January/February 2016 CAPA News by CA Academy of PAs

News

Official Publication of the California Academy of PAs

January/February 2016

\The Magazine

Emerging Trends in the PA Profession by Roy Guizado, MS, PA-C, DFAAPA; President

he PA profession is a sought after career. It again has been ranked in the “100 Best Jobs” by U.S. News and World Report, where it has been placed at number five overall. PA also ranked number four in the best “Health Care Jobs” by U.S. News and World Report. According to the U.S. Bureau of Labor Statistics, the demand for PAs will be high, at about 30 percent through 2024. U.S. News and World Report found that in 2014 the national median salary level was $95,820 while the mean salary was $97,280. The salary at the 75th percentile was $114,760 compared to the 25th percentile of $82,090.

In addition, Glassdoor.com, a very competitive job recruiting site which ranks professions based on the level of pay, the demand for the job skill and advancement opportunities, ranked the PA profession as #7 in the best jobs in America in 2016. The PA profession is not just changing its position in the employment polls, it is also attempting to change the way PAs are perceived. According to an article by Steven Lane from the AAPA entitled “From Physician Assistant to PA,” the AAPA recommends replacing the term of physician assistant with PA. It is

well known that the term “physician assistant” does not accurately reflect the true medical practice of a PA. This was the focus of discussion at an AAPA Board Meeting in 2014 resulting in a PA Communications Guide. This guide recommends that “PA” is the correct term that should be used for the profession. Further, they defined PAs as healthcare providers who are nationally certified, state licensed to practice medicine and prescribe medication in every medical and surgical specialty setting. When describing the relationship with a Continued on page 4

A Refresh for PAs – It Is Sweeping the Nation by Gaye Breyman, CAE; Executive Director

his year we will celebrate 40 years of CAPA. There is so much to be proud of. So much important history. We will acknowledge and celebrate scores of CAPA wins, milestones and challenges in upcoming issues of the CAPA News and in Palm Springs in October.

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I believe in 2016 what will be most remembered is the movement – and that is what it is – a movement – to profoundly reposition the PA profession. To bring new language to the forefront which will communicate a clearer view of PAs. Think of the REFRESH icon at the top of your browser. You click on it and new, refreshed views and information load.

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An important step early on was CAPA’s adoption of the AAPA Communications Guide. On page 4, you will see excerpts of the Guide. I encourage you to read the entire two-page document. I promise you will be exhilarated! (And, if you know me, you know I don’t often say that about a position or policy paper!) You will want to share it with your collaborating physician, your practice manager, your HR department, your PA Program Director, etc. This is a movement and your passion and commitment are key to the success of this exciting refresh for the PA professional. Continued on page 5

News

At the Table

Editor Gaye Breyman, CAE

CAPA meets with Anaheim Fire Chief, Randy Bruegman and Fire Captain, Dave Berry to talk about opportunities to bring team-based care to the community care response unit.

Managing Editor Denise Werner Proofreaders Coryn Henderson Jonathan Kulesza

Editorial Board Roy Guizado, MS, PA-C, DFAAPA Jeremy A. Adler, MS, PA-C Ana Maldonado, MPH, DHSc, PA-C Bob Miller, PA

In November 2015, Jeremy Adler, MS, PA-C attended a reception for Assembly Speaker Toni Atkins in San Diego. In February 2016, Immediate Past President, Jeremy Adler, MS, PA-C and Executive Director, Gaye Breyman, CAE attended the AAPA Leadership and Advocacy Summit.

CAPA Board of Directors President Roy Guizado, MS, PA-C, DFAAPA president@capanet.org Immediate Past President Jeremy A. Adler, MS, PA-C ipp@capanet.org

Our thanks to Bob Miller, PA, Founding President of the CAPA Foundation for a job well done!

Vice President Ana Maldonado, MPH, DHSc, PA-C vicepresident@capanet.org Secretary Christy Eskes, DHSc, MPA, PA-C secretary@capanet.org Treasurer Bob Miller, PA treasurer@capanet.org Directors-At-Large Sue Gilroy, PA-C dirsue@capanet.org Cherri L. Penne-Myers, PA-C dircherri@capanet.org Kevin Robertson, MHS, PA-C dirkevin@capanet.org Saloni Swarup, PA-C dirsaloni@capanet.org Student Representative Emily McCoy, PA-S studentrep@capanet.org

The CAPA News is the official publication of the California Academy of PAs. This publication is devoted to informing PAs to enable them to better serve the public health and welfare. The publisher assumes no responsibility for unsolicited material. Letters to the editor are encouraged; the publisher reserves the right to publish, in whole or in part, all letters received. Byline articles express the opinion of the author and do not necessarily reflect the views or policies of the California Academy of PAs.

