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September 2011 • Volume 9 Number 8

Imaging services Cally Vinz

Medical decision-making Victor Montori, MD

Sleep medicine Jason Cornelius, MD

A philosophy of caring is good. A history of it is better. Caring. It would be nice if you could see it, like an amenity. Or tour it, like an apartment. But you can’t. All we can do is give you our definition: Caring is believing that everyone is someone who deserves to feel loved and valued, and be treated with dignity. That’s not just something we say. As the nation’s largest not-forprofit provider of senior care and services, it’s what we’ve been doing for almost 90 years.

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To learn more about our communities in Minnesota, call 1-888-GSS-CARE.

The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, sex, disability, familial status, national origin or other protected statuses according to federal, state and local laws. All faiths or beliefs are welcome. Copyright © 2010 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 10-G2016

CONTENTS

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SEPTEMBER 2011 • Volume 9 Number 8

12

NEWS

MINNESOTA HEALTH CARE ROUNDTABLE

By Francis X. Moga, MD

PEOPLE

PERSPECTIVE Shannon R. Bruce Horses Helping Humans

8

CARDIOLOGY Treating little hearts as they grow

10 QUESTIONS Jason Cornelius, MD Minneapolis Clinic of Neurology

14 16

BACK PAIN Spine-related pain

18 20

CALENDAR Suicide prevention

T H I R T Y- S I X T H

SESSION

By Daniel Hanson, MD

ARCHITECTURE Design with dignity By Alanna Carter, Assoc. AIA, LEED-AP

HEALTH CARE ROUNDTABLE The wellness revolution

Accountable Care Organizations Accountable to Whom? Thursday, October 13, 2011

10

RADIOLOGY Ensuring the right medical imaging By Cally Vinz

1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers

28 30

ORTHOPEDICS Ankle injuries By Sumner McAllister, MD

FEATURE Shrinking the health care footprint By Victor M. Montori, MD, MSc

Background and focus: Created as part of national health care reform, accountable care organizations (ACOs) are now part of every health care policy discussion. As defined by the 111th Congress, ACOs are organizations that include physicians, hospitals, and other health care organizations with the legal structure to receive and distribute payments to participating physicians and hospitals to provide care coordination, invest in infrastructure and redesign care processes, and reward high-quality and efficient services.

Exactly what this means is unclear, and a confusing array of levels and qualifications for ACOs has been proposed. With 2012 as a start date for Medicare reimbursement through ACOs, Congress is developing firm definitions at this time. Some say ACOs turn physicians into insurance companies; others say they are a way for physicians to take a leadership role in fixing a broken system. As health care organizations race to join, create, or redefine themselves as ACOs, they all face more questions than answers. Objectives: We will review the history, goals, and rationale behind the ACO model. We will review the latest federal guidelines defining what an ACO can be. We will discuss how the ACO will affect health insurance companies, employers, and the pharmaceutical industry. We will illustrate what must not be allowed to happen if the model is expected to succeed. We will examine who decides if ACOs are successful and how those decisions will be made. We will explore why so many people, representing very different perspectives on health care, are opposed to the idea and what can be done for it to achieve its best potential. Panelists include: N Michael Ainslie, MD, Pediatric Endocrinology, Park Nicollet Clinic

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com

N Dave Moen, MD, President, Fairview Physician Associates N Jennifer Sorensen, Executive Director, Minnesota Home Care Association N Vernon Weckwerth, PhD, University of Minnesota School of Public Health, Health Policy and Management

ASSOCIATE EDITOR Mary Scarbrough Hunt mshunt@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR Juline Birgersson jbirgersson@mppub.com ACCOUNT EXECUTIVE John Berg jberg@mppub.com

Please send me tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601. Name

ACCOUNT EXECUTIVE Sharon Brauer sbrauer@mppub.com

Company

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Address City, State, Zip

Advisory Board: Minnesota Medical Association (MMA), Minnesota Hospital Association (MHA), Minnesota Medical Group Management Association (MMGMA), Buyers Health Care Action Group (BHCAG), Minnesota Business Partnership (MBP), Minnesota Healthcare Network (MHN), Advocates for Marketplace Options for Mainstreet (AMOM), Minnesota HomeCare Association (MHCA), Minnesota Physician-Patient Alliance (MPPA), Physicians Service Network (PSN), Minnesota Center for Rural Health, and Minnesota Council of Health Plans. Minnesota Health Care News is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $36.00. Individual copies are $4.00.

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Please mail, call in or fax your registration by 10/06/2011

SEPTEMBER 2011 MINNESOTA HEALTH CARE NEWS

3

NEWS

Report Ranks States For Obesity Rates Minnesota ranks as the 32nd most obese state in the country, according to an annual report on obesity in the United States. “F as in Fat: How Obesity Threatens America’s Future 2010” was released by Trust for America’s Health (TFAH) and the Robert Wood Johnson Foundation. It found that adult obesity rates increased in 28 states last year, including Minnesota, with obesity rates dropping only in the District of Columbia. Officials say the obesity epidemic has troubling racial, regional, and income disparities. For example, 10 of the 11 states with the highest obesity rates were in the South, with Mississippi having the highest rates for all adults (33.8 percent) for the sixth year in a row. “Obesity is one of the biggest public health challenges the country has ever faced, and troubling disparities exist based on race, ethnicity, region, and income,” said Jeffrey Levi, PhD,

executive director of TFAH. “This report shows that the country has taken bold steps to address the obesity crisis in recent years, but the nation's response has yet to fully match the magnitude of the problem. Millions of Americans still face barriers—like the high cost of healthy foods and lack of access to safe places to be physically active—that make healthy choices challenging.” The report says Minnesota could do more to address the obesity epidemic by taking steps such as setting nutritional standards for school meals or for food sold in schools through vending machines. The state also lacks requirements for body mass index screenings of children and adolescents or other forms of weight-related assessments in schools.

HMOs Saw Record Profits in 2010 Despite a troubled economy and rising health care costs, HMOs in Minnesota saw their most prof-

itable year ever in 2010, a new report from health care research consultant Allan Baumgarten shows. The record profits were a result of strong margins on both government and private plans, the report says. In addition, health plan enrollment grew for the second consecutive year. The new report, part of the twice-yearly analysis on hospitals and health plans in Minnesota provided by Baumgarten, focuses on HMO plans in Minnesota, and finds that HMOs and county Medicaid plans in Minnesota had a net income of $264 million, or 3.6 percent of operating revenues of $7.3 billion. The report found a net income from operations of $194 million plus investment income of $69.8 million. Baumgarten notes that in the past 15 years, HMOs in Minnesota had posted a 3 percent margin only once. The data show the health insurance companies overall had strong results. Blue Cross and Blue Shield of Minnesota had a

net income after taxes of $100 million, and its Blue Plus plan had a profit margin of 6.9 percent in 2010. Medica Insurance company had a net income of $44 million. And HealthPartners’ health plans showed a 3.7 percent margin for 2010. As in past years, health plans showed good profits on state government plans, the report says. “In 2010, state public programs (Medical Assistance and MinnesotaCare are the largest) accounted for about 46 percent of revenues but 78 percent of health plan profits. Minnesota health plans improved their net income on Medicaid plans (not including investment income) from $119.5 million in 2009 to $170 million in 2010,” the report says. “On average, HMOs collected $77 more in premiums from the state per member per month than they paid out in medical expenses. Losses on MinnesotaCare offset part of that profit.”

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MINNESOTA HEALTH CARE NEWS SEPTEMBER 2011

The Minnesota Telephone Equipment Distribution Program can provide special telephone equipment at NO CHARGE to Minnesota residents of all ages!! The equipment includes amplified (corded and cordless) phones, speakerphones, captioned telephones, telephone ring signalers, deafblind equipment and other special equipment. To learn more about this program visit our Web site at: www.tedprogram.org or contact us at (800) 657-3663, (888) 206-6555 TTY. Eligibility requirements do apply. The Telephone Equipment Distribution Program is administered by the Department of Commerce Telecommunication Access Minnesota (TAM) and funded by a telephone surcharge.

Federal Program to Cover Pre-existing Conditions A new federal program to provide health insurance for people with pre-existing conditions recently lowered its premiums in Minnesota. The Pre-Existing Condition Insurance Plan (PCIP) was created as part of the Affordable Care Act (ACA) and was designed as a bridge for people with pre-existing conditions until broader health insurance coverage is available in 2014. At that time, under the ACA timeline, pre-existing conditions will no longer disqualify people from being eligible for insurance coverage. In Minnesota, premium rates for PCIP were recently lowered 38 percent, part of a nationwide move by the U.S. Department of Health and Human Services to attract more enrollees for the plan. HHS officials say Minnesotans enrolled in PCIP will have access to a provider network that includes 22,264 doctors, 1,120 pharmacies, and 129 hospitals throughout the state. Federal officials say PCIP provides access to health care coverage for many Americans who have been locked out of the current system. “With PCIP, you’ll be insured for a wide range of benefits, including primary and specialty physicians’ services, hospital care, and prescription drugs,” says Jackie Garner, the Consortium Administrator for Indiana at the Centers for Medicare & Medicaid Services. “You won’t be charged a higher premium because of your medical condition and your eligibility isn’t based on your income.” In Minnesota, the premiums for PCIP now range from $174 to $307 per month. Deductibles vary from $1,000 to $3,000, and a range of copays also apply for clinic visits and prescription drugs. Officials note the program does not have lifetime caps on what the plan will pay out for enrollees.

Since 1976, Minnesota has had a state program called the Minnesota Comprehensive Health Association (MCHA), which was also created to provide insurance for people who could not purchase it on the private market due to preexisting conditions. MCHA’s premiums vary widely based on what deductible is chosen, but in general range from $200 to $1,000 per month. The plan also requires some copays.

DHS Reports Rise In Abuse of Synthetic Drugs A new report on drug trends in the Twin Cities finds a rising level of abuse of synthetic drugs. The twice-yearly report tracks drug use in the metro area by using a range of sources. The report, issued by the Minnesota Department of Human Services (DHS), finds that synthetic drugs are sold online and in head shops as incense, bath salts, or “research” chemicals, but actually are designed and manufactured for human consumption. The drugs—which can be purchased legally—are sought for their psychoactive effects that mimic the effect of illegal party drugs, the report says. The DHS report says that use of synthetic drugs can produce increased heart rate, delusions, agitation, and extreme paranoia. Carol Falkowski, drug abuse strategy officer for DHS and author of the report, says that while it’s difficult to determine the actual rate of use of synthetic drugs, the numbers appear to be increasing. “These are no longer rare, isolated incidents. A pattern of use is emerging with synthetic drugs,” she said. “Young people are attracted to them because the effects are extreme and glamorized and they can be purchased online. Many young people think that if something is purchased on the Internet, it is somehow safe. Nothing could be further from the truth.”

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PEOPLE Blue Cross and Blue Shield of Minnesota has named Zachary Meyer as its vice president of wellness and prevention. Meyer previously was executive vice president and general manager at Ceridian Health and Productivity Solutions and has held positions at Mayo Clinic, CIGNA Behavioral Health, Allina Hospitals and Clinics, and North Memorial Medical Center. At Blue Cross, he will be responsible for leading community and business strategies for wellness and prevention. Therese Zink, MD, of Zumbrota, was recognized June 28 at the Minnesota Rural Health Conference in Duluth for her outstanding contributions to rural health care. Zink received the Minnesota Rural Health Hero award for promoting rural health in Minnesota and across the county. She is a member of the University of Minnesota faculty, a published author, and a family physician in Zumbrota. As a faculty member at the University of Minnesota Medical School, Zink teaches medical students in the Rural Physician Action Program. Zink also edited an anthology of stories, poems, and essays about rural health care today, which she shared with rural medical school programs across the U.S. In Zumbrota, she started a Violence Prevention Committee to raise awareness about family violence and better coordinate efforts among the police, community members, and mental health and health care providers; helped create a fund to help families in need of short-term assistance; and is partnering with a nonprofit to provide preventive care and fluoride washes to school-age children in the local school system. The Minnesota Academy of Family Physicians (MAFP) has selected Anthony Lussenhop, MD, of Alexandria, as its 2011 Family Physician of the Year. The award is presented annually to a family physician who represents the highest ideals

Anthony Lussenhop, MD

of the specialty of family medicine, including caring, comprehensive medical service, community involvement, and service as a role model. Lussenhop has practiced at the Alexandria Clinic for almost 15 years and also serves as the clinic’s medical director. He attended medical school at the University of Minnesota and did his residency at the Duluth Family Medicine Residency Program. The award was presented to Lussenhop during the MAFP All-Member Celebration in April. MAPF awards were also presented to Jeremy Springer, MD, U of M/Methodist Family Medicine Residency Program (Teacher of the Year); Kolawole Okuyemi, MD, MPH (Researcher of the Year); Sara Oberhelman, MD, Mayo Family Medicine Residency Program (Resident of the Year); Lindsey Chmielewski (Medical Student Award for Contributions to Family Medicine); and Jeff Schiff, MD, MBA, medical director/Health Care Programs, Minnesota Department of Human Services (President’s Award). Gov. Mark Dayton appointed the following area residents to state boards, commissions, and councils effective June 30. Nancy Diener of Duluth was appointed to the Commission of Deaf, Deaf Blind, and Hard of Hearing. Chandra Mehrotra of Duluth and Nancy Tuders of Grand Rapids were appointed to the Board of Examiners for Nursing Home Administrators. LaTina Else Siers and Chris Henley, both of Duluth, were appointed to the Board of Psychology. Amy Behning of Duluth and Marmie Jotter of Hibbing were appointed to the State Advisory Council on Mental Health.

