural county is of critical importance to Lincoln County Hospital CEO Steve Granzow. Lincoln County, with a population of about 3,000 people, he said, faces the typical challenges of rural areas.

It does, however, have a good infrastructure with support for the elderly, including a Meals on Wheels component, a long-term care facility and transportation options, he said.

Granzow serves on a task force that includes others focused on health in the county, and the members have been working to identify needs and coordinate care.

Both long-term care and in-home support services are critical in Lincoln. The city’s leaders currently are working to support the long-term care facility in their town, including efforts to make management more local. An out-of-state owner currently

manages the facility, which is owned by the county. It’s a resource they don’t want to lose, he said.

“If we can’t care for them here, then they may have to put them in a home 30, 50, 60 miles away,” Slabach said. “They don’t have that old safety net that they had before because it makes it more difficult for family to visit on a regular basis.”

The concept of aging in place can be especially challenging in rural areas, Monger said.

“With the business model and reimbursement, it’s harder to do the home and community-based service part,” she said.

“People are so much more spread out. Staffing is a really big challenge.”

But on the other hand, the movement to provide services to let the elderly age in place is one of the bright spots Slabach sees in what’s happening, including incentivizing those changes through Medicare, a larger payer for aging services.

The next area of concern is health care and social services, of which that important in-home support is a large part, he said.

So is access to specialists, such as cardiologists and pulmonologists, which seniors need to treat typical aging health issues.

Included also is access to mental health care, Monger said, which is an extremely tough issue everywhere.

Slabach said the providing access to mental health care is one of the top two most challenging issues that rural communities face. The second is emergency medical services.

Nutrition services are the next “big bucket” the NRHA considers, he said.

“Rural seniors lack fresh access to food, and they have difficulty preparing those food items at home,” Slabach said. “Meals on Wheels is not available in many rural communities, as well.”

Kansas is not unique in the challenges seniors face in rural areas, Monger said.

Movement is being made to beef up telemedicine services, which can get access to remote areas and can include psychiatric services, along with physical health services.

But no one, she said, has found that silver bullet that offers answers for struggling rural communities.

Solutions, Slabach said, will come through collaborations and partnerships.

Brock Slabach, with the National Rural Health Association, says elder care in rural areas faces multiple concerns, including social isolation issues, infrastructure needs and health care.

January 2019

37

Kansas Universities Involved In Wide-Ranging Medical Research

Staffing for Elder Care at ‘Crisis Level’

Lyme disease, reproductive immunology among study topics

By Linda Ditch Special to GateHouse Kansas

Rachel Monger, vice president of government affairs at Leading Age Kansas, says most of the organization’s nonprofit members are concerned about critical workforce shortages in aging services.

By Morgan Chilson Staff Writer

“Everywhere we go anywhere in the state, when we talk to health care providers and aging service providers, the number one concern that’s keeping them up at night is staffing. 100 percent.”

Those words from Rachel Monger, vice president of government Affairs at LeadingAge Kansas, summarize the frustration felt across almost every industry in the state.

Monger’s organization represents nonprofit agencies providing aging services throughout the state, and 60 percent of those members are located in small, rural communities.

They can’t find enough staff to provide services to take care of the elderly or fill other health care needs.

“That’s the biggest thing when you’re talking about how many services you can provide and in what way,” Monger said.

“Staffing — it doesn’t matter where you are in the state of Kansas — in long-term care is at crisis level.”

Monger said other states face the same situation and much of the conversation on a national level is about proposing different

38 January 2019

models to address the staffing shortages.

“But it’s a big thing to get our arms around,” she said. “We have to keep trying, and we have to think further and further outside the box.”

LeadingAge has had a blue-ribbon commission for the last few years looking at ways to improve staffing and change things they have control over.

“We are working a lot on workplace culture, on retention and trying to get those turnover rates down, working with lawmakers and even educational institutions and state agencies about how we can open up that pipeline of workers more,” she said.

But the challenges are many. Pay is one.

“What you hear from a lot of our members is Amazon opens up or Walmart starts hiring and we can’t compete with those wages,” Monger said, adding that wages have risen to try to compete but there’s a limit they just can’t exceed.

“There’s a ceiling to what we can pay for nurse aides and nurses,” she said. “More than half of the elder people in nursing homes receive Medicaid. We have a big ceiling on our funding in terms of what we can pay for workers.”