The CAPA office is located at: 2318 S. Fairview St. Santa Ana, CA 92704-4938 Office: (714) 427-0321 Fax: (714) 427-0324 Email: CAPA@capanet.org Internet: www.capanet.org ©2016 California Academy of PAs™

CAPA NEWS

Electronic Ballots Coming to CAPA Members Soon! Reminder: Make Sure Your Email Address of Record Allows For You to Receive a Ballot! In 2014, CAPA adopted electronic ballots as the means for all balloting of the membership. On April 5, 2016 all CAPA members who are eligible to vote will be sent an email with a unique link which will allow them to vote in the election for the CAPA Board of Directors. Eligible Fellow members will also be able to vote for Delegates to the AAPA House of Delegates. Eligible Student members will vote for the Student Representative. CAPA’s electronic balloting vendor will email the unique link for the electronic ballot to the email address you have provided in your membership profile. If you are using a business, school or other email address that filters and deletes mass emails, then you may possibly not receive the sent email with the link to the ballot. Some email spam/junk/content filters are so strong that filtered email may not be viewable in your spam or junk folder. We at CAPA will ensure and document that we have sent the email to you at your email address of record. We cannot ensure you receive it. If you have not received an email with a link to vote in the CAPA election by April 11, 2016, please look in your spam or junk folder. If you don’t see it there, please give us a call at (714) 427-0321 and we will confirm your eligibility to vote and, if necessary, send you an alternate option to cast your vote. If you have specific concerns regarding electronic ballots, please contact the CAPA office. The last day to vote is May 4, 2016.

The Professional PA by Jeremy A. Adler, MS, PA-C; Immediate Past President

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PAs practice across a wide spectrum of medical specialties and practice types. As a result, the role of the PA may vary considerably. Despite these variations, all PAs in California are ultimately governed by regulatory agencies that have a mandate to protect the public. As the PA profession matures, it is important that the processes ensure that PA/physician teams produce high quality care. Processes such as certain documentation requirements, chart cosignatures, percentage based chart review and other tasks specific for PAs are not universally required

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can think of no other profession that mirrors that of the PA. The original vision may have been to “assist” physicians, but the way our profession has developed today the term “assistant” is certainly a misnomer. The conundrum of nomenclature is the fuel igniting the debate about name change; but that is not the point of this article. The point is to focus more directly on how PAs view themselves, our profession and our integration into California’s healthcare.

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across the country. In fact, the American Academy of PAs last year authored model legislation that puts the emphasis on empowering practice level determination of the relationship between the PA and physician. Having all of these processes can easily overburden, and may be unnecessary, for the majority of PAs, but over the years it has been accepted that these processes are just a part of being a PA in California. With the greater need for access to care, it is important to periodically review these processes to ensure that they remain relevant.

An important consideration in the role of the PA is that PAs function as healthcare professionals. A profession is defined in Merriam Webster as “a calling requiring specialized knowledge and often long and intensive academic preparation; a principal calling, vocation, or employment; the whole body of persons engaged in a calling.” PAs choose their career for many reasons, but a unifying theme is their desire to help others. In California, PAs have been granted the privilege to exercise very autonomous and independent medical decision making when practicing with supervising physicians. As long as certain mechanisms for supervision are established, PAs can evaluate patient complaints, obtain appropriate diagnostic testing, provide patient education and provide treatment, including prescription medication, procedures and referral. The contributions of the PA, therefore, cannot be considered an individual performing technical tasks, but Continued on page 15

Inside This Issue At the Table............................................................................................................. 2 Electronic Ballots Coming to CAPA Members Soon!..................................................... 2 The Professional PA................................................................................................. 3 AAPA PA Communications Guide Excerpt................................................................... 4 Using the PA Communications Guide......................................................................... 5 This is YOUR Profession, Be the Change You Want..................................................... 6 A Seismic Shift for PAs............................................................................................. 6 The Glue in the Medical Profession........................................................................... 7 Durable Medical Equipment (DME): CMS Clarification for PAs and New Prior Authorization Process........................................................................ 8 CMS Notice.............................................................................................................. 9 A New PI-CME Opportunity for Any PA.................................................................... 11

Hand Hygiene in the Healthcare Setting................................................................. 11 Collaboration in the Roundtable Setting.................................................................. 12 Walking the Walk.................................................................................................. 13 Controlled Substances Education Course for PAs....................................................... 13 PAs in Primary Care............................................................................................... 14 Basic Info on Concussions....................................................................................... 16 Excerpt from California Assembly Bill No 2127....................................................... 19 Congratulations to the 2016 CAPA Scholarship Winners!.......................................... 21 The Power of Compassion....................................................................................... 22 Welcome New Members......................................................................................... 23 Local Groups......................................................................................................... 23 Correction to CAPA News........................................................................................ 23 JANUARY/FEBRUARY 2016

Emerging Trends in the PA Profession Continued from page 1

physician, the term collaboration is preferred over supervision, i.e., “PAs collaborate with physicians and all members of the healthcare team to provide medical care.”