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MINNESOTA HEALTH CARE NEWS SEPTEMBER 2011

PERSPECTIVE

Horses Helping Humans Equine-assisted therapy

A

unique form of therapy called equineassisted psychotherapy (EAP) is being used more and more by psychotherapists to help victims of domestic violence, as well as those suffering from post-traumatic stress disorder (PTSD), eating disorders, attachment disorder and other behavioral issues, substance abuse, anxiety, depression, and even autism. Similarly, equine-assisted learning (EAL) has been used in non-therapy environments, such as leadership courses. In both EAP and EAL, the focus is on the client learning through experience.

model from other models is that it is experiential: Clients are allowed to discover connections themselves about their relationships. No external voice or force will tell the client what to do; she must rely on herself. In the process, the client learns how empowering this feels. Participants frequently have profound insights into problems because the human-horse interaction helps the client “mentalize,” i.e., mentally and verbally reach conclusions about one’s own thinking and behavior. This provides a sense of ownership and responsibility for one’s own actions and choices, defeating the feeling of powerlessness.

Equine-assisted intervention is gaining respect from mental health practitioners worldwide “Horses Helping Humans” in Minnesota because they can measure the effectiveness in Here in Minnesota, the nonprofit organization clinical outcomes and because the model provides Southern Valley Alliance for Battered Women a quick way to assess a client through observing (SVABW) sponsors and refers clients to a Twin his or her interaction with the horse. Numerous Cities organization called “Horses Helping articles have been written in professional journals Humans“ (HHH), founded in 2009 and one of sevabout horses being used to help individuals over- eral EAGALA-certified programs in Minnesota. come fear, guilt, anger, and feelings of inferiority, Abuse victims can receive up to four half-days of helping them to learn self-confidence, self- therapy cost-free, made possible through SVABW reliance, and assertiveness. EAP and EAL have sponsorship, private donabeen used to help extions, and professionals soldiers with PTSD learn donating their services. The Equine-assisted resiliency skills; to help trauHHH program consists of intervention is gaining ma survivors, at-risk youth, ground exercises in the addicts, criminal offenders, respect from mental health horse arena as well as classfamilies, and couples, and es where clients learn to practitioners worldwide. even to teach leadership recognize “red flags” in skills to corporate groups. relationships, how to tell if a The nonprofit organization called the Equine Assisted Growth & Learning Association (EAGALA) provides EAP/EAL training and certification programs for mental health professionals and equine specialists in the U.S. Certification must be renewed every two years. EAGALA is affiliated with many professional mental health organizations in the U.S., including the American Psychological Association. How it works Horses make ideal therapy partners for several reasons: because of their size and strength, because they are prey animals, and because flight is their instinctual response to danger. Horses are acutely aware, perceptive, and sensitive to body language and non-verbal communication cues; they respond very accurately to the internal emotional states of those around them. Participants never actually mount a horse; riding is not the therapeutic element or the goal. Rather, participants interact on the ground while accomplishing tasks such as taking the horse through an obstacle course, playing a game, or solving a puzzle. Accomplishing individual tasks is not the goal, however; what is important is the experience during the process. What distinguishes the EAGALA

person is trustworthy, how to develop confidence, become assertive, and how to use “narrative therapy” to help their children overcome past trauma. Learning is done in groups of eight, one group per week. Sessions last for four hours twice weekly for two weeks. Often by the time survivors reach HHH, they have spent years living with an abuser and have learned to become ”invisible” in order to avoid abuse. While interacting with a horse, clients learn to rely solely on themselves, discovering hidden strengths—often for the first time in their lives. One woman recently shared tearfully that the act of merely placing a halter around the horse’s head gave her a glimpse of how confidence feels. Another client, while using an unsuccessful strategy to accomplish a task with the horse, was reminded of how often she had tried an ineffective coping mechanism to avoid abuse, only to face the abuse again and again.

Shannon R. Bruce Horses Helping Humans

Shannon R. Bruce is the founder of Horses Helping Humans, an equine-assisted learning program for domestic violence survivors. She also developed a 16-hour, equineassisted pilot therapy program at the University of Minnesota Equine Center in St. Paul. Bruce is a domestic violence specialist, a former support group facilitator for SVABW, and a former crisis line counselor for the Domestic Abuse Project in Minneapolis.

Through the unique process known as equineassisted therapy, domestic violence survivors and others learn to confidently face and overcome challenges, manage anger and other emotions, and trust their instincts as they interact in the world.

SEPTEMBER 2011 MINNESOTA HEALTH CARE NEWS

7

10 QUESTIONS

& Jason Cornelius, MD Dr. Cornelius is a board-certified neurologist and sleep specialist practicing with the Minneapolis Clinic of Neurology at their Golden Valley and Maple Grove locations. He is also associate medical director of the North Memorial Sleep Health Centers in Robbinsdale and Maple Grove. What is “sleep medicine”? Sleep medicine is a specialty dedicated to the diagnosis and management of sleep disorders, which affect more than 70 million people in the U.S. There are more than 80 different conditions recognized by the International Classification of Sleep Disorders. We have become increasingly aware of the important consequences that sleep disturbance has on quality of life and overall health. What special training is required to become a sleep medicine doctor? The practice of sleep medicine is multidisciplinary, so its specialists come from a variety of medical training/degree backgrounds including neurology, pulmonology, psychiatry, pediatrics, and otolaryngology. In order to be recognized by the American Board of Sleep Medicine, providers must pass a certification exam in addition to either satisfying practice experience requirements or completing a 12-month fellowship program. What are some common reasons to see a sleep medicine doctor? The most common complaints are difficulty falling asleep or staying asleep, feeling excessively sleepy during the day, and trouble maintaining a regular sleep/wake cycle (usually due to shift work). The underlying problem can range from mild to life-threatening. People become concerned when they experience poor memory/concentration, low motivation, irritability, and/or inappropriate dozing—particularly drowsiness when driving. Patients or their bed partners may also recognize characteristic features of disorders like obstructive sleep apnea, restless legs syndrome, and narcolepsy. What causes obstructive sleep apnea? What are the signs and symptoms? Obstructive sleep apnea (OSA) is caused by a collapse or a narrowing of the upper airway. Normal physiologic changes that take place during sleep can promote OSA in patients with susceptible anatomic features like a large tongue base or extra fatty tissue around the neck. Snoring and pauses in breathing during sleep are clues that the upper airway is narrowed. OSA often leads to daytime sleepiness because sleep at night is fragmented when the brain is woken due to upper airway narrowing. OSA also contributes to a number of serious health problems like high blood pressure, diabetes, heart attack, and stroke.

Photo credit: Bruce Silcox

Are there any new advances in the treatment of obstructive sleep apnea? Continuous positive airway pressure (CPAP) remains the first-line therapy for OSA. Unfortunately, a significant percentage of patients become noncompliant with CPAP. A promising alternative is an upper airway stimulation device. It is implanted like a pacemaker and stimulates a nerve activating muscles that move the tongue forward to prevent collapse of the upper airway during sleep. The patient can activate the device at bedtime using a handheld programmer. The North Memorial Sleep Health Centers in Robbinsdale and in Maple Grove are participating in a study to prove that the device is safe and effective. What kind of metrics and devices are typically used in an overnight sleep study? An overnight sleep study, or “polysomnogram,” involves sleeping overnight in a

8

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2011

Good sleep hygiene means doing everything one can to ensure a proper night’s rest. laboratory designed like a hotel room. Small electrodes are attached to your head, face, and legs to record brain waves, eye movements, and muscle activity. Flexible bands are placed around your chest and abdomen to measure breathing. A technician places a clip on your finger to detect blood oxygen levels, activates video recording and a microphone to record snoring, then places a sensor under your nose to measure air flow/pressure. Most people are comfortable with the equipment. Your sleep is monitored remotely from another room. What should people know about over-the-counter (OTC) and prescription sleep medications? Your health care provider may recommend OTC or prescription sleep aids after careful consideration of such things as your age, current medications, and other medical conditions. You should review potential side effects and start treatment in a familiar setting until you know how you will respond. Prescription sleep aids are typically used for one to two weeks while the patient makes sleep habit and behavior changes. They are usually not recommended for long-term use, except under the direction of a sleep specialist. What can you tell us about insomnia? “Insomnia” refers to the inability to fall asleep or stay asleep despite adequate sleeping conditions, resulting in impaired daytime function. Ten to 30 percent of the general population experience some form of insomnia. Stress, depression, anxiety, too much caffeine, smoking, chronic pain, undiagnosed sleep disorders, or poor sleep habits can all contribute.

Insomnia is usually temporary but can develop into a chronic disorder. Although medication can be useful for short-term management, sleep specialists will focus on detailed sleep hygiene and behavior modifications. What is restless legs syndrome (RLS)? RLS involves a strong urge to move the legs (or arms), predominantly in the evening hours during periods of inactivity. Moving or stretching reduce symptoms, but RLS can still impact one’s ability to fall or stay asleep. The condition can be worse in pregnancy or iron-deficiency. Some patients also have jerking of their limbs while sleeping. This condition is known as Periodic Limb Movement Disorder (PLMD). Regular exercise and avoiding stimulants like caffeine or nicotine can help reduce RLS or PLMD symptoms, but medication may still be required. What should people do to maintain proper sleep hygiene? Allow sufficient time in your schedule for sleep—most people need 7 to 8 hours. Think about how your daily activities affect sleep: Limit caffeine intake after noon; don’t smoke close to bedtime; avoid alcohol or heavy meals several hours before bed; and get regular exercise. Establish a routine that includes an hour of quiet relaxation before going to bed. Your bedroom should be dark, quiet, and kept at a cool temperature. Use the bedroom only for sleep (and sex)—not studying, paying bills, using a computer, or discussing problems. Finally, try to get up at the same time each morning, and avoid napping.

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RADIOLOGY

P

atients with medical questions rely on physicians to suggest the best course of action. In some cases, it is appropriate to use high-technology diagnostic imaging (HTDI) procedures such as magnetic resonance imaging (MRI), computer tomography (CT), positron emission tomography (PET), and nuclear cardiology tests. However, while incredible technological advances in HTDI are helping to ensure more accurate diagnoses, the steep increase in the number of tests ordered has not corresponded proportionately to improved patient outcomes. Potential overuse of such tests can expose patients to unnecessary radiation, delay diagnosis, and contribute to rising health care costs. Through a collaboration of medical groups, health plans, and the Minnesota Department of Human Services, the Institute for Clinical Systems Improvement (ICSI)—a nonprofit, independent organization in Minnesota—developed a patient-oriented, cost-effective approach to ordering HTDI scans that enables patients and physicians to discuss medical imaging options based on evidence and consistent standards of practice. Before developing this “decision-support” model, ICSI coordinated a three-year study in which 4,500 providers in five Minnesota medical groups ordered more than one million HTDI scans. Providers included Allina Medical Clinic, Essentia Health, Fairview Health Services, HealthPartners Medical Group, and Park Nicollet Health Services. The study showed that using an evidence-based, decision-support option increased the likelihood of appropriate imaging, improved the diagnostic quality of scans ordered, and ensured that patients got the right test in a timely manner. In November 2010, ICSI made this tool available to all medical groups and hospital-based clinics in Minnesota—the first time a common set of criteria has been adopted by many medical groups on a statewide level.

Ensuring the right medical imaging Improving access to care By Cally Vinz

Strengthening the provider/patient relationship

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MINNESOTA HEALTH CARE NEWS SEPTEMBER 2011

Prior to implementation of this new option, if a patient complained of a nagging headache, the physician might have thought an MRI was warranted. Before the test could be ordered, however, the physician would need to contact a radiology benefits management (RBM) firm to determine if the scan would be covered by the patient’s insurance plan. The call might take only a few minutes, but approval could sometimes take a day, and if coverage was denied, the physician would need to determine if there was an alternate diagnostic test. With the ICSI solution, the physician enters a patient’s symptoms into the decision-support software, along with the scan selected. The decision-support tool then rates the diagnostic value of the imaging scan selected. Scores of 7, 8, and 9 are shown in green, indicating scan types that are highly warranted for the condition. Moderate ratings of 4, 5, and 6 are shown in yellow, while low scores of 1, 2, and 3 are shown in red, signifying that a test may not be indicated for the symptoms. When this happens, the software suggests better options based on criteria from the American College of Radiology. Now when a patient complains of a persistent headache, patient and physician can see together what is most appropriate and share in the decision-making. Because many Minnesota health plans accept the decision support tool’s criteria for selecting appropriate scans, most physicians do not need prior approval from an RBM firm.

Helping physicians help the patient

With this tool, we are more likely to get the right test done the first time.�

Physicians already using decision support say it’s reassuring to know Providing value that other health care providers “We don’t want to perform the developed the criteria used in the wrong test,� Truwit said. “Some software. physicians might order a CT withAllina Medical Clinic District out contrast solution to evaluate for Director Phil Hoversten, MD, said, metastatic disease. Unless a patient This example shows that a chest CT would provide marginal “Quality is defined by a whole has large metastatic lesions, we are value for the patient. Based on evidence, the decision-support group of constituents, not by inditool is recommending an MR. not going to see them on the regular vidual doctors or clinics. The CT scan or characterize them well. amount of information in the comThe decision-support tool has algorithms that have looked at posiputer makes using the decision-support tool far superior to calling tive and negative exams given the history of the patient. We try not an RBM. Plus, the tool’s simple drop-down menu and immediate to do a study that isn’t going to have a high likelihood of a yield.� response are very convenient.� Since November 2010, this has become a statewide initiative, “Physicians are committed to using the latest scientific knowlthe objective being to standardize HTDI ordering and base it on eviedge to make good decisions,� said Kevin Larsen, MD, chief meddence. This is the first time a common set of criteria have been ical informatics officer and associate medical director at Hennepin adopted by many medical groups statewide. County Medical Center (HCMC). “This tool supports physicians in “Patients are very sophisticated now,� said Truwit. “In this electhat effort. Physicians cannot always keep up with all of the changes tronic era, they know an awful lot about their conditions. This tool in today’s medical environment,� said Larsen. “If we see a medical enables us to engage them in their care in a new way. It’s better for situation we don’t encounter often, this is a way to bring us up-tothem, better for physicians, and better for the health system. It has date, patient-specific information with the latest evidence telling us no downside.� what the right test might be.� “The average length of time for a new technique or business Cally Vinz is vice president of clinical products and strategic initiatives at practice to become established is about seven years,� said Ross ICSI, headquartered in Bloomington, Minn. Chambers, MD, of Fairview Medical Group in Milaca, Minn. “For years, a doctor may have ordered an MRI for headache, but if something were to change in the field of neurology, it might take seven years for that doctor to change. We now can educate providers at the time they order a test. This can impact practices very quickly.� “We have integrated the RadPort software (part of the decisionmaking tool) in our electronic health record,� said Chip Truwit, MD, chief of radiology at HCMC. “This is not a trivial matter. It lessens both patient frustration and physician time to have everything coordinated.� Health care *V organizations can also access the II +YM HI % Z EM decision-support criteria via the Web, P EFP I making this option available to all types of clinics. ;I  LE Z I  FI I R M R FYW M RI W W  E P QSW X   ] I E V W  E RH O RS[ X LI  HM J J M G YP X M I W  Avoiding unnecessary radiation X LE X  G SQI  [M X L LI E V M RK  P SW W   (S[RP SE H SYV  J V I I  +YM HI  X S ,I E V M RK  4V SHYG X W  X S P I E V R X LI  FE W M G W  ] SY RI I H X S O RS[  3V   K M Z I  YW  E  G E P P  Physicians are also concerned about E R H  [ I  [ M P P  L I P T  J M R H  X L I  T I V J I G X  W S P Y X M S R  J S V  ] S Y V  R I I H W  exposing a patient to unnecessary radiation if a CT scan is inappropriately ordered. In a majority of cases, the diagnostic potential of a CT scan outweighs the risk, but a 2007 New England Journal of Medicine article reported that exposure to too much radiation, especially in children, is estimated to contribute to 1.5 percent to 2 percent of cancer deaths in the United States each year. (S[RP SEH KYM HI  [[[ LE V V M W G SQQ G SQ J V I I K YM HI “Radiation exposure concerns us greatly as radiologists,� said SV  'EP P  YW  

    Truwit. “We want to make sure patients are not exposed needlessly.