Monger said there are no indications that Medicare and Medicaid, which are administered through the federal government, plan to adapt reimbursements to allow health care be more competitive in paying wages.

“A lot of this is going to be at the state level,” she said. “We know that it’s on their radar certainly.”

In 2017, the Kansas Department of Health and Environment put published the “Kansas Primary Care and Rural Health Professional Underserved Areas Report.” It broke down health care needs throughout the state, highlighting professional shortages in primary care, dental health and mental health.

The state has stepped up programs to address shortages, said Cynthia Snyder, KDHE director of special population health, primary care and rural health. There are a number of programs in place that help attract physicians to practice in rural areas.

The Kansas Bridging Plan, for example, offers loan forgiveness for primary care and psychiatry residents provided they practice for at least 36 months in underserved counties in the state. Each year the state funds up to 13 slots for primary care and three slots for psychiatry.

Eighty-five percent of the physicians continue practicing in Kansas once they complete their commitment, according to the KBP website.

Another option, Snyder said, is the J-1 Visa Waiver program, Snyder said. It helps to facilitate immigration for doctors by waiving the two years they would need to return to their home countries after completing their residencies provided they commit to practicing in designated locations where there are health professional shortages.

The program has brought many doctors to the state, Snyder said. The visas are administered by the U.S. State Department and each state gets 30 slots.

Monger said that on a national level, there is more and more discussion about the importance of foreign-born workers.

“These are the kinds of topics that we in health care, certainly long-term care, have never dipped our toes into, but the with the way things are going, we’re starting to get into bigger and bigger issues that are touching our field,” she said. “The biggest one is workforce and where are we going to have the people to take care of older folks across the nation, not just in rural areas.”

The cornerstone of any medical treatment is research. When you buy cold medicine over the counter, eat low-carb or antioxidant-rich foods, or walk for 30 minutes a day, there was more than likely a clinical study done at a university to support those actions. And possibly, that research was conducted here in Kansas.

Virginia Rider, chairwoman of Pittsburg State University’s biology department, said this is an exciting time in medicine, especially with research leading to new products, drugs and biomedical research promoting human health.

“Thanks to large-scale genome projects, we are able to understand global changes in how people respond to external signals, drugs and combat diseases,” she said.

Medical research covers a vast range of topics. Studies are conducted in the fields of pharmacology, biology, chemistry and toxicology, just to name a few. The goals are to create new medicines and procedures, or to improve ones already in existence, which will benefit human health.

The University of Kansas Medical Center has robust research programs in several areas, said Richard Barohn, vice chancellor for research, most notably in the areas of Alzheimer’s disease, cancer, cardiac, kidney and rare neurological diseases. Barohn pointed to the following: • KU Medical Center is home to the University of Kansas Cancer Center, which is one of only 70 National Cancer Institute-designated cancer centers nationwide.

• The University of Kansas Alzheimer’s Disease Center is one of only 31 National Institute on Aging-designated Alzheimer’s centers nationwide.

• A five-year, $25 million grant from the National Center for Advancing Translational Sciences of the National Institutes of Health that supports KU’s clinical and translational science institute, Frontiers, that works to accelerate research in all areas of the university and partner institutions.

Barohn said KU Medical Center is one of only 27 institutions that has all three of those national designations, each of which comes with significant federal funding.

Pittsburg State’s current research projects include the following: • Anuradha Ghosh, assistant professor of biology, has conducted a surveillance study for three years that investigates the distribution of three dominant tick species in southeast Kansas, particularly the non-native Ixodes spp, that carries the pathogen for Lyme disease, and uses a molecular technique to detect tick-borne bacterial pathogens. She also has research interests in food safety, antimicrobial resistance in the environment, pollutant detection and more.

• Assistant professor Kristi Frisbee and professor Barbara McClaskey, both in the Irene Ransom Bradley School of Nursing, are collecting data at Via Christi Hospital regarding neonatal opioid withdrawal syndrome. The second phase of their study will focus on intervention. Frisbee is collaborating with researchers in other states.

• Ram Gupta, associate professor of polymer chemistry, is working with students to research biobased polymers, biocompatible nanofibers for tissue regeneration, biodegradable metallic implants and green energy production and storage using conducting polymers, among other things.