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CAPA is leading the charge by eliminating the words “physician assistants” from the common uses of its association name. The former “California Academy of Physician Assistants” has embraced “PA” by being the first in the nation to change its name, now known as the “California Academy of PAs™” In June of last year, the CAPA Board moved forward with a plan to reposition how PAs are referred to and ultimately perceived. CAPA Executive Director, Gaye Breyman, CAE, was quoted in the AAPA’s PA Professional, January 2016 edition, “As the PA profession evolves, so does the language used to talk about it. The explosive growth of the profession, coupled with the continued modernization of PA laws, is rapidly changing the way PAs

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practice and the language we use to describe what they do. This is a reference guide for how to communicate about the profession in a way that reflects the realities of modern PA practice.” At the 2015 Annual CAPA Conference held in Palm Springs, Immediate Past President,

Jeremy Adler, MS, PA-C, presented a talk entitled, “Influencing the Position of the PA Profession” in which he pointed out that the word “assistant” does not capture the true essence of the PA profession. His talk was recorded and caught the attention of the AAPA. Both he and Gaye attended the AAPA’s Annual Leadership and Advocacy Summit, where they were able to share CAPA’s experiences with other constituent organizations as we all begin the process of implementing the repositioning of “PA.” It is clear that both CAPA and the AAPA are making an impact on the way PAs are perceived and how we collaborate with other healthcare providers, healthcare organizations and patients. CAPA, again, is a leader in this movement. As PAs, we should support this move to REFRESH the terminology and, ultimately, the position of PAs in the healthcare workforce. 

Excerpted from the AAPA PA Communications Guide January 2016 A Guide for Writing and Talking About PAs

The PA Abbreviation Use “PA” as the title of the profession, not “physician assistant,” in all copy. We do not use “physician assistant” any longer to refer to the profession as the name does not adequately depict the medical services PAs provide to patients every day. If you must spell it out to aid in external audience awareness, only use “physician assistant” once in parentheses after the first PA reference (i.e., PA (physician assistant)); for all subsequent references, use the title PA. What do PAs do? • PAs practice medicine. • PAs practice in every medical and surgical specialty and setting. • PAs manage the full scope of patient care, often handling patients with multiple morbidities. • PAs conduct physical exams, diagnose and treat illnesses, order and interpret tests, assist in surgery, coordinate care, counsel on preventive healthcare, prescribe medications and more. Outdated Lexicon/Myths/Misperceptions • Inaccurate Terminology: “PAs are mid-level providers, physician extenders, non-physician providers, advanced practice providers or advanced practice clinicians.”

CAPA NEWS

These terms are often misunderstood by consumers and do not accurately portray or describe how PAs practice medicine to other providers or patients. Nor do they reflect their license or legal title. If PAs need to be referenced as part of a larger group, use “healthcare provider”, “healthcare practitioner,” or “clinician” but the preferred reference would include simply the title name of each profession (e.g., “PAs and NPs”). • · Inaccurate Terminology: “PAs work on physician-led teams.” or “PAs are supervised by a physician.” It is no longer the case that physicians have to be at the helm of the patient care team. Today’s PAs collaborate with physicians. Supervision should only be referenced when required by legal and regulatory documentation. For example, patient-centered medical homes allow for various health professionals to function as leaders of teams, including PAs. © AAPA Communications Guide, January 2016

A Refresh for PAs – It Is Sweeping the Nation Continued from page 1

Once you embrace and commit to using the terms in the Guide, you and your colleagues will begin to catch each other when some of the “old” terms slip out. We do that at CAPA at all levels, in all meetings, in print material and when talking to PAs and employers on the phone. It has only been about 8 months since we started the change in terminology and it is now a wonderful, empowering habit (with a few slips now and then). And, with the change in terminology comes a natural and inspiring shift in the way PAs view themselves and colleagues view PAs.

empowered themselves to frame how PAs are viewed, spoken of and utilized. Once again CAPA and California PAs will lead the nation. Stay tuned, you will hear a lot more about this in the coming weeks and months. Visit www.capanet.org/refresh for Important Resources/Reading Material You will find links to: • The entire AAPA Communications Guide, January 2016 – Just 2 pages! A must read and must share. • The video entitled Influencing the Position of the PA Profession – We All

2016 will be remembered as the year California PAs and PAs across the nation

Have a Role. Presented by Jeremy Adler, MS, PA-C at the CAPA Conference in October 2015 • The article entitled, From Physician Assistant to PA from the January 2016 issue of PA Professional (see excerpt below). Note: You may notice there are many instances on our website that have not been updated with the new terminology. This is because we are working on a totally new website which will be much more userfriendly. We want to be good stewards of our members’ dues dollars and not spend a lot of money to update a site that is going to be deleted over the next several months. 

Reprinted with permission from the AAPA.

Gaye Breyman, CAE CAPA executive director

COURTESY COURTESY OF CAPA OF CAPA

Gaye Breyman, CAE CAPA executive director

“The fact that [the PA Communications Guide] comes “The fact that [the PA from the national organization Communications Guide] comes really helps. Recently, an advertiser from the national organization was using phrasing we did not love. really helps. Recently, an advertiser I was able to forward the guide to was using phrasing we did not love. them and let them know that CAPA I was able to forward the guide to has adopted the guide. People are them and let them know that CAPA impressed with how consistent and has adopted the guide. People are intentional we are.” impressed with how consistent and intentional we are.”