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Radiation exposure concerns us greatly as radiologists.

SEPTEMBER 2011 MINNESOTA HEALTH CARE NEWS

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CARDIOLOGY ith up to 500 operations per year, Children’s Hospitals and Clinics of Minnesota performs the most pediatric cardiac procedures in Minnesota. Alongside these surgeries, Children’s also conducts a growing number of adult surgical procedures. Adults who were born with heart defects and were operated on as children require lifelong care for their condition—by doctors specially suited for their oncetiny hearts.

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Treating little hearts as they grow

medical practices and techniques have advanced so that even infants with major heart defects are living longer and healthier lives. As a result, we regularly see patients well into their 20s and beyond.

Early successes One example of the long-term relationships we now have with our heart patients is the story of Nick Zerwas. Nick was born with a condition called tricuspid atresia; his heart had three chambers instead of four and he needed surgery

Background The idea of performing heart surgeries on adults at a children’s hospital may seem odd, but at Children’s Hospitals and Clinics of Minnesota, it’s becoming more and more common. This phenomenon is partly due to the success we have had in treating major heart issues in children. Twenty or 30 years ago, many children with heart defects didn’t live long. But today,

Pediatric cardiac care continues into adulthood Francis X. Moga, MD

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MINNESOTA HEALTH CARE NEWS SEPTEMBER 2011

days after he was born. This was in 1980, well before most heart defects could be detected in utero, so his parents had taken him home from the hospital before they realized anything was wrong. When Nick started turning blue, he was rushed to Children’s, where he was diagnosed and operated on. Nick endured nine more openheart surgeries. When he was first diagnosed, he was not expected to live past his seventh birthday. Today, Nick is 30, married, and still receives care from our cardiovascular staff. This trend of treating adult patients in pediatric facilities is no longer a surprise to those in the medical community. According to the journal Circulation, the number of adults in the U.S. with congenital heart defects is estimated at upward of 1 million—meaning that there are nearly 1 million people with heart defects who will continue to need specialized care. Amy Wynia is another example. Now in her late 30s, married, with two children, Amy has endured heart surgery three times: once immediately after her birth in 1973, and again at ages 5 and 15. The last two surgeries took place at Children’s. She was born with tetralogy of Fallot, sometime called “blue baby” syndrome, a defect that is a combination of four heart abnormalities and results in a lack of oxygen in the blood. Her first surgery took place when she was less than 24 hours old. The cardiac surgeon created a connection between the aorta and the artery to the lung, providing more blood flow and thus improving her color. Amy’s physicians knew she would need more surgeries later on. As she grew, so too would the strain on her heart. By the time she was five, Amy’s heart needed a more complete repair. Surgeons closed the hole between the two lower chambers of

her heart, removed the additional muscle tissue obstructing blood flow to her lungs, opened the pulmonary valve, and closed the surgical connection of the lung artery and aorta created when Amy was a newborn. By age 15, Amy’s heart had again outgrown its previous repairs, so surgeons placed a valve to stop the backflow of blood from her lungs. As she grew, we followed her closely, especially during her two pregnancies, and helped her make the transition from her teenage years into motherhood. Amy continues to see us for regular check-ups.

Pediatric specialists for adult hearts

of our cardiologists and surgeons consult with older patients and their care teams in adult facilities.

Improving treatment When it comes to treating heart defects and the many surgeries they require, numbers matter. At Children’s, we’ve performed more than 11,000 pediatric heart surgeries since our program’s inception in 1973; we are the largest provider of pediatric cardiovascular services in the region. In April 2010, we opened a new cardiovascular center at our Minneapolis hospital, which features a state-of-the-art operating room and around-the-clock access to cardiac specialists. The new facilities are helping us improve treatment of children and adults with heart defects, helping them live fuller, richer lives well into their 30s, 40s, and beyond.

We regularly see patients well into their 20s and beyond.

When a child is diagnosed with a congenital heart defect, it is a bitter pill for a family to swallow. Thankfully, the outcomes for that child’s survival and the chance of living a full life are much greater today than they were decades ago. Today, more than 95 percent of congenital heart defects can be detected in utero, most commonly at 18–20 weeks of gestation. This early diagnosis vastly improves a child’s chances of survival. One of the great success stories in the last few decades is the surgical repair of hypoplastic left heart syndrome (HLHS). HLHS is a complex and rare heart condition in which the chambers and arteries on the left side of the heart are small and underdeveloped, with valves that don’t work properly. Prior to the mid-1980s, HLHS was a fatal diagnosis, but in 1985, surgeons at Children’s became the first in the Upper Midwest to perform the three-part surgery required to treat HLHS. Today, Children’s is a leader in HLHS treatment, with one of the highest success rates in the country. Patients like Eric Carlson are alive today because of these livesaving procedures. Eric was diagnosed with HLHS while still in the womb. Six days after he was born, we performed the first of three surgeries he would need to repair his heart. The national survival rate following the first stage of surgery is approximately 82 percent, but the survival rate at Children’s over the past three years has been nearly 100 percent. Before his third birthday, Eric had two more operations that were required to completely repair his heart. He is now an active second-grader who enjoys riding his bike and playing with his two older brothers. Eric, and others like him, will still need to see a specialist throughout his life, but because of the HLHS procedure and everimproving outcomes, children who would otherwise not survive are living well into their adult years. The doctors best suited to treat their hearts are the ones who have been treating them since the beginning. This trend of intermingling child and adult cardiac specialties has led many pediatric cardiac surgeons to seek extra training in adult care, and adult cardiac surgeons to seek extra training in pediatrics. This training is steadily becoming standard, and many

Francis X. Moga, MD, is a pediatric cardiothoracic surgeon at Children's Hospitals and Clinics of Minnesota, located in Minneapolis.

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B A C K PA I N

T

Spinerelated pain Causes and treatment options By Daniel Hanson, MD

alking about spine-related pain can seem confusing due to the variety of symptoms involved and because of other, pre-existing conditions. There are also a number of care options the patient may take: conservative (exercise or physical therapy), interventional (e.g., injections), and surgical—all of which have a place in treating spine-related pain. Spine care professionals have long emphasized the need for an individual to develop strong “core” muscles around the spine and pelvis in order to improve spine health. Some popular exercise activities such as Pilates, yoga, and kettle bells focus on strengthening and stretching the muscles and ligaments around the core. Only 20 to 30 minutes a day is enough time for a full set of exercises and enough time to strengthen the spine. Developing an exercise program that can be adhered to and practiced four

or five times per week is probably the most important thing a person can do to maintain a healthy back. Other areas of spine health include good nutrition, adequate fluid intake, and enough rest. Many websites feature core-stabilizing exercises that are helpful, but getting expert advice and attention from a trained health care professional—a physical therapist, athletic trainer, or chiropractor, for example—is often very helpful when beginning a core-strengthening program. Causes of spine injuries We can injure our spines in many ways. Often the process of aging itself brings arthritis, which is caused by the disks in the spine (the cushions between the vertebrae) becoming dehydrated. This makes them more susceptible to degenerative conditions that can cause pain. So it’s important to drink enough water each day. Pain can be localized to the back and neck but can also cause “referred” pain, pain that radiates into the arms or legs.

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MINNESOTA HEALTH CARE NEWS SEPTEMBER 2011

The most common cause of back and neck pain is muscle strain. This happens when a person lifts something improperly and does not have a sufficiently strong core. Pain caused by muscle strain is routinely treated with a brief period of rest and over-thecounter anti-inflammatory medicine. Occasionally, stronger pain medications are needed, such as muscle relaxants. Pain radiating into the arm or leg is more concerning. It is often due to nerve compression, which is often associated with an area of numbness or muscle weakness. When this occurs, seeing your primary care physician or spine specialist is often recommended. Many nonsurgical options still exist, but an MRI or CT myelogram (an MRI or CT using contrast dye) is needed eventually to diagnose the source of the nerve compression and to focus nonsurgical treatment on that nerve or area. Types of back pain Some of the most common causes of back pain in children are scoliosis (curvature of the spine) and pars fractures—also known as spondylolysis— commonly due to sports-related injuries. (Spondylolysis means that stress on the fifth lumbar vertebra has fractured it, weakening the spine so that it cannot maintain its proper position and starts to shift out of place.) In adults, the most common cause of back pain is disk herniation in the lower back and neck. The disk is a flat, round structure that separates the vertebrae in the spine. In disk herniation, the disk’s central portion “herniates,” or slips into the spinal canal, putting pressure on a nerve root which then causes pain. As we age, additional problems such as spinal stenosis (arthritic bone spurs that narrow the spinal canal) can become more common. This can often prevent an older person from standing or walking for a long periods.

three types of injections, transforaminal—or selective nerve root— injections allow the steroid to be concentrated in the area of nerve compression. They are also performed to confirm or diagnose the source of painful symptoms. Confirmation of the source of pain leads to significantly better surgical results. Other types of injections to treat back and neck pain include facet injections and medial branch blocks. The term “facet” refers to the facet joint, the small stabilizing joint between each vertebra. The nerves in the facet joint are called “medial branches”; “block” means to numb the pain. If the pain is at the facet or medial branch, a procedure called a medial branch rhizotomy (deadening the nerve in a facet) can be performed, which will provide two to 18 months of pain relief. When nonsurgical treatments fail, then surgery may be recommended. The physician will determine the scope of treatment options based on the patient’s diagnosis and diagnostic imaging to determine the source of compression or degenerative changes. Technological advances are being made all the time, resulting in improved surgical outcomes. Examples include minimally invasive approaches and motion preservation technologies such as cervical and lumbar disk replacements. Sometimes a spinal fusion is recommended. The combination of conservative care (adapting a healthy lifestyle), diagnostic/therapeutic interventional therapies, and surgery provide most patients with a successful outcome in managing their back, arm, and leg pain. Daniel Hanson, MD, is a board-certified spine surgeon with Midwest Spine Institute and a member of the American Academy of Orthopedic Surgeons and the Norwegian American Orthopedic Society. He is also medical director of orthopedics at Unity Hospital in Fridley.

Spine-related pain treatment options While various minimally invasive surgical treatments are available, there are more conservative, nonsurgical measures that can be tried first, such as bracing, core-strengthening exercises, and/or injections. The most important thing one can do to prevent back pain is to develop a weekly exercise routine. Another helpful intervention involves a diagnostic and/or therapeutic injection in the spine. Epidural steroid injections are commonly used to treat cervical and lumbar-mediated arm and leg pain. In either of these conditions, a nerve in the neck or lower back is compressed. Common causes of nerve compression are disk herniation, spinal stenosis (arthritic bone spurs), balance instability, and narrowing of the nerve foramen. The foramen is a natural opening or cavity in a human body, usually one through which blood vessels and nerves pass through bone. In addition, inflammatory reactions can occur around the nerve. Many studies have been performed that show the therapeutic benefit of injections. Steroid drugs help because they stop inflammation, breaking the cycle of pain and contributing to stabilization of the nerve membrane. There are several types of epidural steroid injections, including caudal, interlaminar, and transforaminal. Of these

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SEPTEMBER 2011 MINNESOTA HEALTH CARE NEWS

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ARCHITECTURE

A

t a conference on aging, a speaker asked the audience, “If you could take only one item with you to a nursing home, what would it be?” As the room rang with stories of pocket watches, love letters, and photo albums, I realized that these items represented different symbols for the same possession: family. Since that conference, the focus of my architectural design in senior care communities has been to create an environment that supports residents, their loved ones, and the providers who care for them. Every room in a care center offers an opportunity to contribute to the autonomy, dignity, and independence of residents. As we age, even though our day-to-day tasks change and our lives stop revolving around careers, there remains the desire and need for

D E S I G N with dignity

Home Care by Seniors for Seniors There’s a huge difference in the kind of home care you can receive from someone who really understands what your life is like as a senior, especially your concerns and desire for independence. Our loving, caring, compassionate seniors are there to help. We offer all the services you need to stay in your own home, living independently. • Yard Work • Companion Care • Handyman Services • Housekeeping Services • and more • Meal preparation/Cooking • Respite Care • Overnight and 24-hour Care • Transportation • Shopping • Doctor Appointments Call us today. Like getting a little help from your friendsTM. If you’re interested in becoming a provider we would like to hear from you too. Minneapolis Area: 763-694-0165 • St. Paul Area: 651-274-4285 ©2010 Each office is independently owned and operated. All trademarks are registered trademarks of Corporate Mutual Resources Incorporated.