Pittsburg State’s Rider, a leading scientist in the area of reproduc-

The University of Kansas School of Medicine is nationally known for cancer research. Professor Shrikant Anant is chairman of the cancer biology department. Photo Submitted tive immunology, is overseeing students researching implantation and immunology of pregnancy in hopes that understanding the process will help women who want to have children someday.

KU Medical Center’s Barohn said: “Our Alzheimer’s disease center is leading the nation with its clinical trials in exercise and diet. Right now, exercise is showing great promise in preventing cognitive decline from Alzheimer’s disease. We are expanding those trials in the next year as we continue to learn more about Alzheimer’s disease. At the KU Cancer Center, we are leading the nation in immunotherapy trials and cellular therapeutics such as Car

T, where a patient’s own cells are used to fight their cancer. We also are seeing new novel drug therapies being tested for neurological illnesses such as ALS and muscular dystrophy.”

Rider pointed out this area of the state is prime for researching the effects of coal mining on human health.

“There are important health issues open for exploration in a unique setting like southeast Kansas,” she said.

While Pittsburg State doesn’t receive money from pharmaceutical companies for research projects, KU Medical Center does, along with federal funding. The center is expanding its investigator-initiated

clinical trials and pharmaceutical-sponsored clinical trials.

Barohn and Rider said the amount of research being done at their respective universities is increasing, with Barohn adding: “We are seeing an expansion in the number of cutting-edge therapies being developed for many different diseases. In many fields, you see an excitement that maybe wasn’t as apparent a decade ago. We are very optimistic for the future of health care research, both in general and here at KU Medical Center.”

Linda Ditch is a freelance writer in Topeka. She can be reached at lindaditch@gmail.com.

January 2019

39

Native American Chef Teaches Cooking, Nutrition to Tribes Nationwide

Chef Jason Champagne

Family physician Dee Ann DeRoin is active throughout the American Indian community, working to tackle health disparities that affect her community. Thad Allton/Staff Photographer

Chef Jason Champagne, who bills himself as Jason the Native Chef, gives presentations throughout the country on cooking, health and nutrition in an effort to have an impact on American Indian communities.

By Morgan Chilson Staff Writer

Jason Champagne grew up dreaming of being the best chef in the world.

He built a solid foundation under those dreams, working in construction after graduating high school to save money. He attended Le Cordon Bleu College of Culinary Arts at Brown College in Minnesota and then went to work at Disney World as a chef.

But in the midst of using his talents to feed hundreds, even thousands, of people, Champagne lost his drive. And losing enthusiasm at a stressful job working 100 hours a week left him uncertain about his future.

40 January 2019

“I got to the point in my life where I’m cooking for volume — but am I really helping anyone?” said Champagne, who is originally from Baldwin.

One night, cooking a 2,000-person steak and lobster dinner, Champagne knew he’d lost sight of his original goals to cook and connect with people. He decided to return to school, attending the University of North Dakota and earning his master’s in public health nutrition.

As an American Indian and a member of the Red Lake Band of Chippewa, Champagne knew he wanted to work in a role that would let him be a role model in his community.

He formed a business, Jason The Native

Chef, that offers cooking, nutrition and food safety classes.

Champagne wants to be a mentor for youths and teach health, nutrition and how to cook good food in American Indian communities throughout the country.

“I want them to know my story. I want them to know that hey I worked construction five years out of high school because I had the lowest grades out of everybody,” he said. “People don’t realize that I did have a good family, but I didn’t excel in school because I thought I didn’t have it up here.” continued on page 41

Native American chef continued from page 40

(He pointed to his head.)

His success in working as a chef, then in attaining his master’s of public health degree will hopefully inspire youths to seek out their dreams, Champagne said.

And the cooking classes will help to improve health on reservations throughout the country.

Nutrition is an important topic for communities that grapple with poorer health outcomes than most other racial or ethnic groups. Data collected by the County Health Rankings and Roadmaps show a significant disparity in things like poor or fair health, poor mental health and premature death.

In the premature death stats, for instance, which show the years of potential life lost before age 75 as a rate per 100,000 in population, Kansas whites lost 6,700

years and Hispanics lose 5,000 years. But African-Americans lose 10,600 years and American Indians/Alaskan Natives lose 11,800 years.