Using the PA Communications Guide The PA Communications Guide was developed in 2014 to provide ways of talking about the PA profession that reflectthe the profession’s true place in the modern healthcare arena. The preface to the guide captures its Using PA Communications Guide intent succinctly: The PA Communications Guide was developed in 2014 to provide ways of talking about the PA profession that reflect the profession’s true placethe in the modern healthcare arena. Theexplosive preface to the guide As the PA profession evolves, so does language used to talk about it. The growth of thecaptures profes- its intent sion, succinctly: coupled with the continued modernization of PA laws, is rapidly changing the way PAs practice and the language we use to describe what they do. This is a reference guide for how to communicate about the proAs the PA profession evolves, so does the language used to talk about it. The explosive growth of the profesfession in a way that reflects the realities of modern PA practice. sion, coupled with the continued modernization of PA laws, is rapidly changing the way PAs practice and the language we use to describeGuide whatwas theysent do. This is AAPA a reference guide constituent for how to communicate about proThe PA Communications to all members, organizations (COs)the and PA fession inina 2015. way that reflects of already modern replaced PA practice. programs More thanthe 70 realities COs have “physician assistant” with PA on their websites, and many are using it to help educate all the stakeholders they work with. The California Academy of PAs, The PA Communications Guide was sent to all AAPA members, constituent organizations (COs) and PA which was one of the first COs to use “— Academy of PAs” on its website, letterhead, and newly printed programs in 2015. More than 70 COs have already replaced “physician assistant” with PA on their websites, promotional materials has been one of the standard-bearers in using the guide. and many are using it to help educate all the stakeholders they work with. The California Academy of PAs, “We are using it as an educational tool and it is really effective,” says CAPA Executive Director Gaye Breywhich was one of the first COs to use “— Academy of PAs” on its website, letterhead, and newly printed man, CAE. “The fact that it comes from the national organization really helps. Recently, an advertiser was promotional materials has been one of the standard-bearers in using the guide. using phrasing we did not love. I was able to forward the guide to them and let them know that CAPA has “We are using it as an educational tool and it is really effective,” says CAPA Executive Director Gaye Breyadopted the guide. People are impressed with how consistent and intentional we are.” man, CAE. “The fact that it comes from the national organization really helps. Recently, an advertiser was Breyman is also on the Board of Trustees of Marshall B. Ketchum University in Fullerton, Calif., where a using phrasing we did not love. I was able to forward the guide to them and let them know that CAPA has new PA program was accredited this past year. The university has embraced the PA Communications Guide adopted the guide. People are impressed with how consistent and intentional we are.” as well, Breyman says, and is moving toward implementing its recommendations on all of its PA-related Breyman is also on the Board of Trustees of Marshall B. Ketchum University in Fullerton, Calif., where a communications: “People use it everywhere. All at MBKU are embracing CAPA’s name change and being new PA program was accredited this past year. The university has embraced the PA Communications Guide really conscientious in speaking and writing about the profession.” as well, Breyman says, and is moving toward implementing its recommendations on all of its PA-related “Our members, our board and stakeholders are excited to be part of a movement,” Breyman adds. “We communications: “People use it everywhere. All at MBKU are embracing CAPA’s name change and being are very enthusiastic and they understand the need for the change. I hope it goes nationwide. It will take a really conscientious in speaking and writing about the profession.” lot of people being passionate, consistent and patient but I see it happening. We consistently offer adver“Our members, our board and stakeholders are excited to be part of a movement,” Breyman adds. “We tisers, authors of articles and others an opportunity to change their written material [to “PA”] and they do. are very enthusiastic and they understand the need for the change. I hope it goes nationwide. It will take a Each incident is a learning opportunity. It will take time, but it will be those little things that will add up.” lot of people being passionate, consistent and patient but I see it happening. We consistently offer advertisers, authors of articles and others an opportunity to change their written material [to “PA”] and they do. Each incident is a learning opportunity. It will take time, but itPAwill up. P Rbe O F Ethose S S I O Nlittle A L | things J A N UA Rthat Y 2 0 will 1 6 | add A A PA . O”R G |

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JANUARY/FEBRUARY 2016

This is YOUR Profession, Be the Change You Want by Eric Glassman, MHS, PA-C; Public Education Committee Chair and Nominating Committee Chair

I’d like to see each and every PA take part in the process of educating the public. We can be proactive 6

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PAs also need to take charge of the change you want and the image you want to portray for our profession. We need to spend some time and focus on what “we” can do. We have the best knowledge of what we as PAs do on a day-to-day basis; we see patients all day, meet new people in our social lives every day, we “tweet,” we “post” and our personal reach is powerful.

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Your AAPA and CAPA membership dollars are being well spent to protect and promote PA practice. Of this you can be sure.

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Recently, during one of my searches to learn what is being discussed among PAs, I saw that comments still pop up that AAPA and state chapters need to do more to educate the general public about PAs, PA value and PA practice. In recent years, we have jumped leaps and bounds in this arena. AAPA has expert staff dedicated solely to promoting PAs and their PR staff is first rate. At CAPA, we never miss an opportunity to promote the profession and we create opportunity where it doesn’t already exist.