www.SeniorsHelpingSeniors.com 16

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2011

Lessons from 24 hours in a senior care center By Alanna Carter, Assoc. AIA, LEED-AP

family, a need to feel connected to others, and a need to feel valued. To create an environment that supports each senior’s whole self, I felt that, as a designer, I must first walk in his or her shoes. And that’s exactly what I did. Experiencing long-term care In order to better understand the challenges that residents face in a skilled care center, I asked a client if I could spend 24 hours as a resident in her care center, a building developed in the 1960s as a model medical institution. I was admitted in the morning and given a stroke diagnosis, along with an associated care plan. The right side of my body was immobilized, and I was in a wheelchair. Being in a wheelchair helped me to see firsthand obstacles associated with the inability to move on my own. My main focus was identifying physical challenges posed by the building’s design, but I quickly found myself preoccupied with an emotional struggle. As I made my way to the dining room, lifts and medical carts cluttered the hallways due to a lack of storage, making it very difficult for me to navigate down the narrow corridors. Because of the clutter in the corridors, I was not able to access the handrails along the wall to pull myself down the corridor. Transition strips located between the carpet and hard surfaces presented another challenge. The height differential made it very difficult for me to get my wheelchair through the doorway into the dining room. After a couple of failed attempts, my 32-year-old independent spirit was broken and I found it easier to depend on the staff to transport me. When I finally made it to the central dining room, I wanted to get to know my tablemates. Unfortunately, the capacity of this dining room was 70 people. Since there was a fixed food schedule, all 70 residents were eating while the staff pushed squeaky metal carts around the room and tried to coax residents to finish their meals. I could not even hear myself think, let alone the question a woman sitting beside me asked. Given that mealtimes are traditionally a time of socializing and connecting, this was a lost opportunity. The physical design challenges were considerable, but the biggest lesson I learned was that, though the structures that compose a setting are important, the greatest opportunity to positively

affect a resident’s life lies with the caregivers. Not long after I arrived, my morning cup of coffee kicked in, and I needed help going to the bathroom. I pulled the cord and the assistant came, helped get me onto the lift, and began unbuttoning my pants. I’m sure that this was a completely insignificant task for the assistant, but for me it was an awakening to awareness of how little dignity is left for residents of a care center, and how little selfcare they are able—or allowed—to do themselves. When stripped of dignity and the ability to care for one’s self, or contribute meaningfully to life, it is understandable how the will to live can fade. After my experience in a care center designed under the medical model, I promised myself that I would no longer design nursing homes this way, but I would focus on supporting the individual’s needs and desires. This is culture change. Further, it is not only the design of the physical building that provides this support, but also the way in which care is delivered. The goal of the culture change model is to transform nursing homes into comfortable environments that support dignity, self-determination, and a sense of home. The model develops places where residents are supported in being as independent as possible, and visitors are comfortable spending the day with loved ones. “Back to basics” design How do you design for this environment? It’s simple: Go back to the basics. At the core of culture change is home. Homes are associated with independence. Care centers operating under the culture change model strive to be as close to home as possible while still providing state-of-the-art care. Here are some strategies used to achieve this. Flexible wake-up schedules. No longer is there a fixed, oneschedule-fits-all mindset. Residents wake up on their own instead of having the staff wake everyone on a pre-determined schedule. Not only does this give residents more self-determination and independence, but they are also more rested throughout the day. Thus, they tend to participate in more activities, interact socially with peers and staff, and have a better appetite. Open dining plan. Another change is to replace central dining areas with serving kitchens and attached dining rooms that serve the 10 to 20 residents of a “household.” Similar to the flexible wake-up time, open dining permits residents to eat on their own schedule. Serving kitchens in each household allow staff members to double as shortorder breakfast cooks, so residents can have a warm breakfast of their choosing, regardless of what time they get up. This supports greater connection between residents and staff, as residents can sit at the counter and talk with providers while watching breakfast being made. Improved resident/staff interaction. Better interaction between staff and residents is an important aspect of the culture change model. In the past, the nurses’ station was a central desk. Staff Design with dignity to page 19 SEPTEMBER 2011 MINNESOTA HEALTH CARE NEWS

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September Calendar Suicide Prevention Week September 2–8 Suicide takes the lives of nearly 30,000 Americans every year. Research has consistently shown a strong link between suicide and depression, with 90 percent of the people who die by suicide having an existing mental illness or substance abuse problem at the time of their death. It is not only young adults and adults who are at risk; children and the elderly also can suffer from major depression. Most suicidal people do not want to die; they want the pain to stop. The impulse to end it all, however overpowering, does not last forever. Your willingness to talk about depression and suicide with a friend, family member, or co-worker can be the first step in getting help and preventing a suicide. Watch for these warning signs: • Ideation (thinking, talking, or wishing about suicide) • Substance use or abuse (increased use or change in substance) • Purposelessness (no sense of purpose or belonging) • Anger • Trapped (feeling like there is no way out) • Hopelessness (there is nothing to live for, no hope or optimism) • Withdrawal (from family, friends, work, school, activities, hobbies) • Anxiety (restlessness, irritability, agitation) • Recklessness (high risk-taking behavior) • Dramatic changes in mood If you or a friend is in immediate danger, call 911. If you or a friend is in crisis, call the National Suicide Prevention Hotline at 1-800-273-8255. For additional suicide prevention and depression information, visit Suicide Awareness Voices of Education (SAVE) at www.save.org.

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Emerging Research on Spinal Cord Injury Kenny Grad School is an education series for people with a spinal cord injury and their families. We will explore how to locate clinical trials and determine whether the research is of interest. Information also will be provided on how to best find and evaluate research findings. Free, but registration is required; call 612-863-7306. Tuesday, Sept. 13, 6:30–8 p.m., Sister Kenny Rehabilitation Institute, 800 E. 28th St., Minneapolis

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Joint Replacement: What’s New? Is it Right for Me? Attend this seminar for the latest information in joint replacement. Experts in orthopedic medicine share their knowledge so you can make smart health care decisions. To register, call 952-806-5696. Wednesday, Sept. 14, 7–8 p.m., TRIA Orthopaedic Center, 8100 Northland Dr., 2nd Floor, Bloomington

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4th Annual David A. Rothenberger Lecture Attend this presentation and hear Dr. William R. Brody, former president of Johns Hopkins University and provost of the University of Minnesota’s Academic Health Center, speak about the tough issues facing today’s academic health centers. Presented by the University of Minnesota Medical School, this event is free and open to the public. Thursday, Sept. 15, 4–5 p.m., Mayo Auditorium, 420 Delaware St. S.E., Minneapolis

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Infant CPR Do you care for an infant? This class provides basic cardiopulmonary resuscitation instruction for parents or child caregivers. Certification is not given with this class. Please register by calling 651-480-4440. Monday, Sept. 19, 7–9 p.m., Regina Medical Center, 1175 Nininger Rd., Family Birthing Center, 1st Floor Classroom, Hastings

27 Suicide Grief Support Group This support group is for adults and high school students who have experienced a death by suicide. Family and friends are welcome to attend. Advance registration is required; call 952-758-4431. Tuesday, Sept. 27, Mayo Clinic Health System (Queen of Peace), 301 2nd St. N.E., New Prague Locate additional Minnesota support groups at www.save.org.

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Aging Eye Forum Eye specialists from Phillips Eye Institute will discuss glaucoma, cataracts, intraocular lens implants, macular degeneration, low vision, and retinopathy. Refreshments will be served. Free, but seating is available. Registration is required. Please call Beth at 612-775-8964. Wednesday, Sept. 21, 6–8 p.m., Phillips Eye Institute, 2215 Park Ave. (enter doors on 710 E. 24th St.), Minneapolis

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Interstitial Cystitis (IC) Education IC is also known as painful bladder syndrome. This quarterly session offers women an opportunity to learn more about IC and visit with other women dealing with these issues. Each meeting has a special guest speaker. Free, but registration is requested; call 952-993-0377. Thursday, Sept. 22, 6:30–8 p.m., Park Nicollet Stilts Bldg., 6700 Excelsior Blvd., St. Louis Park

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Young Parkinson’s/Movement Disorder Support Group This support group is designed for people with Young Parkinson’s Disease/Movement Disorder and their families. This is a great place to share questions, concerns, or feelings with other individuals living with Parkinson’s. If you have any questions, contact Tanya Rand at 651-232-2258. Wednesday, Sept. 28, 6–7:30 p.m., Bethesda Hospital, 559 Capitol Blvd., B-Level Conference Rm., St. Paul

Send us your news: We welcome your input. If you have an event you would like to submit for our calendar, please send your submission to MPP/Calendar, 2812 E. 26th St., Minneapolis, MN 55406. Fax submissions to 612-728-8601 or e-mail them to jbirgersson@ mppub.com. Please note: We cannot guarantee that all submissions will be used. CME, CE, and symposium listings will not be published.

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MINNESOTA HEALTH CARE NEWS SEPTEMBER 2011

Design with dignity from page 17

spent most of their time in this fixed location, leaving the area to check on residents when a problem arose. Centralized nursing keeps providers and residents separate; culture change stresses decentralized nursing. In the new model, staff and residents work, live, and socialize together. Charting and other tasks take place on a comfortable couch in a household living room instead of at a desk chair behind a behemoth nurse station. In addition, staff are available to one another at all times via text messaging and phone calls, making overhead paging obsolete. Accommodation of visitors. Another important element in design is catering to visiting family and friends. The culture change model takes steps to ensure that visitors are comfortable spending time in the facility. For example, the smells of ammonia and images of stained carpets have cast a dark shadow in the minds of many individuals. Now there are carpet tiles that can be quickly and easily replaced when soiled, and products that eliminate ammonia from fibers to reduce the acrid smell. In addition, many facilities now offer wireless Internet connection and have coffee shops and gift shops that residents and their guests will appreciate.

The goal of the culture change model is to transform nursing homes into comfortable environments that support dignity, self-determination, and a sense of home. Next in the layout are the kitchen, dining room, and living room spaces. They serve as semi-private spaces where residents in the household can come and go as they please and visit with family and friends. In the back of the cottage are the bedrooms. Each resident has his or her own room, offering complete privacy. Residents can decorate their rooms as they wish. This is an area where residents can spend uninterrupted quality time with their family and friends. My research as a resident within a nursing home was invaluable, resulting in a whole new perspective with regard to designing senior communities. Adopting the culture change model is a positive step toward offering seniors the dignity, independence, and overall environment that they deserve. For people who cannot safely stay in their own homes, designers can best support them emotionally and physically by creating a positive, home-like environment. After all, home is where the heart is. Alanna Carter, Assoc. AIA, LEED-AP, is director of senior environments at Mohagen/Hansen Architectural Group and the founder and current president of Sage Minnesota (Society for the Advancements of Gerontological Environments).

Creating a home-like atmosphere Designing for a home-like environment is a key concept in a senior living center layout. In older facilities, everything is shared—even the bedrooms. In contrast, the culture change model includes public, semiprivate, and private places. Mirroring the familiar idea of living in a house, a facility is separated into smaller cottages, each housing 12 to 20 residents. This arrangement supports improved care for residents in many ways: • There is a better staff-to-resident ratio, allowing for efficient, more personalized care.

Leg Pain Study Do your legs hurt when you walk? Does it go away when you rest? Or, have you been diagnosed with PAD? You may have claudication, caused by lack of blood supply to the leg muscles The University of Minnesota is seeking volunteers to take part in an exercise-training program, funded by the National Institutes of Health

• The family-oriented environment encourages stronger social bonds among the residents.

To see if you qualify, contact the EXERT Research Team at

• Residents have more privacy because they are sharing their immediate living space with only a handful of others, rather than with 40 to 80 people on a large, impersonal ward.

or email EXERT@umn.edu or visit EXERTstudy.org

The culture change model notes the importance of normal social patterning and designs in a hierarchical household system. For example, when residents walk into their cottage, they enter a lobby area that brings to mind a household porch or foyer. This is a common area where residents can meet and greet visitors, staff, and other residents, but need not feel obligated to allow them passage further into their home.

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MR. CHRISTENSON: How do you define wellness? DR. LAWSON: Wellness is really about fully embodied health from a holistic standpoint. All the perspectives—mental, emotional, physical, environmental, relational—need to be involved. If you are just talking about wellness from a physical standpoint, you are missing three-fourths of the boat. The second part of it is that wellness does not exclude disease or disability or injuries. Many, many people who are suffering from some kind of diagnosis or injury can still pursue their highest level of wellness and well-being for themselves—that is important. The third thing is that it is not a set place that any of us are ever going to arrive at. It is a moving target, an ongoing evolution, and a commitment to a conscious participation in a welllived life. DR. RADCLIFFE: As someone who sees patients every day, I see wellness as a balance. It is a way to meet people where they are, with their experience, their heredity, their laboratory tests, and their resources, and then finding out what they are willing to do and how we can make a difference in their lives. MS. SARGENT: Health is about individuals truly understanding what is happening in their lives and developing a path and a plan to best achieve wellness at it relates to what they are experiencing. Expanded to the employer, it is the same thing. Every employer needs to have an understanding of where they are and where they want to be and customize that plan for wellness for their organization. MR. CHRISTENSON: Bill, how do you distinguish between wellness and preventive medicine? DR. LITCHY: Some people confuse preventive services and preventive medicine and wellness. Preventive services are those things we provide—at first-dollar coverage—to people to make sure they do not have or are not susceptible to certain diseases. Preventive care is about how you maintain health and sometimes even restore health. Wellness to me is a philosophy. All of those things go together. As allopathic physicians, we have been taught to cure disease. We should be thinking about how we restore health. MR. CHRISTENSON: Tom, what do you see as the generator of this wellness revolution? MR. HENKE: One big piece is that the finan-

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About the Roundtable Minnesota Physician Publishing’s 35th Minnesota Health Care Roundtable examined wellness as the centerpiece of a changing focus in health care. Seven panelists and our moderator met on April 28 to discuss this topic. The next roundtable, on Oct. 13, will explore the role of accountable care organizations in health care reform.