HEALTH FOOD CHOICE The numbers are no surprise to family physician Dee Ann DeRoin, who is a member of the Iowa Tribe of Kansas and is active in working to better the health of American Indians. She is active in the the four tribes in Kansas, the Southern Plains Tribal Health Board and as part of the Association of American Indian Affairs.

Work like what Champagne is doing pleases DeRoin, who is intimately familiar with the havoc diabetes, heart disease and other health problems exacerbated by poor diet and lack of exercise wreak on native communities. It’s a big subject to tackle, she said.

“The first thing you do is you have to make healthier foods available,” DeRoin said. “You have to give people an opportunity to taste healthy food, prepared different ways because not everybody likes everything the same way. And you have to make it economical and you have to help them learn how to prepare it themselves, and how to introduce it to their reluctant families.” Many Indian reservations are challenged by food deserts, she said, or areas where residents don’t have nearby access to grocery stores.

“I think if you look at the four reservations, the closest grocery store to any one of them is five miles,” DeRoin said.

Working with the Association of American Indian Physicians a few years ago on a diabetes project, DeRoin explored the grocery store near the Kansas Kickapoo tribe.

“I went to that grocery store, and you could not get whole-grain bread, you could not get yogurt that did not have sugar or

corn syrup in it,” she said. “Even if there is a grocery store, because the communities are not demanding it they may not have the healthier choice on their shelves.” Through his work, Champagne knows that many people are unfamiliar with how to prepare vegetables and other healthy foods. In addition, many assume they won’t be tasty, especially if they don’t have salt, he said.

But making changes in diet can be life-changing, he added.

“In my mind, food is medicine,” Champagne said. “I am a perfect example. I was very unhealthy at one point in my life and lost like 50 pounds and got off all my medications for diabetes because I was eating fresh vegetables on a consistent basis. I was exercising, and I was drinking a lot of water, and I didn’t drink alcohol. I know this food cures.” continued on page 42

January 2019

41

Native American chef

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continued from page 41

In two years time, Champagne went from being on numerous medications to taking none.

In his presentations, he tends to focus on preparing vegetable dishes.

“I share how to cook it, how to present it, how to make it taste good, how to incorporate colors, incorporating art into food,” he said. “I stress it a lot that people eat with their eyes. If you can get a plate to look really nice — it doesn’t matter how it tastes — you have a person over 60 percent of the way that they’re going to like it.”

Plate presentation counts, and it’s something many people don’t consider.

“I’ve had so many people come up to me after my presentation and say: ‘Thank you.

I needed to see that. I did not know I could use fresh basil and fresh oregano like that. I didn’t know vegetables tasted so good without salt, with fresh lime juice or fresh lemon juice,’” Champagne said. “A lot of people leave my presentations able and confident that they’ve seen it done, that they can do it at home. And I show them that it’s cost effective as well.”Champagne laughed.

“Another thing I always tell people in my presentations is if your body could talk right now, if your digestive system could talk, it would say thank you,” he said. “It’s like an engine running low on oil. Your body needs those nutrients.

The more you give it to it, it’s just like medicine.”

FORCE OF ENERGY Champagne, who is quiet but passionate one-on-one, becomes a force of energy during his cooking presentations.

“It’s not just Jason’s personality and it’s not just the knowledge he imparts or the skill that he uses to impart it,” DeRoin said. “It’s the pride in

42 January 2019

having this Native man bring these skills to our community.

And he loves working with young people, children and adolescents.”

Working with Native American children ages 5 to 13 at Boys and Girls Clubs in the summer of 2018, Champagne said, was a joy. He had the children yelling out in unison, responding to questions like “What is a garnish?” and “Why do we want food to look good?”

“I think it’s very important to be an example. If I had my dream, I would see more Native American chefs who have a culinary and a public health or nutrition background doing these community demonstrations like I’m doing,” he said.

Although there is a push in American Indian communities to return to a more traditional way of preparing foods, Champagne said his presentations focus on making healthier choices with what is available, accessible and even how to be more healthy with the foods distributed as part of U.S. programs to support low-income families. Those foods, he said, are often high in carbohydrates.”Yeah, in a perfect world, we’d have venison running around and we’d have bison, and we’d be hunters and gatherers and we’d have plenty of berries and nuts to go gather,” he said. “I look at it practically, reality. How can we incorporate some of our native foods back into it, but more of looking at using contemporary dishes, incorporating partial traditional foods if possible, but focusing more on plate presentation and portion control.”