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any, if not all of us, are connected to each other via social media. Social media has changed our lives in so many ways. It may be our main source of getting the latest news, learning what is going on in the gossip world, checking on what’s happening with our favorite sports team or even networking with colleagues. Many PAs take part in Instagram, Facebook, Twitter and LinkedIn. Many PAs are also actively involved with different discussion forums (e.g. AAPA’s Huddle) regarding our profession.

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and seize every opportunity to be a shining example of what a PA is and does. I think we all have come to the realization that an “ad” about PAs in a magazine or newspaper isn’t going to have the impact we once believed it would. Collectively, we are 10,000 PAs strong in California and 100,000 strong across the country. Together we have the greatest voice. We are PAs! Only we can best answer: “What is a PA?” “When will you be done with your training?”

“Are you like a doctor or a nurse?” This list can go on and on. I know all of you have heard these questions too many times to count. More importantly, let’s shift the discussion. Let’s craft the dialogue. Hopefully, you are aware of the shift to and rationale for utilizing the term “PA” exclusively when referring to our profession. This move, if consistently and purposefully made by all of us, will have a tremendous impact. I have been introducing myself as a “PA” for many years, as have many of you. Now we can join the movement to encourage everyone to do the same. Not just PAs, but all who work with PAs; educators and employers as well. We are all very proud of our profession and the care we provide to our patients. We need to take these necessary, profound and important steps to strengthen and reposition our profession moving forward. Everyone needs to get on board; we are all in this together… 

NCCPA Recertification Exam Proposal Learn More About This Seismic Shift for the PA Profession Get Informed and Take Action! Check out CAPA’s website for links to up-to-date information.

www.capanet.org/nccpaproposal

Using the resources provided, inform yourself about: • NCCPA’s Proposal and AAPA’s Assessment of Supporting Literature • AAPA Assessment of NCCPA’s Survey • Resources to help PAs develop comments and responses to the proposal • The potential risks to PAs and the potential impacts on both healthcare access and costs • AAPA’s and CAPA’s actions to advocate for evidence-based methods to assess competency

The Glue in the Medical Profession by Sonny Cline, PA-C, MA, M.Div; Political Action Committee Chair

ot that long ago I attended a PA society meeting at a local restaurant in Sacramento, where the topic discussed that evening was the new (not so new now) drug Harvoni. The gentleman giving the talk was a PA in the field of gastroenterology. He was well educated and did a wonderful job leading the discussion. Before the dinner began, I had a chance to get to know him a bit and found out that he had worked in family medicine, dermatology, some emergency medicine and now gastroenterology. I shared with him the three different areas I have worked in throughout my career as a PA. We had a “Our knowledge of other wonderful discussion specialties allows us to about the uniqueness of the PA profession have conversations with a to experience such broader range of medical a varied career. He referred to us as “the professionals which are glue” in the medical more meaningful and profession. That idea has stuck with me intimate when we can since our discussion.

relate to their work day. ”

Glue is an amazing product. Most of us who are old enough remember the old Elmer’s glue we used in kindergarten, sometimes for purposes not intended. Since those early days of kindergarten I have noticed that glue comes in a wide variety now, with many applications. I remember when Krazy Glue® came out and the funky commercials which accompanied it. Glue has so many applications across so many mediums now, it’s hard to imagine living without it. But, no matter what type of glue you need for the wide variety of jobs, you may encounter two basic principles about glue that are universal. First, it is, in its essence, a bonding agent and

as such, forms bonds with whatever material it contacts. Second, it is a connector bringing together two or more pieces to create a more holistic working product. When I reflect on glue, I believe the PA I spoke with that evening was exactly on the mark by describing us as the glue in the medical profession. The truth is, we are a bonding agent in the medical profession. Many of us have worked across a variety of specialties during our careers. The knowledge we acquire in one specialty and then bring to another often times ends up being the missing puzzle piece that is needed in so many cases. Our knowledge of other specialties allows us to have conversations with a broader range of medical professionals which are more meaningful and intimate when we can relate to their work day. When I am working in family medicine and I refer someone to the ER, many times I call the ER to let them know who is coming and why. Because I have worked in our local ER in the past, the conversation is completely different than if I had never worked there. They know that I understand their environment, the appropriate use of the ER and the limits of the ER. There is, in fact, a bond that is created because of this uniqueness to work across specialties and that bond translates into better patient care, in my opinion. Secondarily, we, like glue, connect others. We are frontline soldiers and, as such, we are in the thick of the battle every day. Because of our position, we have quick and direct access to everyone on the team; the doctor, the nurse, the MA, tech, etc. In so many practices and hospitals, we are a primary connecting point for the medical team. Because we have always had (and continue to