The Wellness Revolution A changing focus in health care cials of health care have changed dramatically. The plan designs offered to consumers through employers have radically changed over the last five or six years. Now the majority of consumers have high-deductible plans —or if they do not have a high-deductible plan, they have much more personal accountability for the amount they spend in health care. With that, they have decided they spend too much. One of the drivers here is the consumer saying, “If this is going to cost me a lot, what could I do to avoid that?” The other part that put this in a supercharged position is that the government payment model changed to encourage accountable care organizations and to make rewards or payment to the care providers. It is much more beneficial for a care provider to get upstream and work on wellness to avoid the cost that will follow patients who are out of compliance or not at their optimal wellness state. Also, in the past, employers and health plans did not know what things had a good return on investment (ROI) in terms of wellness. We all knew that we should eat right, exercise, should not smoke or drink. But how do we best influence consumers to do that inexpensively, efficiently? The data is finally coming in.

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MR. CHRISTENSON: Not so long ago, health care insurance had no deductibles, no copays— it covered everything. Now—with copays, deductibles, et cetera—people are beginning to ask: Do I pay $20 or $30 to go to a physician when I can go to a wellness practitioner and pay the same amount for a whole-service visit? MR. HENKE: There has been a trend to covering less traditional or nontraditional practitioners over the last 15 years. One piece to this is that some employers are taking a very aggressive approach, using biometric screening—cholesterol levels, body mass index, weight measurement. It’s a first step in connecting to whether an individual is doing the work he or she needs to do. Employers are driving that because it comes back to cost. An overweight patient is much more likely to have additional health care costs, and employers just cannot afford it anymore. DR. LAWSON: Cost is by no means the only driver for consumer behavior. Twenty years ago, American consumers were spending significantly more out-of-pocket dollars to see complementary and alternative (CA) medicine providers. There were more visits to CA providers than to primary care providers in the United States at that time— and that was before those economic changes with payment policies and stuff with third parties. There has also been a growing grassroots hunger from the American population to the effect that “this is not enough, we want more.” DR. ZEIGLER: If you look at public policy on a national level as well as a local level, it is turning itself upside down—and with good reason. We are a country that per capita pays just about the most in dollars per person but has overall outcomes that are only moderate or worse. Looking at Third World countries in comparison to our own, we do not have much to brag about. We are a rich nation. We have generally a high standard of living. We have access to a lot of care, yet we tend not to change our health care behaviors. So how do we effect change in a society that is very much oriented to the here and now? It comes down to creating value-based systems that consumers are willing to purchase. We are seeing, as Karen said, consumers moving to other areas of health care because of its cost effectiveness, because of their preferences, because of their outcomes. We need to take a step back and look at how we design

these systems and address those obvious shifts in what consumers are doing today. DR. RADCLIFFE: From the perspective of the consumer, there are a couple things that drive this strong interest in wellness. One is the change in our consciousness and awareness of how we see health and wellness. I see it as being driven by the availability of information from other traditions— Eastern philosophy and how other people are living their lives and how they are thinking about their health—and also from access to the Internet. Suddenly you are aware that there are all these other options. DR. LITCHY: With regard to ROI, there are issues that are very difficult to address. People struggle to find ROI in a variety of programs, whether it is health and wellness programs, disease management programs, whatever. But one issue that we always have to keep in mind is that it is not just the health care dollar that is being spent. It is—for employers— the absenteeism and presenteeism that is well beyond the dollars they spend for health care. DR. HALBERG: At General Mills, we have not been measuring absenteeism/presenteeism, but seeing the loyalty and the morale that lead to increased productivity. Our department of global health is about advocacy and helping employees understand their health and improve on it. We look at loyalty and morale —and thereby productivity. MR. CHRISTENSON: While new possibilities for cross-disciplinary partnerships are clear, much of the progress is stymied by the reimbursement system. What are the major causes of this problem? DR. RADCLIFFE: We have been stuck in the idea that we need to have a certain type and quantity of studies that prove efficacy. Though science is important, we need to be able to take a bigger-picture look. For instance, menopause. A patient has menopausal symptoms and can’t take hormones, so she wants a different solution. I have had really good luck having people do Chinese medicine and acupuncture. Knowing that there is a good response, I can refer her to get a treatment that may be beneficial for her. We need more data that shows that it is beneficial. I am looking for that as I try to find out where I can send people to do other alternatives. I also think that a lot of times

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when we send people for alternative treatments, we are also empowering them and they are making other changes that then impact other areas of their health. When we send people for Chinese medicine and acupuncture, they don’t need to stay on it for the rest of their lives. We create a change, and they are instructed in some health-changing lifestyle techniques that also play a role. There is a bigger picture to not having just science. DR. ZEIGLER: Our third-party payer system has historically reimbursed for disease management versus health promotion. Now there is a trend by third-party payers to look at how can we save dollars and move patient populations to providers who give care with the best evidence and the best cost-efficiency that improves patient satisfaction. Take lowback pain, for instance. I am aware of some third-party payers who are trying to move those patients to providers who they know are going to prevent low-back surgeries or more expensive procedures that are going to drive up the cost. Secondly, as you look at the movement toward medical homes and the encouragement to bundle payments, it does not matter when you have a collaboration of providers in the medical neighborhood, so to speak. It is about getting the patient as well as you possibly can in order to save the most dollars. It is a driver we are going to see being explored in Minnesota and across the country over the next two to three years. MR. CHRISTENSON: Why have health plans been hesitant to get into wellness? MR. HENKE: It is important to note that I don’t speak for a health plan at the moment, but have in the past. One piece of it is the way in which all systems are paid. Right now they are paid dominantly in this market by transactions. So every time something is done, a payment is made. That is starting to evolve with accountable care organizations (ACOs). In that world, we have coaching that is intangible—it’s very difficult to code exactly what conversation just occurred. That coaching time was pressed down as all the care delivery systems went to production models that required faster and faster visits. One statistic I find fascinating: There is a recent RAND study that showed that the 10 most common things done in the retail

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Julia Halberg, MD, MPH, MS, is vice president of global health services and chief medical officer of General Mills. Halberg earned her medical degree from the University of Connecticut. She received a master’s degree in biology/ecology and a master’s of public health degree in epidemiology from the University of Minnesota. She is board-certified in occupational medicine. Halberg has published extensively on several topics, including shift work and blood pressure. At the University of Minnesota, she is an adjunct assistant professor in the department of environmental and occupational health. Halberg serves on the Occupational Medical Residency and the Midwest Center for Occupational Health and Safety (MCOHS) advisory boards. Tom Henke, MBA, is president and CEO of QuickCheck Health. Henke’s 25 years in health insurance include 15 years of executive experience with Medica Health Plans as chief innovation officer, senior vice president and general manager of commercial markets, and vice president of sales and account management. In these roles, Henke had overall responsibility for Medica’s largest segment, representing 1 million members and more than $2 billion of revenue. He successfully launched many new products in many new markets and delivered market-leading growth. Henke has an MBA in finance from the University of St. Thomas. Karen Lawson, MD, is an assistant professor in the Department of Family Medicine and Community Health at the University of Minnesota Medical School and director of health coaching at the university’s Center for Spirituality and Healing. She is board-certified in both family medicine and integrative and holistic medicine, and was a founding diplomat of the American Board of Integrative Holistic Medicine. Lawson is the co-leader and initiator of the National Team for Standards, Certification, and Research for Professional Health and Wellness Coaches. At the university, Lawson is active in undergraduate and graduate medical education, and in the center’s graduate program. William Litchy, MD, is chief medical officer of MMSI, the Mayo Clinic health plan administrator. With graduate degrees from Saint Louis University (MS, Anatomy), the University of Minnesota Medical School, and the Mayo Graduate School of Medicine (Neurology), Litchy initially joined the Mayo Clinic staff in 1982 and currently is a consultant in neurology. He also is the chair of Mayo Health Plan Operations Committee, which is responsible for the oversight of Mayo Clinic employee health plans. With MMSI and the health plan, he has been involved in the development of wellness and care management programs for Mayo Clinic employees as well as other commercial and government-based companies. Noël Radcliffe, MD, is a family medicine physician at Edina Sports Health & Wellness, PA. Within her practice, she includes alternative, holistic, and spiritual care. A board-certified, active member of the American Holistic Medical Association, she began pursuing this area of interest when constraints of the managed-care system threatened the values of medicine she felt were important, namely caring and compassion. Radcliffe lectures locally and nationally on topics such as consciousness and healing, depression, and forgiveness. She received her MD from the University of Wisconsin Medical School, with specialty training in family medicine at Hennepin County Medical Center. Jennifer A. Sargent, MS, is vice president of corporate wellness for myHealthCheck. Prior to joining Life Time and myHealthCheck, Sargent was senior vice president of sales for U.S. Preventive Medicine. Her career also includes time at Matria Healthcare as vice president of sales and at Medica Health Plans as fitness program manager, as well as managing health enhancement programs for 3M and the University of North Dakota. A graduate of the University of Minnesota Duluth, Sargent has a master’s of science in kinesiology and is pursuing her MBA at the Carlson School of Management. Mark T. Zeigler, DC, a graduate of Northwestern College of Chiropractic, was named president of Northwestern Health Sciences University in 2006. Prior to that, he was in private practice for 26 years in Sturgis, S.D., and was the city’s mayor from 2001 to 2006. Under his leadership, Northwestern completed a major 2008 campus expansion; attained a 10-year re-accreditation; established clinical education partnerships with the University of Minnesota, the Mayo Clinic, and HealthPartners; and founded the Center for Health Care Policy and Innovation. Zeigler is vice president of the Association of Chiropractic Colleges and is on the board of the Minnesota Campus Compact and Foundation for Chiropractic Progress. Robert Christenson has 40 years of experience in health care policy and consulting. He helps solo and small-group practitioners build a full practice of ideal clients and improve their net revenue. SEPTEMBER 2011 MINNESOTA HEALTH CARE NEWS

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M I N N E S O T A clinic—Minute Clinic or Target Clinic—represent 10 percent of its revenue. Those same 10 things also represent 18 percent of all primary care visits and 12 percent of all emergency room visits. In a world where we are spending enormous resources, $25 billion spent in clinics and emergency rooms for things that can be done in a Minute Clinic is not an efficient use of human capital. So you have a large, clogged-up health system. We have insurers that are paying the way they’ve always paid and, because of that, every portion is optimized in their piece. It does not allow for new thought processes. Since 1975, health plans, at least in Minnesota, all have covered preventive medicine and they have covered large numbers of wellness services, but they are not always well known. The nursing coach lines have been in place. We have also had chiropractic services that have been covered for many years in the local health plans. Acupuncture has been covered for quite a while. It is evolving, but to a great degree consumers did not know what they could use within the health plans. MR. CHRISTENSON: How well do thirdparty payers reimburse chiropractors? DR. ZEIGLER: The chiropractic profession, by and large, is covered by all third-party payers. It’s not the coverage, really—it’s how you drive patients to the right providers. In South Dakota they just had a legislative war on copays. The insurance industry, in particular Blue Shield, raised copays for a chiropractic visit to more than $50; for medical providers, it remained $15. So they introduced a bill in the Legislature saying that you cannot discriminate copays for the same services. It passed both the House and the Senate, but was vetoed by the governor. Both chambers overrode his veto. In the industry today it is all about eliminating barriers and getting the patient to the right provider. What we need to do in the future is watch the General Mills and the Life Times, as purchasers of health care design systems that will be value-based. They will look at leveraging and driving consumers and their employees to areas that ultimately save money. It will be business, not the public arena, that will change the way health care is going to go. MR. CHRISTENSON: What is the role of integrative health care and integrative medicine in helping to advance this wellness revolution? DR. LAWSON: The two big pieces of integrative health care are that it takes a holistic

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perspective to get us looking at all the components and all the perspectives of a person or a family or the system, and that it is open to and available to the best therapeutic interventions and resources that are available for that person’s situation and resources— whether those are things that may be perceived as conventional or things that have been outside the mainstream. Prior to the ’90s, we had alternative medicine—people were doing [either] that or this. Then we had complementary medicine. People were doing both things, but often they were not communicating between providers or telling one doc what the other was doing. With integrative health care, if you are, for example, an oncology patient, you may be receiving chemotherapy and seeing a naturopath for supplements and an acupuncturist for acupuncture. As you are doing that, everybody knows about everything. What that can bring to this movement has always been, to some extent, about wellness and wellbeing. It has always been about optimizing a way of living and the ability to live and do as one wants. A philosophy and focus that that movement has held for 25 to 30 years is now moving into the mainstream.

that exists for the condition, and the clinical experience. At our institution we have a chiropractic program, an acupuncture and oriental medicine program, and a massage therapy program. We concentrate on the whole person and try to deliver care with natural components and in a natural setting. We understand that there is a fit for all providers and a need for different delivery systems. That is why we seek out models of care that are integrated—whether it be with our Woodwinds Clinic in HealthEast, with our students at Abbott Northwestern, with our massage therapy students at Regions Hospital, with our chiropractor program at Methodist. We work with the Center for Spirituality and Healing. We put these young students together in an integrative setting and they go through diagnosis, the process of developing treatment plans, and then they allow patients to decide which route of care

There comes a point where personal accountability has to step in. Tom Henke, MBA

MR. CHRISTENSON: Much of integrative care is happening in a team environment. If we look at medical homes, who should be included on the team that is working with the patient? DR. HALBERG: You have to be open and inclusive. I use the integrative approach with our employees when I see someone who is not healing. They have been diagnosed, they have a condition and it is being medically treated, but their mind is not there. We are very fortunate to have high-quality integrative care in the Twin Cities. The holistic approach is what we need to look at with the medical home as well. Rather than saying who should be included, I think most people should be and you can pick from them all. DR. ZEIGLER: It depends on the condition and the situation. Certainly in a number of environments there are providers who excel because of their experiences and their training. The collaboration of providers takes into account patient preferences, the best evidence