Portion control, for example, is “huge,” he said. Native American communities get a lot of pasta as part of the U.S. commodities programs. Champagne works to teach people how much is a healthy portion size of pasta and then how to expand that meal by adding

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zucchini, squash, fresh garlic and other vegetables.

Whenever Champagne talks about food or nutrition, his voice fills with energy and his enthusiasm is palpable. For someone who says he really doesn’t like public speaking, doing food presentations is almost an “out of body” experience, he said.

“I can be up there for 45 minutes to an hour and literally, I don’t remember much of the last because

I’m speaking from the heart. This other personality comes out that is energetic and enthusiastic, getting people making them laugh, telling stories as I cook, keeping them excited, keeping the whole atmosphere fun,” he said.

Although passionate about food, Champagne is a little concerned about running his own business.

He’s not a marketer at heart, and that quieter personality tends to assert itself. But he’s building a

reputation throughout the country and being invited to speak and present at more and more events.

He’s motivated to help people change their eating habits, and to have an impact on the American Indian communities. “I go to a lot of these conferences. People are up there saying we need to come together right now. We need to start doing this for our kids, and then the next year it’s the same thing.

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January 2019

43

VA Hospitals, Clinics In Eastern Kansas Provide Array of Services Primary care, surgery, physical therapy, suicide prevention among focuses

By Phil Anderson Staff Writer

Veterans across the eastern portion of Kansas have no shortage of locations to receive health care.

The VA Eastern Kansas Health Care System, with an annual budget of $330 million, provides care to about 40,500 veteran patients.

The organization’s 1,900 full-time employees serve at VA locations in Topeka, Leavenworth and Junction City, as well as eight other community clinics throughout eastern Kansas and western Missouri.

Joseph L. Burks, spokesman for the VA Eastern Kansas Health Care System, said the role of the VA is to “provide the best care anywhere by providing accessible, courteous, comprehensive, and quality health care to veterans in an environment of excellence.”

The VA’s vision, Burks said, can be summed up as follows: • Promote the health and wellness of the veteran population.

• Achieve distinction as a quality patient-driven health care system that provides the full range of medical, behavioral, rehabilitative and preventive services to veterans and others.

• Improve clinical care through research, education and creative administration to become a model for the future.

Burks added: “Our organization’s motto is ‘Honoring Our Veterans… Healing Our Heroes.’ We own it, and we take this very seriously.”

Burks said the VA Eastern Kansas Health Care System is a two-division Joint Commission-accredited health care system serving veterans throughout 20,000 square miles and 37 counties in eastern Kansas and northwestern Missouri.

In addition to the two main campuses in Topeka and Leavenworth, the VA Eastern Kansas Health Care System operates seven rural health clinics in Kansas in Chanute, Emporia, Fort Scott, Garnett, Junction City, Kansas City and Lawrence.

In Leavenworth, the Dwight D. Eisenhower Veterans Affairs Medical Center had its beginning in 1884, Burks said. By 1886, 17 buildings had been completed.

The Leavenworth VA hospital has about

44 January 2019

The Colmery-O’Neil VA Medical Center in Topeka once was known as the Winter VA hospital. Photo Submitted

VA hospitals continued from page 44

The VA Medical Center at Fort Leavenworth had its beginning in 1884. Photo Submitted 200 beds. At present, there are 12 medical beds in one unit under construction. After construction, there will be 17 total beds.

There is also a six-bed intensive care unit, a 22-bed Community Living Center and a 150bed domiciliary. The emergency department currently has seven beds but will expand after construction.

In Topeka, the Colmery-O’Neil VA Medical Center once was known as the Winter VA hospital. The Winter VA hospital, along with the Menninger Clinic, set up the largest psychiatric training center in the country after World War II. The Topeka VA hospital has about 160 beds.

The general medical-surgical unit has 17

beds; intensive care unit, four; acute psychiatry unit, 17; Stress Disorder Treatment Program, 22; Psychiatric Rehabilitation and Wellness Program, 17; Sunflower Memory Care unit for dementia patients, 12; and Geriatric Care unit, 15. The emergency department has eight beds, which will expand after construction. The Fresh Start unit will have 17 beds after it reopens later this year, and the Community Living Center will have 17 beds when it opens this summer.