redefine) a collaborative relationship with physicians, they are responsive and helpful in walking through those more difficult cases with us. My experience working with nurses through the years has been overwhelmingly positive with the support I have received and the knowledge they have imparted to me. The MAs and the techs have worked tirelessly, balancing many patients at one time while trying to complete a number of tasks I have requested. While each one of us has our role, all of these connections are dynamic, and at times, happening simultaneously, many times with us as the connecting point. I would submit that because we are capable of crossing the lines of different specialties, we carry with us a unique ability to connect others that is found nowhere else in the medical profession. I want to clarify that I do not believe we are the most important part of the medical team, simply a part of the medical team, and that part seems to be the glue of the medical profession. Personally, I like being glue. I like that we come in wide varieties, with a multitude of purposes. I like that we connect other pieces of the medical team to bring about a more holistic approach to medical care. I like that we are involved in the entire system of medical care. We get to view it from so many perspectives and consequently carry those perspectives with us to share with others. I guess it’s fair to say I like what we do. I like what I do every day and I think we should keep doing it with excellence. 

JANUARY/FEBRUARY 2016

Durable Medical Equipment (DME): CMS Clarification for PAs and New Prior Authorization Process by Bob Miller, PA; Professional Practice Committee Chair

ME is also known as DMEPOS (Durable Medical Equipment, Prosthetic, Orthotics and Supplies) under Medicare. Certain items will now require a prior authorization process explained in the final rule published on 12/30/2015. DMEPOS is defined in the Code of Federal Regulations (CFR) in 42 CFR 414.202 as equipment furnished by a supplier or a home health agency (HHA) that: • Can withstand repeated use;

“This final rule explaining the prior authorization process has been developed as a result of ongoing pilot projects in several states looking at improper payments for these devices.”

• Effective with respect to items classified as DME after January 1, 2012, has an expected life of at least 3 years; • Is primarily and customarily used to serve a medical purpose; • Generally is not useful to an individual in the absence of an illness or injury;

• Is appropriate for use in the home. Examples of DME include items such as wheelchairs, hospital beds and prosthetic devices. This final rule explaining the prior authorization process has been developed as a result of ongoing pilot projects in several states looking at improper payments for these devices. California was one of the states included in projects focusing on power mobility devices (PMDs). The projects revealed that there were improper payment 8

CAPA NEWS

patterns in what they termed “… unnecessary utilization…” and much attributed due to “…insufficient documentation…” Below is an overview excerpted from the CMS website: www.cms.gov. Prior Authorization Process for Certain Durable Medical Equipment, Prosthetic, Orthotics, Supplies (DMEPOS) Items CMS Finalizes Rule Creating Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Items (CMS 6050-F) Update: 12/30/15 OVERVIEW The Centers for Medicare & Medicaid Services (CMS) today issued a final rule that would establish a prior authorization process for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items that are frequently subject to unnecessary utilization. This prior authorization process will help ensure that certain DMEPOS items are provided consistent with Medicare coverage, coding, and payment rules. CMS believes the final rule will prevent unnecessary utilization while safeguarding beneficiaries’ access to medically necessary care. Under the final rule, the prior authorization process will require the same information necessary to support Medicare payment today, just earlier in the process. It will not create new

clinical documentation requirements. The prior authorization process assures that all relevant coverage, coding, and clinical documentation requirements are met before the item is furnished to the beneficiary and before the claim is submitted for payment. This helps ensure that beneficiaries are not held responsible for the cost of items that are not eligible for Medicare payment. CMS believes prior authorization is an effective way to reduce or prevent questionable billing practices and improper payments for DMEPOS items. Access is preserved in this rule by having both specified timeframes for review and approval of requests, and an expedited process in cases where delays jeopardize the health of beneficiaries. The above rule explains the same information will still be required, as before, but it will be necessary “... just earlier in the process.” Look to the CMS website for lists of items requiring prior authorization. There has been confusion as to how the PA fits into this whole process regarding documentation, the required face-to-face visit for certain DME and co-signatures. I asked for some clarification from Michael Powe, Vice President, Professional & Reimbursement Advocacy at the AAPA. Mr. Powe provided the CMS notice, on pages 9 and 10, dated October 2015 clarifying the role of the PA and that a co-signature from an MD or DO is no longer required. 

See CMS Notice on pages 9 & 10.