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they would like to take. MR. CHRISTENSON: One of the most interesting innovations has been a new team member called a health coach. DR. LAWSON: For years we called it the missing provider. When you see an MD or a chiropractor or a naturopath, that provider says, “This is what you need to do.” Out in the parking lot, you ask yourself, “How am I going to do that in my life? What do I start on first? What are my barriers?” There was not a professional to help people navigate that. It’s the health coach or the health and wellness coach; the definition is still evolving. A national team is working on setting the standards for this. Team members have defined certified health and wellness coaches as “professionals from diverse backgrounds

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M I N N E S O T A in education that work with individuals and/or groups, in a client-centered process, to facilitate and empower a client to achieve self-determined goals related to health and wellness. Successful coaching occurs when coaches apply clearly defined knowledge and skills so that the clients mobilize their own internal strengths and external resources for sustainable life change.” The movement is coming from everywhere—fitness, recreation, wellness, mainstream medicine, psychology, behavior change, and everything in between. MR. CHRISTENSON: What type of training and oversight should be given to a health coach? DR. LAWSON: We are still working on that, but there is agreement that it is not a weekend class. This is not something that just anybody should be able to write on their

People come to the table with not just labs, but with their whole history and experiences. Noël Radcliffe, MD

business card. It will probably settle out between 130 and 150 hours of education in addition to a bachelor’s degree. There will need to be a requirement for four to six months of clinical supervision. There will be a national board-certification testing process that will identify knowledge in areas around lifestyle and lifestyle medicine. MR. CHRISTENSON: Should there be a process to certify wellness programs? DR. HALBERG: I am a little nervous about that. The more certifications you require, the more barriers you put up. Wellness programs need to be individualized; one size does not fit all. I think certification would take away innovation, as well as putting up barriers. DR. LITCHY: I am also concerned about certifi-

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cation of a program when we still are trying to define what everything really means. As it matures, there may be a time in the future, but I don't think the time is now. Program certification would more likely hinder progress at this time, because certification in general does that.

we prepare it. Look at tobacco use and how we continue to abuse alcohol in certain socioeconomic areas. Obesity still tends to be one of the largest problems within the United States. Look at cardiovascular disease and diabetes. The debate really is a public policy debate.

MR. CHRISTENSON: When did you begin your wellness programs at Mayo, Bill?

DR. HALBERG: I would take it one step further from a business standpoint, and say health and wellness have to be part of strategic vision for companies to be successful going forward. We have a senior leadership believing in that and that helps a lot to make a more open environment where we work.

DR. LITCHY: There has been a long history in the wellness programs we offer commercial clients, starting with health assessments and identifying how you can use them and then going into providing information through websites, books, and a variety of things. Mayo has a whole series of books, even one on complementary medicine. Now there is a strong move to approach all these things from multimodalities. Each person learns differently, each person will work differently. If you have only one tool to use with people, you will lose a lot of them. MR. HENKE: As Karen mentioned, consumers have been paying for things outside the health care insurance world all along, and we are not taking advantage of that. Winning models will win—period. Right now, even on the insurancecovered things, a typical deductible is between $1,000 and $3,000. That means something on the order of 50 percent or more of all patients will not reach their out-of-pocket maximum. So, in essence, they have zero coverage for the current system. That means that anything that is not covered by insurance is on an equal footing with covered things because it is 100 percent paid by consumers. The question is whether the world really is ready for this—and I would suggest it is. Then I would suggest we focus on adding value directly to the consumer. If it is there, employers will pay for it, insurers will pay for it. If it is not there, it won’t be paid for. It is about getting consumers what they need. DR. ZEIGLER: It goes deeper than just the health care system. Wellness needs to be part of our public policy. We have to take a stand on how we feed our children in school, how we promote good food, how we promote healthy living. It is changing perspectives of consumers and changing behaviors. Look at how we buy our food, how we cook it, how

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DR. LITCHY: Until senior leadership takes the role of wanting it and talking about it, it just does not happen. When we work with new companies, that is the biggest thing we emphasize. The stronger a company’s senior leadership, the more successful wellness programs are. That’s simply the way it is. MS. SARGENT: One of the biggest reasons we have seen employer wellness programs fail is because they don’t change their culture. They will put a wellness program in place, they may have a health risk assessment, do some biometric screening—but their cultural aspect does not change. They are still serving unhealthy foods and they do not have an environment that is conducive for people to exercise and manage stress. It does not become a part of what they do as an organization. It is more than just putting a program in place and hoping that it works. You have to have it be a part of your strategy and change your organization, your culture, and who you are. MR. CHRISTENSON: Many chronic conditions are linked to unhealthy lifestyle choices. What are some examples of how our society encourages people to make the wrong choices? MS. SARGENT: We have a society of convenience and a little bit of entitlement. We as a society have this “I want it and I want it now and I should have it now” kind of feeling— because we have such high-stress, busy lives and unhealthy things are convenient. Because healthy behaviors are much less convenient, it makes it easier to choose the unhealthy over the healthy. DR. RADCLIFFE: One thing that concerns me is advertising. How many ads [like this] do we see: “If you have the symptoms, see your doctor”? There is no empowerment, and very little public health information out there. DR. ZEIGLER: I read an article about a study at the University of North Carolina–Greens-

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boro. Two economists studied Walmart Supercenter openings in almost 1,600 locations nationwide. They demonstrated over 10 years, from 1996 to 2005, that when a Walmart Supercenter enters a county, on average the residents of that county gain about a pound and a half and the county’s obesity rate goes up by about two percentage points. So, fundamentally, our society is trying to make choices for us. It comes back to consumers making healthy decisions. It is the obligation of our educational institutions to talk to our future providers about changing behaviors, shifting consumer choices that consumers are making, and providing good, sound information that can change those behaviors.

DR. LAWSON: One of the most groundbreaking is Dean Ornish’s work with reversing heart disease. He put together a multidimensional team approach that was not using high-cost interventions. Many, many practitioners said, “You are never going to get people to eat that way, to exercise, to do group support.” And now it is reimbursed by Medicare because the cost of reversing heart disease by a lifestyle-change program at $5,000 per year versus a typical quadruple bypass, which starts and goes up from about $30,000 a year—with similar morbidity/ mortality outcomes—is pretty significant.

MR. HENKE: The alignment centers in health care are very, very difficult to put in place. Let me use this silly example. If I am not driving with my seatbelt on, I can get arrested. But my brother-in-law can get on his motorcycle without a helmet. That is a very simple example of an odd choice for society to make. Health plans struggle with not being able to say they won’t cover a statin if you haven’t stopped eating fats. We can’t do that. There comes a point where personal accountability has to step in. I would suggest that, rather than complain about the system and society, we just go after the targeted areas and win in those markets where there is interest. Rather than mandate that everyone has to eat right, let’s reward the people who are eating right. We are going to have to break down some of the insurance regulations to have that flow-through to the consumer. Right now consumers do not get rate cuts for following the right practices— even if they are following doctors’ orders.

MS. SARGENT: Partnering with employers succeeded when employers understood that you have to take the program past education to intervention. As an industry, we have done the education piece pretty well. But we have not had programs in place to intervene. The successful programs are where the employer took charge of the program and said, “We need to do more. We need to institute walking programs and we need to have a fitness center. We need to have fruits and vegetables available to our people,” and then incorporated the whole family. Kids are a big part in making a wellness program successful.

MR. CHRISTENSON: Jennifer, when you were with U.S. Preventive Medicine, what were some of their successful programs?

DR. HALBERG: With regard to responsibility, I vetoed a requirement that you had to fill out a health questionnaire before using our fitness center. I could not see instituting another barrier for liability purposes. People ask what small employers can do. There are so many things you can do, even at small companies: Join with the American Heart Association, American Cancer Society, American Diabetes Association. They have walks and runs all the time. You can buy T-shirts and get your people involved. To feel good about ourselves and to feel healthy, we need to engage. Volunteering is one way.

DR. HALBERG: We trademarked a real-time health risk assessment. Our Health Number gives people a snapshot in time of their health status. Then there are health coaches to educate, motivate, and help them choose one thing to move forward with. We use inkdated fingersticks to do fasting glucose and lipids. We record weight and blood pressure. And we ask six objective questions. We categorize scores on a scale of zero to 100. It’s all done anonymously. Everyone gets their own Health Number. Then we project what their peers are doing. It’s a healthy competition, totally confidential, but it motivates them to take the next step.

MR. CHRISTENSON: If a significant portion of wellness involves making healthy choices, what are some examples of successful programs?

MR. HENKE: The employer is an important centerpoint for a lot of change, but it is not the only place. People spend half their time

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at home, so reaching out just to the employer is not enough. Some successes I have seen are where the stakeholder—whether a government agency, employer, a vendor—takes a what’s-in-it-for-me approach and aligns it and meets with immediate response. If you are an employer who wants employees to behave differently, you have to have a carrot or a stick, and it will absolutely make a difference. If you put either rewards or penalties in, you will see dramatic change in participation. If you do it incorrectly, you can make people pretty unhappy as well. DR. LAWSON: While behaviors are critical and they are often the easiest thing to measure, belief change is a huge piece of this. Too

It will be business— not the public arena— that will change the way health care is going to go. Mark T. Zeigler, DC

often we minimize the impact and empowerment of learning to think of your life differently, working your life differently in everything from reducing pain to improving quality of life. A lot of people, when they ask about health coaching, really focus on behavior. We need to be thinking broader than that. MR. CHRISTENSON: What are some incentives that will make these programs successful? MS. SARGENT: There are a lot of ways you can do incentives—and you can take a stick and paint it orange and call it a carrot. More and more employers are moving away from the traditional carrot approach—I am going to pay my employee $300 because maybe they did a few things over the course of a year— to more of an outcome-based incentive program design. This is where you look at key indicators and tell people, “If you don’t reach certain goals, you are going to pay more.”

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M I N N E S O T A Maybe that’s a long-term strategy; it’s not that you have to get to these goals tomorrow. DR. ZEIGLER: Tom and Jennifer are right. Incentives can create tremendous shifts in behavior. They are taking nontraditional approaches to create those levers and using relationships as a driver in changing behavior. In other words, it is not just the fact that I am going to drop $100 into your HSA or I am going to reduce your annual health coverage by $200 if you meet these markers, but it is creating these communities of participants. You create obligations of one on another: If you don't meet your marker, you are letting down your friend, your coworker on the team. So I will get up at 6:30 a.m. be-

Kids are a big part in making a wellness program successful. Jennifer A. Sargent, MS

cause if I don’t, I am going to let down my team. Would I get up at 6:30 on my own? No. It is this obligation they are creating to incentivize behavior changes. DR. LITCHY: We spend a lot of time talking about how we are going to help the employee, but many of our employees are married and have children. Our cost for the dependents and children is more than the employee costs. We are challenged on how we can engage the other members of the family. DR. HALBERG: We have a healthy night out we sponsor for the community at the schools with parents, grandparents, and providers. We introduce fun ways of looking at nutrition, exercise—not just for our families but the whole community. Recently we joined with American Harvest: For employees who needed to lose weight, for every pound of weight they pledged to lose, we would give a

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pound of food to the local food bank. That tie to the community was a great motivation for our employees. MR. HENKE: One thing that is happening is a retailization of health care. Consumers are much more involved in their own decisions— good or bad—than ever before. One example we are working on now at QuickCheck Health is the question of how to monitor prediabetics. If someone is prediabetic, it is optimal to measure their A1c up to two times a year to see if it is progressing. In a perfect world, we would have a physician spending time with the patient twice a year doing that work. That is optimal. However, to have a prediabetic come in for an A1c check might mean two visits because the health system is not organized to do the test first and follow with the doctor immediately thereafter. It is organized to see the doctor, then go get your tests, and then you won’t have your score until you come back. That needs to be redesigned. A second piece is that it costs $200 to $300 for a typical office visit with some labs. So now we’re saying we are going to spend $400 a year on the 25 percent of all adults in America who are prediabetic. That is a huge increase in health care costs across the board. During a single year, only a portion of those will migrate upward towards diabetes. How do we address that? An example of what I would consider a disruptive innovation is a rapid test that could be sent to the home. The patient might have a $10 gift card for completing the rapid test. The patient cannot see the score until the doctor sees the score. If we could move to a world where that is the approach to health care rather than centralizing everything at the clinic, consumers win, doctors can spend less time on patients that don’t need to be there and more time with those who do, and the system can win. MR. CHRISTENSON: How have medical doctors begun to incorporate wellness more into their practice? DR. RADCLIFFE: It comes on many levels. The first is personal, how we chose to live our lives and model for patients. How do we as employers take care of our employees? But also wellness in the office: We take more time. We want to talk to patients, to look not just at their labs or their family history, but

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to understand the barriers to them living a healthier life. Are they caring for a sick mother? Are their kids having issues that take up a lot of their time? Is their workplace unsupportive? What are the issues and how can you help them so that they have the time and energy to focus some of their energy on themselves and their wellness? The patients I see fall into two groups. The first group feels helpless. How many people do we know who would save hundreds of dollars if they quit smoking and still they don't quit smoking? It isn’t about money. They do not feel like they can do it. Part of that holistic approach is understanding that people come to the table not just with labs, but with their whole history and experiences. In my clinic we spend a little extra time talking about those aspects versus just looking at their labs. DR. ZEIGLER: I was in private practice in Sturgis, S.D., for 26 years. When I entered practice in the late ’70s, I put an ad in the local newspaper talking about my approach to the whole person—body, mind, and spirit—and about eating healthy, having an active lifestyle, and taking care of ourselves. I remember getting chastised by my medical counterparts. In today’s environment, open up any magazine, any newspaper and look at how the ads are talking about health care. There is a remarkable generational shift. What excites us now in education is that we have an opportunity to build on that and break down the barriers to create better outcomes. MR. CHRISTENSON: Bill, is there a growing number of holistic practitioners at Mayo? DR. LITCHY: Yes. They have formed a section of interactive medicine. The philosophy at Mayo has always been that the patient comes first. Generally, the approach has been to treat the whole patient, although we as allopathic physicians have been constrained by our training. DR. HALBERG: I could not agree more that we are restrained by our training. I am old enough to say it was always about disease— we never did prevention. It was always what kind of technology or pharmacology you are going to use to get the person better. It is an awakening for those of us who are older to embrace these different treatments. MR. HENKE: But there always is this issue of compensation. Who is going to pay for it? DR. LAWSON: The restraints fascinate me. Yes, your payment plan covers acupuncture, but it has to come with a referral and the