Among early leaders of the Topeka VA Medical Center was Karl A. Menninger, who was the director of the facility from 1945 to 1948. The Topeka VA Medical Center also can claim another leader, Harry W. Colmery, who

is credited with writing the draft of what became the Serviceman’s Readjustment Act of 1944, more popularly known as the G.I. Bill of Rights.

On March 15, 1989, the Veterans Administration was elevated to cabinet status, becoming the Department of Veterans Affairs. Nine years later, Burks said, the Dwight D. Eisenhower VA Medical Center in Leavenworth and the Colmery-O’Neil VA Medical Center in Topeka were integrated, forming the VA Eastern Kansas Health Care System.

Burks said most of the organization’s patients come from northwest Missouri

and eastern Kansas, adding, “However, with several of our specialty units, we have referrals from around the country.”

An assessment of demographic trends for VA Eastern Kansas Health Care System finds that while the number of living veterans has been declining, the number of veterans using VA health care has increased substantially during the past two decades. This has resulted from expanded eligibility and higher reliance on VA health services by newer veterans.

Projections show demand will continue to increase, Burks said, before leveling off or even declining over the subsequent decade.

“The decline is the result of the passing of World War II veterans, the end of the wars in Iraq and Afghanistan, and the continuing decline in the size of the veteran population,” Burks said. “Changes in eligibility, newly diagnosed military diseases or another protracted military conflict will influence our future health care needs.”

He added: “Future demands project our nation’s veterans on average have elevated rates of many health conditions,

when compared to non-veterans. Veterans who rely on the VA for health care have higher rates of chronic conditions and mental illness than veterans who do not use the VA health system. All of these issues contribute to the veteran population for which we serve.

“To meet demands of the future, VA Eastern Kansas Health Care System will continue to substantially increase its capacity outside the two parent hospitals at Leavenworth and Topeka and into the communities. A mixed strategy will be needed that includes hiring more providers, granting VA advanced practice nurses full practice authority, expanding use of virtual care and making strategic use of purchased care.”

Burks said VA Eastern Kansas uses the Strategic Capital Improvement Planning and Integrated Master Planning process to identify current and future capital needs.

Said Burks, “Future demands indicate a significant expansion in the capabilities offered in the Manhattan area and several new services at the Topeka campus, including Positron Emission Tomography scan capability, consolidating and expanding ophthalmology-optometry services into an eye center, and growing the new community care program.”

At the Topeka campus, Burks said, “Future capital improvements include modernizing and expanding the Behavioral

Health Outpatient clinic, consolidating and expanding inpatient geriatric services, modifying surgical services and gastroenterology to better meet the patient’s need, and the construction of a new Day Treatment Center.”

At the Leavenworth campus, Burks said: “We will be strengthening the specialty care service capabilities to better meet the veteran’s needs. Projects include building and expanding a new Behavioral Health Outpatient Clinic, modernizing and expanding optometry and ophthalmology, and modernizing the entire operative and perioperative areas. A new pain clinic is currently in development that will include services such as yoga, tai chi, meditation, acupuncture, chiropractic, biofeedback, a guided imagery-mindfulness and pain school.”

Both medical center campuses will receive new, stateof-the-art emergency departments that will provide 24/7 access to care for veterans.

Burks said the VA also is making efforts to prevent suicide among veterans.

“Suicide prevention is the VA’s highest clinical priority,” Burks said, “and we at VA Eastern Kansas take this nationwide problem seriously and personally. One life lost to suicide is one too many.”

continued on page 45

January 2019

45

Syphilis, Chlamydia, Gonorrhea on Rise In Kansas

KDHE, county health departments focusing on treatment, education

By Jonna Lorenz Special to GateHouse Kansas

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The rate of sexually transmitted diseases has risen sharply nationwide, including in Kansas.

Health care providers have been working to combat a recent outbreak in Neosho County, where 15 cases of early syphilis were reported in 2017, compared with one the year before.

“The state of Kansas has been helping us,” said Teresa Starr, administrator of the Neosho County Health Department. “We have been tracking the people that are (affected), and most of them, unfortunately, also have some drug issues. What we’re trying to do is follow them and get them treated.”