Durable Medical Equipment Medicare Administrative Contractor

Face-to-Face and Written Order Requirements for High Cost DME Revised October 2015 Dear Physician, For certain specified items of durable medical equipment (see Table A), the Affordable Care Act requires: 1. An in-person, face-to-face examination with the treating physician (MD, DO, DPM, PA, NP, CNS)*; and, 2. The treating physician must document that the beneficiary was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered; and, 3. The face-to-face examination must have occurred sometime during the six (6) months prior to the date of the order for the item. *The Medicare Access and SCHIP Reauthorization Act of 2015 eliminated the ACA requirement that the NP, PA or CNS face-to-face examination documentation be co-signed by an MD or DO. The purpose of this letter is to provide additional details of these requirements. Medicare rules stipulate that a face-to-face examination meeting the requirements discussed below be performed each time a new prescription for one of the specified items is written. A new prescription is required by Medicare: • For all claims for purchases or initial rentals • When there is a change in the order for the accessory, supply, drug, etc. • On a regular basis (even if there is no change in the order) only if it is so specified in the documentation section of a particular medical policy • When an item is replaced • When there is a change in the supplier These requirements are effective for all new Medicare orders (prescriptions) for the specified items created on or after July 1, 2013. Face-to-face Examination Requirements For Medicare beneficiaries, the treating physician must have a face-to-face examination with the beneficiary in the six (6) months prior to the date of the written order for the specified items of DME. This face-to-face requirement includes examinations conducted via the Centers for Medicare & Medicaid Services (CMS)-approved use of telehealth examinations (as described in Chapter 15 of the Medicare Benefit Policy Manual and Chapter 12 of the Medicare Claims Processing Manual - CMS Internet-Only Manuals, Publ. 100-02 and 100-04, respectively). For the physician prescribing a specified DME item: • The face-to-face examination with the beneficiary must be conducted within the six (6) months prior to the date of the prescription. • The face-to-face examination must document that the beneficiary was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered. • Remember that all Medicare coverage and documentation requirements for DMEPOS also apply. There must be sufficient medical information included in the medical record to demonstrate that the

NHIC, Corp. http://www.medicarenhic.com

DME MAC Jurisdiction A 75 Sgt William B. Terry Drive Hingham, MA 02043 A CMS CONTRACTOR TMP-ADM-0007 V5.0 04/17/2015

JANUARY/FEBRUARY 2016

CMS Notice continued from page 9

applicable coverage criteria are met. Refer to the applicable Local Coverage Determination for information about the medical necessity criteria for the item(s) being ordered. • The treating practitioner that conducted the face-to-face examination does not need to be the prescriber for the DME item. However the prescriber must:  Verify that the in-person visit occurred within the six (6) months prior to the date of their prescription and have documentation of the face-to-face examination that was conducted; and,  Provide a copy of the face-to-face examination and the prescription for the item(s) to the DMEPOS supplier before the item can be delivered. Prescription (order) Requirements These items require a written order prior to delivery (WOPD). A WOPD is the standard Medicare detailed written order, which must be completed and in the DMEPOS supplier’s possession BEFORE the item can be delivered. The prescription (order) for the DME must meet all requirements for a WOPD and include all of the items below: • Beneficiary’s name, • Physician’s Name • Date of the order and the start date, if start date is different from the date of the order • Detailed description of the item • The prescribing practitioner’s National Provider Identifier (NPI), • The signature of the ordering practitioner • Signature date For any of the specified items provided on a periodic basis, including drugs, the written order must include: • Item(s) to be dispensed • Dosage or concentration, if applicable • Route of Administration, if applicable • Frequency of use • Duration of infusion, if applicable • Quantity to be dispensed • Number of refills, if applicable Note that prescriptions for these specified DME items require the National Provider Identifier to be included on the prescription. Prescriptions for other DME items do not have this NPI requirement. Date and Timing Requirements There are specific date and timing issues: • The date of the face-to-face examination must be on or before the date of the written order (prescription) and may be no older than 6 months prior to the prescription date. • The date of the face-to-face examination must be on or before the date of delivery for the item(s) prescribed. • The date of the written order must be on or before the date of delivery (DOS). • ALL DMEPOS suppliers must have documentation of both the face-to-face visit and the completed WOPD in their file prior to the delivery of these items. This letter is intended to be a general summary. It is not intended to take the place of the law, regulations, or national and local coverage determinations. Detailed information about these requirements can be found on the CMS web site http://www.cms.gov or on the DME contractors’ web site. Sincerely,

CAPA NEWS

Wilfred Mamuya, MD, PhD Medical Director, DME MAC, Jurisdiction A NHIC, Corp.

Stacey V. Brennan, MD, FAAFP Medical Director, DME MAC, Jurisdiction B National Government Services

Robert D. Hoover, Jr., MD, MPH, FACP Medical Director, DME MAC, Jurisdiction C CGS Administrators, LLC

Eileen Moynihan, MD Medical Director, DME MAC, Jurisdiction D Noridian Healthcare Solutions

A New PI-CME Opportunity for Any PA by Christy Eskes, DHSc, MPA, PA-C; Secretary and CME Committee Chair

f you are in the 10-year certification cycle, every 2 years of the first 8 years in that cycle, you need to complete 20 hours of either self-assessment (SA) or performance improvement (PI) CME, or a combination of both. CAPA is proud to offer a new PI-CME activity that has been approved by AAPA for 20 hours of PI-CME, which can fulfill the requirement for one of your 2-year blocks. The PI-CME activity, Hand Hygiene in the Healthcare Setting, will apply to PAs in nearly any healthcare setting

and will help educate providers and staff on the value of hand hygiene. This is a vital issue for patient safety, as avoidable infections continue to be a serious problem in healthcare. The goal of this activity is to recognize limitations and obstructions to hand hygiene in your working environment and strive to change them for the benefit of you and your patients. You begin this activity with a preassessment to evaluate baseline hand hygiene practice in your setting and then develop a plan for improvement. The post-assessment measures the

effectiveness of your plan and a final evaluation will be completed. To obtain credit for this activity, all components must be finished. It is estimated that the entire process will take 3-4 months. Special thanks to PAs Eric Glassman and Ray Contino for their time and expertise in developing this CME activity. We think you will find Hand Hygiene in the Healthcare Setting to be tremendously helpful, not only for completing your CME requirements, but also for improving patient care in your practice. 