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Let’s make this an evolution versus revolution. Julia Hallberg, MD, MPH, MS

port. We have talked about senior leadership, which is key, but we also found out that middle management has to kick in too or it will not be successful. MR. CHRISTENSON: Bill, how do you market your programs to employers?

referral specifically has to be from your primary care provider. Then I have to provide a pitch with research documents to my primary care provider to get them to write the referral. Or we will cover massage, but only if it is for a diagnosis. If I go preventively once a month, then I don’t get a diagnosis. DR. ZEIGLER: I practiced in an environment that was defined by patient preference. They could come to me for low-back pain or they could go across the street to the osteopath or MD. Now Optum Health— which has tens of thousands of chiropractors, physical therapists, and occupational therapists as part of their network— has developed a paradigm for low-back pain because of what they know through their data. They are going to shift many of their enrollees to chiropractors because they know the cost savings, the cost efficiency, and the patient satisfaction. Would they have done that 10 to 15 years ago? No. But because of the numbers they have, they know exactly the dollar amount they are going to save if they can get it to a certain provider before it goes to a specialist and on to probable surgery. Like it or not, that drives a lot of decisions—good [ones], most of the time. MR. CHRISTENSON: What are the most important things employers need to evaluate when they look at the myriad wellness programs available to them? DR. HALBERG: We always like to look at outcomes measurements, of course. Is the program going to engage people, sustain behaviors, and how is it going to go moving forward? There are a lot of good programs out there. There is no one-size-fits-all, whether it’s nutrition or getting moving. The programs also have to have management sup-

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DR. LITCHY: The brand opens a door, but does not close the deal. We are cognizant that some of the things we do simply will not work with some organizations. We want to make sure there is a match. Sometimes it does not match, not because we have a program that is not good or the company is not a good company. There can be different philosophies. You also have to be able to demonstrate that you can succeed at what you do. Outcomes are critical and that magic word “data” is essential. Sometimes it is hard to get the data you need. You may not be able to show the ROI, but you can show the engagement. MS. SARGENT: I will echo some things that have been said. Not every program is going to fit every employer. The program and company need to be flexible and nimble to meet the needs of the employer and build a strategy around it, not just put a program or a product in place. It also needs to offer a variety of modalities for people to engage. It cannot just be telephonic. There needs to be a physical way for people to engage, whether at the worksite or in other ways. One key is finding a wellness program that will integrate with other programs you provide. Employers may have disease management with a carrier and they may have an employee assistance program and they may have case management and then a wellness program. How does it all fit? How do we not confuse members with somebody calling from this company and somebody calling from another company for the same thing? We need partners that are willing to sit together on the client’s behalf to integrate the solutions for a seamless member experience.

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DR. HALBERG: One other point is to get a local champion. If you can get one or two employees to really engage people, that local champion will help determine success. MR. CHRISTENSON: What are some of the broader environmental and cultural aspects that affect the general health and wellness of employee populations? MS. SARGENT: There are a number of things —smoking policies, food served in the cafeteria, lots of little up to big things that culturally and environmentally can impact health. Are you willing to do the tough thing to change your culture and deal with the impact? MR. CHRISTENSON: What obstacles inhibit companies from investing in wellness programs? DR. LITCHY: Money—simply that and whether people are willing to realize that it is an investment in their organization. To be very frank, there are organizations where the investment really is not of value. If they have a turnover of 150 percent a year, I can see why they would choose not to invest in their population. If you have turnover of 2 percent a year—Mayo, for example—there is a big incentive to take care of the population. MR. HENKE: It is all about how the senior management culture sees health care. When they see a 10 percent renewal increase for health care and they are looking at cutting benefits, there is not an appetite for adding things that cost money unless they are absolutely proven to have a result. DR. ZEIGLER: We got a Blue Shield grant to apply for a wellness program. It was a god-

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Belief change is a huge piece of this. Karen Lawson, MD

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M I N N E S O T A send because it gave us the green light to implement a change. It did change the work environment, and you have to have the support of senior management to do that. And you have to allow these things to evolve. The return on investment came quicker than we expected. Within two years we had premium drops in our overall insurance that we all collectively shared. MR. CHRISTENSON: What are some of the factors that inhibit wellness programs from being effective? DR. RADCLIFFE: Patients often do not feel supported in their workplace. Without that, it is very hard for them to implement any change. Understanding how your workplace is stressful or unhealthy is critical to being able to help people commit to these programs. MR. HENKE: The data is really compelling on this. If there is one thing you can do, it is about the senior management engagement and the champions. If you do not have the local champion, it just won’t work. MS. SARGENT: There is a lot of research going on right now about intrinsic versus extrinsic motivation. The program has to have a component of working with the individual to find out what is going to intrinsically motivate them to make the change. That is the hard thing to do. DR. HALBERG: We combined health and safety; our safety managers were also our health managers. Often, people say, “I’m not sure I want my employer asking me about my health—that is very personal to me.” But from a safety perspective, it is all about behavior change. What do I have to do to be

The stronger a company’s senior leadership, the more successful wellness programs are. William Litchy, MD

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and are still challenged.

MR. CHRISTENSON: What role should health insurance companies play in keeping the wellness momentum going?

DR. RADCLIFFE: I would like us just to make some steps forward. One thing that stands out is the need to personalize any type of wellness plan. I love the idea that it starts from the top, but how do we do that? How do we actually get owners and senior managers involved in championing it? I think it will happen on its own because they themselves will be facing their own health issues. I think that will come.

DR. RADCLIFFE: I would like to see them offer incentives to employers to clean up their workplace. Maybe they would have to do some kind of analysis, but in the long run I think it would be a healthier workplace and healthier employees. MR. CHRISTENSON: There are lots of wellness programs where there are no medical practitioners involved at all. What issues are posed by how these establishments archive patient data? DR. RADCLIFFE: Having at one time practiced as a medical professional in an environment that was set up for what you are describing, there is not often educational expectation of things such as even basic rules of HIPAA. Certainly those wellness centers are very focused on client empowerment and the client being responsible for his or her own issues, challenges, and medical information. But there needs to be a certain level of safety triage awareness, because clients don't always understand what the level of knowledge is at the different places. I have seen those issues coming up more and more in the last five years as coaching has really taken off and we are getting a lot more partnerships among fitness facilities, community health places, and medical facilities. DR. LITCHY: On the other hand, it is critical to be able to integrate the data from all the different areas from which people are seeking wellness, so that we can do the evaluations that are essential to continued improvement. The struggle is how to obtain the data legally through HIPAA and how we can transfer that data among groups. Because, unfortunately, a field in one person’s data set is not the same field in another data set. We are working right now in a consortium of several major medical centers around the country and trying to figure out how we can put the identified data together in a single database. We are now at 18 months of very rigorous work

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MR. CHRISTENSON: We have come to our final question of the afternoon: How do we win the wellness revolution?

DR. LITCHY: Fifteen years ago we were worried about how we were going to take care of the high-dollar-cost people in the plan. Then we went on to say, “Let’s take care of everyone.” Now we’re talking about the high-cost people again. We talked about wellness a while ago and then forgot about it. We are now bringing it back again. MS. SARGENT: In order to win and not lose— or however you want to frame that—you need to have some common vision and collaboration among the key stakeholders: carriers, providers, employers all starting to move in the same direction with some sort of common vision. DR. ZEIGLER: We do know that the consumer is purchasing health care differently today than they did 10 years ago. They are spending their own dollars to purchase care the way they want to see it. I believe we need to listen to how consumers want to see their health care and use health care education to our advantage to shift those populations into different behaviors and different systems. MR. HENKE: If we focus exclusively on the consumer, focus exactly on what their problems are and what they need, and we don’t worry about the other stakeholders—who gets paid, who wins, who loses—that is how we are going to win. DR. LAWSON: As long as we have the mindset that there is a barrier, something to overcome—if there is a loser and a winner—we will continue to flail. MR. CHRISTENSON: The last word, Julia, is yours. DR. HALBERG: Slow and steady, let’s make an evolution versus revolution.

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ORTHOPEDICS

Ankle injuries ach year, foot and ankle problems send Americans on millions of clinic visits, according to the National Center for Health Statistics. Ankle injuries affect people of all ages, regardless of whether or not they are physically active. This article describes common reasons patients seek care for ankle injuries, treatment choices, and advances in care.

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Treatment advances speed return to active lifestyle By Sumner McAllister, MD

Lateral ankle sprain By far the most common ankle injury is a lateral ankle sprain, on the outer side of the ankle. Sprains represent a stretching or tearing of the bands of fibers, called ligaments, that connect bone to bone. According to the American Academy of Orthopaedic Surgeons (AAOS), every day about 25,000 people sprain their ankle. About 90 percent of these involve the ligaments on the outer side of the ankle. Most sprains heal with time and protection from further overuse or injury, along with proper rehabilitation of the injury. Rehabilitation helps decrease pain and swelling; restore range of motion, strength and flexibility; and prevent chronic problems. Besides ice and nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy techniques such as ultrasound and electrical stimulation may help reduce pain and swelling. Balance and strength training may help prevent reinjury or chronic joint weakness. Proper initial care and rehabilitation of an ankle sprain may greatly reduce the need for surgery.

Applying the PRICE (protection, rest, ice, compression, and elevation) acronym is advised for ankle sprains, and ankle splinting or other orthopedic devices may be helpful for more significant sprains. Certain patients and significant ankle sprains may still require surgical attention to improve recovery and future level of activity or performance. Medial ankle sprain Spraining the deltoid ligaments on the inner aspect (medial) of the ankle is rare due to the strength of these ligaments and the bony structures of the ankle joint. Spraining a deltoid ligament, called a medial ankle sprain, often ties to other injuries like a fractured fibula, tendon tears, nerve injuries, or fractures of other ankle bones. X-rays are often recommended with moderate to severe medial and lateral sprains to help identify the particular bone injuries. With no fracture, treating a medial sprain mirrors that for a lateral sprain, but recovery may take much longer.

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Extensor tendonitis Patients with general pain on the top of their foot, along with pain when the extensor tendons are stretched, may have extensor tendonitis. The tibialis anterior tendon is most often irritated in athletes who run, hike, ski, or bike. To help prevent recurrence, patients should wear properly fitting shoes and not tie laces too tight. Orthotics such as pads in the front of the shoe can relieve pressure. While the pain can be significant—and often mimics that of a stress fracture—rest, not surgery, is needed. Regularly stretching the calf muscles and strengthening the extensor muscles also reduce the likelihood of reinjury. Fractures About 15 percent of ankle injuries involve breaking a bone. As part of the exam, clinicians should ask patients about any previous ankle trauma, whether they heard a sound like a “pop” when the injury occurred, and about weight-bearing ability. The inability to bear weight immediately after an injury or at the time of an x-ray, along with specific locations of bone tenderness, indicate increased risk of a fracture and further justify obtaining x-rays. To make patients comfortable following a fracture requires pain management and appropriate immobilization of the ankle. In cases of serious ankle fractures or very unstable injuries, patients are often referred to an orthopedist. Achilles tendonitis Tendons connect muscles to bone and allow motion. Tendonitis is an irritation of the tendon through overuse or injury. The Achilles tendon connects the large calf muscles to the heel and is frequently irritated by certain activities, such as running or jumping, or in poorly conditioned individuals who increase the intensity of their activity too quickly. The pain of Achilles tendonitis is usually just above the heel and is worse in the morning or with exercise. Proper stretching, conditioning, and exercise are the best practices to prevent irritation. Among many options to treat Achilles tendonitis are a period of rest or decreased activity, proper stretching, ice applications, NSAIDs, good shoe selection, and certain shoe inserts such as a heel wedge or lift. Achilles tendonitis generally does not require surgery, though a complete tear usually heals faster with surgery. Steroid injections to treat Achilles tendon problems should be avoided as they can increase the risk of a tendon tearing completely. Preventing injuries involves maintaining flexibility in the ankle joint, including regularly stretching the Achilles tendon, and orthotics to support the foot and correct balance or rotation problems through the foot and ankle. Chronic ankle instability Patients with chronic ankle instability feel like the outer side of their ankle often “gives way” when they are walking, exercising, or simply standing. Weakened ligaments cause the instability, which can develop after multiple ankle sprains, especially following a sprain that did not heal sufficiently. X-rays, CT scans, or magnetic resonance imaging scans may be used in diagnosis. The patient’s activity level also guides treatment. Nonsurgical options range from use of NSAIDs to manage pain and inflammation to physical therapy and use of an ankle brace for sup-

Proper initial care and rehabilitation of an ankle sprain may greatly reduce the need for surgery. port. Surgery to repair or reconstruct damaged ligaments and, in some cases, to perform other soft tissue or bone procedures, is needed for more serious injuries or in cases not responding to other courses of treatment. Arthritis in the ankle While not an ankle injury, arthritis in the ankle can result from a previous ankle injury. Patients with “ankle arthritis” have worn out the cartilage and bone of the tibiotalar joint, typically due to one or more factors such as being overweight, having a genetic tendency for arthritis, prior injuries to the ankle and foot, and more. Most patients find pain relief with changes in footwear, such as cushioned inserts or “rocker-bottom” soles, and by limiting high-impact activities. Besides medications like NSAIDs for inflammation and pain, braces or inserts and cortisone injections may be helpful. Certain patients with ankle arthritis may benefit from orthopedic evaluation when other treatments have not adequately controlled the pain or returned the patient to an acceptable level of activity. Surgical options, ranging from minimally invasive techniques to ankle replacements, are advancing, allowing patients more range of motion, less pain, and higher levels of functioning. Ankle injuries to page 34

In the next issue.. • Pre-diabetes • Sexual health • Preventing falls

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SHRINKING the health care footprint

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s the nation struggles with the costs of an oppressively large health care footprint, many patients with chronic conditions face a health care footprint of their own that is ever-growing and never-ending. Beyond the expense, the burden of illness—symptoms, disability, and avoidance of activities to prevent symptoms— can significantly reduce patients’ independence, quality of life, and ability to care for loved ones and pursue goals and dreams. For the chronically ill, the goal often is not a cure, but rather controlling the condition and reducing the risk of long-term complications. There has been an explosion in chronic conditions, due in part to aging of the population; improvements in survival of previously lethal conditions; and, increasingly, defining conditions based on risk. Examples include diabetes (defined as blood sugar levels above which patients are at high risk of vision impairment or loss), hypertension (blood pressure levels above which treatment reduces the risk of stroke), and dyslipidemia (LDL cholesterol levels above which treatment reduces the risk of damage to the heart). As a result, many patients, particularly older ones, have multiple chronic conditions. Many of these people are fundamentally healthy—they have few symptoms and experience little illness—but receive a large amount of health care: Medicare patients with five or more chronic conditions account for almost 70 percent of health care expenditure. For them, the fundamental problem is not the burden of illness, but the burden of treatment.