KDHE’s Bureau of Disease Control and Prevention includes a Disease Intervention Program to reach out to every individual who has been diagnosed and identify all of his or her sex and needle partners.

Through Partner Services, the state then works to track down those people who also are at risk of infection and get them tested and treated. Skilled workers educate patients and health care providers about STDs and prevention.

“We’re able to intervene in the transmission process,” said Jennifer VandeVelde, director of the Bureau of Disease Control and Prevention.

Testing is key to stopping the spread of syphilis because many people don’t realize they are infected or, because the disease mimics many other diseases, they think they have something else. It often starts with a single painless lesion that goes away.

“The average person during their

infectious period will infect anywhere from three to 10 people,” VandeVelde said.

Along with syphilis, the state also has seen increases in chlamydia and gonorrhea. The state’s rate of STDs, which includes all three diseases, averaged 6.3 cases per 1,000 population in 2017, up from 4.7 in 2012, according to data from the KDHE reported by Kansas Health Matters. The rate ranges from 0 in Comanche County to 12.9 in Wyandotte County.

Nationwide, there were 1.7 million cases of chlamydia, 555,608 cases of gonorrhea and 30,644 cases of primary and secondary syphilis in 2017, up 22 percent, 67 percent and 76 percent since 2013 respectively, according to the Centers for Disease Control and Prevention.

The three predominant STDs — chlamydia, syphilis and gonorrhea — have very different risk factors, VandeVelde said.

Chlamydia, which mostly affects young people ages 15 to 24, is widespread throughout the state, with a total of 13,549 cases reported in 2017, appearing in all but two counties: Graham and Comanche.

Gonorrhea is concentrated in more densely populated areas and is associated with higher rates of drug use and multiple partners. A total of 4,545 cases of gonorrhea were reported in Kansas in 2017, with the highest incidence being in Sedgwick County (1,309), followed

by Wyandotte County (622), Shawnee County (596) and Johnson County (581).

Syphilis is episodic, with risk factors that vary depending on when and where the outbreak occurs, VandeVelde said. During the past 10 years, it has occurred predominantly among gay men, but in more recent years it has appeared

among heterosexual meth users.

The state saw 330 cases of early syphilis in 2017.

Gonorrhea is the STD that sees the most changes.

“It is able to mutate and create different hormones and enzymes that counteract the medicines, so it’s a very tricky little bug,” VandeVelde said.

Kansas hasn’t seen the antibiotic-resistant strains of gonorrhea that have troubled health care providers in other areas of North America. Gonorrhea has become resistant to all but one class of antibiotic, according to the CDC. “We are fully prepared to do resistance testing on gonorrhea cases if we see resistance in Kansas,” VandeVelde said.

It’s unclear why the rates of STDs are up, but the trends could reflect increased awareness, testing and treatment, VandeVelde said.

Most cases of chlamydia, gonorrhea and syphilis go undiagnosed and untreated, according to the Centers for Disease Control and Prevention. While the diseases are treatable with antibiotics, they can cause severe health effects, including infertility, ectopic pregnancies and stillbirth in infants, if untreated.

“We recommend that anyone that’s sexually active be tested annually for any STI,” said Hope Harmon, a registered nurse at Crawford County Health Department.

Testing is available at county health departments for low or no cost.

“We don’t turn anyone away,” Harmon said.

Those who test positive for an STD can receive treatment at the health department. Hepatitis C or HIV patients are referred to a Fed-

Teresa K. Starr, administrator of the Neosho County Health Department, said health care providers have been working to combat a recent outbreak in Neosho County, where 15 cases of early syphilis were reported in 2017, compared with one the year before. Photo Submitted

erally Qualified Health Center.

County health departments reach out to their communities in a variety of ways.

The Neosho County Health Department works to educate the public about STDs, sharing information through visits to the local college and posts on the department’s Facebook page.

Health department officials talk about abstinence and ways to

reduce the risk of STDs and the importance of using condoms, even for those who believe their relationship is monogamous.

“You may think you’re sleeping with one person, but that one person may have just slept with 20,” Starr said.

Jonna Lorenz is a freelance writer.

She can be reached at jonnalorenz@ gmail.com.

January 2019

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48 January 2019

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