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A call for minimally disruptive medicine By Victor M. Montori, MD, MSc

To understand the role of treatment as a burden, we have to understand what modern health care requires of patients. Most of the recommended care comes from guidelines that focus on a single condition. These guidelines require tests to diagnose, prognosticate, monitor, and trigger referrals and treatment; indicate measures to ascertain the quality of care performed; and propose treatments, dictating the outcomes that need to be achieved. These guidelines are problematic for a number of reasons: • The research on which they are based is often corrupt. Consider, for example, reports of selective publication of studies favorable to antidepressants, with suppression of those not so favorable. • The guidelines’ writers are often specialists with narrow expertise and important financial relationships with corporations that stand to profit from adherence to the recommendations. • The recommendations fail to account for patient context—including what other conditions and treatments they have and take, but also patient circumstances. Attention to these circumstances has been minimal. To bring this into focus, let’s consider the case of John, a fictional patient who resembles an increasing number of my own patients. A case study John is a 55-year-old accountant, husband, and father of two. He has diabetes, for which he takes metformin and glipizide; abnormal blood lipid levels, for which he takes a statin; and high blood pressure, for which beta blockers were recently added to his diuretic because his office readings were above goal. After this addition, John experiences dizziness when he stands up. His weight seems parked at 238 pounds. He also has depression and chronic low back pain, as well as some nerve pain in both feet. To achieve guideline targets for patients with type 2 diabetes, John’s primary care clinician refers him for evaluation by specialists in podiatry, dietetics, diabetes education, and endocrinology. John must take time off work for each of these appointments. He emerges with advice to cut back on carbohydrates, fats, salt, and calories; to take his pills regularly; to check his blood sugars twice per day; to exercise; and to check his feet daily. John feels no one paid much attention to his back difficulties when advising exercise. Because of back stiffness and abdominal obesity, he will have to ask his wife to take a look at his feet regularly. Meanwhile, his complaints of pain and difficulty sleeping remain largely unaddressed. One reason John doesn’t sleep well is the situation at work. He used to be one of three accountants; through downsizing, he is now the only accountant. He takes work home regularly, feels pressure to perform, and is noting that the numbers are not adding up. He wor-

ries that the company may be going under—and with it his job, his health insurance, his ability to pay his debt, and his mortgage. But mortgage payments are not the main concern about his home situation. A few months ago, seeking refuge from an abusive husband, John’s daughter returned home, bringing with her two beautiful granddaughters. John’s daughter is drinking heavily. As John sits in his La-Z-Boy reviewing all these concerns, he opens a letter from his primary care physician. Working in a payfor-performance environment, she must report diabetes outFor Medicare patients comes for her patients. In her with five or more letter, she says that, because of John’s failure to achieve chronic conditions, diabetic care goals, she will the fundamental prob- no longer treat him and he must find a new primary care lem is not the burden clinician. of illness, but the John’s “failure” to achieve diabetes goals despite his burden of treatment. physician’s efforts is usually interpreted as John “not taking personal responsibility” or being “noncompliant.” Much of what has been written about not following physician’s advice or taking medicines as recommended, often called nonadherence, suggests that John’s nonadherence is intentional. This is often related to beliefs about disease (e.g., If I do not have symptoms, I must not be sick) and treatment (e.g., If I take these medicines, they will harm me) that are not correct and that lead patients to opt out of some aspect of the treatment program. Solutions to the problem of intentional nonadherence therefore require doctors to learn about their patients’ beliefs, educate patients about the condition and treatments, present them with options, invite them to participate in shared decision-making, and provide tools (such as pill boxes) to help them implement the agreed-upon plan of action. The burden of treatment But intentional nonadherence is only part of the story. The problem with John’s adherence to therapy, visits, tests, diet, exercise, etc., is that these tasks do not fit into his life. His physician, instead of working with John to create a program that fits into his life, has chosen to intensify therapy. She expected the endocrinologist to start John on an injectable agent to reduce his blood sugars. A greater emphasis on self-management, she thought, would make John check his sugars two or more times per day. Indeed, a study reveals that on average patients with diabetes spend 48 minutes per day taking care of their diabetes—but still frequently miss recommended activities. An estimate of how much diabetes patients ought to be doing places these demands at 122 minutes per day. This type of nonadherence reflects treatment burden, a situation in which the treatment workload exceeds the patient’s capacity to take on the work of being a patient. Treatment burden could result from reductions in patient capacity (through pain, depression, isolation, illness burden), from increasing treatment workload, or both, especially for patients with multiple chronic conditions. Poorly coordinated, disease-focused care can result in treatment intensification for each condition, with each demanding its own lifestyle changes, tests, monitoring requirements,

treatments, and visits—resulting in large, inefficient increases in treatment burden. The solution to this form of nonadherence requires that the focus of care shift from caring for each condition to the care of the patient as a whole person. In particular, clinicians and patient must work together to take stock of the patient’s capacity and workload. Patients’ capacity comes from their ability to enlist family, friends, coworkers, and others in the work of being a patient; their resilience in the face of illness; their general literacy, and, in particular, their health literacy; their quality of life; and their capacity to take care of family, recreation, and work. These are not measured routinely in medical practice. Nor do we know how effective patients are at conveying—and clinicians at eliciting—a sense of the patient’s ever-changing capacity to do patient work. Treatment workload may be easier to assess. But even the best records will not note all the recommendations and advice that patients accumulate from different health professionals, or how patients perceive all these actions. Principles of minimally disruptive medicine To improve outcomes for patients with multiple chronic conditions by reducing nonadherence, clinicians and patients must work together to lower the burden of treatment, i.e., to optimize the balance between workload and capacity. In pursuit of this goal, our research group, in collaboration with others, is working to develop a measure of treatment burden that patients can report. To reduce treatment burden, minimally disruptive medicine requires that clinicians take an unusual step: Stop guideline-mandated Shrinking the health care footprint to page 32

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SEPTEMBER 2011 MINNESOTA HEALTH CARE NEWS

31

Changing the practice of medicine

Shrinking the health care footprint from page 31

interventions. Consider, for example, patient monitoring of blood sugar levels. According to the American Diabetes Association Standards of Care for 2011, this practice is of benefit, albeit small, for patients with type 2 diabetes who take insulin—to improve the safety of this treatment—and for patients who want to see the impact of changes in their lifestyle or treatment on sugar levels. For patients like John, routine self-monitoring significantly increases the workload and will not produce a big enough benefit to justify it. John’s situation would require that his clinician help him identify his goals and prioritize the available treatments according to their ability to achieve those goals. This will require John’s doctor to state goals in ways that John can “own”: We should not discuss LDL cholesterol, HbA1c, or bone density. Rather, the focus should be on the effect of treatment on the outcomes that are important to John: living independently, being able to care for loved ones, being able to live unhindered by complications of the diseases or treatments, and avoiding premature death. Our research group reported in the Journal of the American Medical Association in 2010 that only 1 in 20 diabetes trials reported the effect of treatments on patient-important outcomes. We need more of this research. For example, it has been clear since 2008 that tight control of blood sugars is unlikely to favorably affect John’s quality of life, lifespan, or risk of most diabetes complications. We need more research of this type to help John’s physician answer important questions: What treatments would help John accomplish his goals? What other treatments are less likely to help and could be discontinued or delayed until John is able to do them?

The agenda of minimally disruptive medicine calls for judicious use of evidence-based interventions that are consistent with the patient’s context, values, and preferences. However, the medicine being practiced today is the medicine of overtesting and overtreatment in pursuit of disease-centered outcomes that will get clinicians bonuses in pay-for-performance schemes. These costly practices contribute to health care inflation and to the well-being of the health care industry. Everyone appears to benefit—except patients like John. Minimally disruptive medicine thus requires clinicians to skillfully determine a patient’s context and to engage him or her in a shared approach to designing a treatment program. This form of personalized medicine seeks to optimize the treatment workload, enhance patient capacity, and reduce the burden of illness and the burden of treatment, all while pursuing the patient’s goals for care and life. Patient participation is essential to minimally disruptive medicine. Furthermore, patients will need to push political levers to swing the pendulum back from disease-centered systems that pit clinicians against patients who “fail” to achieve quality metrics. Minimally disruptive medicine will move us closer to realigning the goals of doctor and patient, improve adherence to effective therapy, and allow patients to receive care that is for and about them. Everything else will follow—including a smaller health care footprint. Victor M. Montori, MD, MSc, is a professor of medicine in the Department of Medicine and director of health care delivery research for the Knowledge and Evaluation Research Unit in the Department of Health Sciences Research at the Mayo Clinic, Rochester.

Minnesota

Health Care Consumer August survey results... Association

1. I, or a member of my immediate family, have spent at least one night in a hospital in the last 5 years.

Each month members of the Minnesota Health Care Consumer Association are invited to participate in a survey that measures opinions about topics that affect our health care delivery system. There is no charge to join the association, and everyone is invited. For more information, please visit www.mnhcca.org. We are pleased to present the results of the August survey.

80

50 40 30

26.1%

20

30 21.7% 15.2%

10

6.5% 2.2%

0

32

Strongly agree

Agree

Does not apply

Disagree

Strongly disagree

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2011

40 30 20

19.6%

17.4%

15.2%

10

17.4%

15 4.3%

10 5

10.9% Strongly agree

Agree

Agree

Does not apply

Disagree

37.0%

35

37.0%

25

0

0.0% Strongly agree

5. I felt the care delivered after discharge was adequately coordinated. 40

30

20

0

No

Percentage of total responses

40

20

Yes

30.4%

35

50

47.8%

10

40

54.3%

Percentage of total responses

Percentage of total responses

60

4. I was allowed to participate in decisions about where care would be continued after discharge.

Percentage of total responses

Percentage of total responses

60

50

73.9%

70

0

3. I felt the attending physician knew about the information given at discharge.

2. I felt the information received at discharge was clear and easy to understand.

Does not apply

Disagree

Strongly disagree

30.4%

30 25 20

17.4%

15 10.9% 10 4.3%

5 0

Strongly agree

Agree

Does not apply

Disagree

Strongly disagree

Strongly disagree

Minnesota

Health Care Consumer Association

Welcome to your opportunity to be heard in debates and discussions that shape the future of health care policy. There is no cost to join and all you need to become a member is access to the Internet.

SM

Members receive a free monthly electronic newsletter and the opportunity to participate in consumer opinion surveys.

www.mnhcca.org

Join now.

“A way for you to make a difference� SEPTEMBER 2011 MINNESOTA HEALTH CARE NEWS

33

Ankle injuries from page 29

Heel fractures Sixty percent of tarsal fractures involve the calcaneus, also known as the heel. Heel bone fractures are often severe and disabling, preventing many daily activities and most sports. Beyond confirming the fracture by x-ray, CT scans show the severity and other possible injuries, and help determine the most effective treatment plan. A cast or an immobilization device is used if the broken bones have not been displaced. Otherwise, surgery helps restores the normal position of the bone pieces and speeds healing. The AAOS notes that research for improving outcomes has focused on three areas: smaller incisions for fixing the fracture; defining which treatment method works best for which type of fracture and which type of patient—for example, smokers or people with diabetes; and inventing better plates and screws. Treatment advances According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, advances in diagnosing and treating injuries to the ankle and foot include: Arthroscopy. The biggest advance is using arthroscopy to view joint problems without major surgery. Tiny incisions mean less trauma, swelling, and scar tissue than with conventional surgery, as well as decreased hospitalization and rehabilitation. Because injuries often are addressed earlier, success is more likely. Tissue engineering. Unlike other tissues, injured joint cartilage

34

MINNESOTA HEALTH CARE NEWS SEPTEMBER 2011

does not heal on its own. Techniques such as transplanting one’s own healthy cartilage or cells to improve healing are used today for small cartilage defects. Questions remain about the usefulness and cost of this treatment. Targeted pain relief. New pain-killing, medicated patches and gels can be applied directly to an injury site rather than be taken systemically, thereby limiting some of the potential side effects. Treatments on the horizon According to the institute, future developments likely will include: • Technical advances and new imaging methods for improved diagnosis and treatment • Improved rehabilitation techniques that may reduce the need for surgery • Treatment improvements based on the role of nutrition in healing • Musculoskeletal tissue engineering Most of the ankle injuries we see in our 24-hour urgent care are minor and heal relatively quickly with proper instructions and treatments begun promptly after the injury occurs. It’s good to know, however, that advances in the care of ankle and foot injuries are being made in a wide area of diagnostic and therapeutic options, enabling people to resume healthy and active lifestyles more quickly and completely. Sumner McAllister, MD, practices family medicine at Apple Valley Medical Clinic.

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Minnesota Health care News September 2011