Hand Hygiene in the Healthcare Setting

PI-CME

• Approved for 20 PI-CME credits by the AAPA • Designed to be completed in 3-4 months in your work environment • Easy to follow guidelines and instructions Hand Hygiene in the Healthcare Setting provides you with:

• A pre-assessment questionnaire that will demonstrate your current workplace compliance toward hand hygiene. • Educational resources that will guide you to correct any demonstrated areas of weakness. • A post-assessment questionnaire to evaluate your success in improving hand hygiene practices.

Registration Fees:

CAPA Member: $100 Non-Member: $175

Purchase online today at www.capanet.org JANUARY/FEBRUARY 2016

Collaboration in the Roundtable Setting by Teresa Anderson, MPH; Public Policy Director

hat is the value of a Roundtable Discussion? In order to really answer this question, it is important to know what a roundtable discussion is and the intended purpose of such a discussion. Though I have seen a few different definitions of roundtable, they all lead to the same conclusion: a roundtable is a facilitated discussion that gives each participant the maximum amount of group input on a given subject of common interest in a short amount of “Every single person at that time. Over the years, CAPA has been table represents a different fortunate to receive and participate in interest, yet it revolves various roundtable invitations. around the common

interest of improving and

I have learned the value of a roundtable increasing the lives of discussion is subjective and as people battling cancer. ” individual as the people participating in it. The format is somewhat universal in that there is typically a facilitator who is well-versed in the subject matter, a presenter[s] who is the content or subject matter expert and the participants who share an interest in the subject matter. The time is limited and managed carefully to keep the discussion moving along and reduce the chance that any one person will monopolize the discussion, allowing for maximum participant input. Group size and question format can vary but, overall, the meeting or discussion style is very accommodating and useful for discussing everything from molecular engineering of conjugated polymers to strategies for increasing access to care in underserved areas and everything in between. 12

CAPA NEWS

CAPA recently received an invitation to participate in the Commitment to Oncology Roundtable in which the value of oncology medications was the focus of the discussion. As the meeting began, it quickly became apparent, through opening remarks and introductions, I was sitting amongst a very diverse, incredibly smart and well-informed stakeholder group. Throughout the meeting, the question or concept of value kept getting stronger for me as I listened intently to each stakeholder position. Was there value in the knowledge, networking opportunities, advances in science and technology, issues raised during the discussion or patient advocacy? After opening remarks and introductions, two of the scientists – Albert Bourla, PhD, DVM and Mikael Dolsten, MD, PhD – discussed their experiences in developing and advancing oncology medications. I liken it to what it must have been like to listen to Einstein or Pascal and realize you don’t know what you don’t know. Admittedly, the scientific part of their discussion was way outside of my frame of reference. However, as they continued, the personal side of their experience became apparent as they discussed a colleague who battled cancer. In no more than a breath, the matter-of-fact science and procedural reminiscence of developing specific medications turned to a compassionate expression of dedication and drive marked by a softer voice and smiling eyes as they talked about their friend and colleague. Their presentation was, without a doubt, impressive, but the comment that really captured me was, “Time makes a difference for cancer patients.” I found it very difficult to process what was being said for the next few minutes after

that statement was made. I sat at the table contemplating what that statement really meant. Such a true and simple statement – “Time makes a difference for cancer patients.” Time, for a person with cancer….having more time with their loved ones, time to enjoy a beautiful sunrise or sunset, more time to experience life, less time suffering from debilitating cancer pain…. is the real value. Advances in science and technology, in many cases, give patients time. As the discussion continued, more and more issues came to light: disparities in access to clinical trials, the need to increase outreach to providers (especially in low-income areas), the need for userfriendly resources for patients and providers, strong desire to reduce silos and encourage collaborative efforts and the need for concerted efforts to increase diversity in patient populations participating in clinical trials. The one thing that seemed to be a constant was the need to remain patient centered. The roundtable was held at the Rinat Laboratory in South San Francisco. We were all privileged to receive a tour of the facility after the discussion. It truly was a privilege to tour the facility and see firsthand the hard work and dedication that goes into the day-today work of the scientists. Trays and trays lined with small vials and precise droplets being ever so cautiously dropped into the vials with even the smallest details being diligently recorded. I imagine the hundreds of hours spent in trial and error and the patience it must take to engage in that process. I was impressed by all the machines, solutions, beakers and supplies in the lab. A few key facts I want to share with our readers:

Walking the Walk • Cancer death rates have fallen by 20% since 1991 • The overall 5-year relative survival rate for childhood cancer increased significantly over the past three decades, going from 58.1% diagnosed cases in 1975 – 1977 to 82.5% diagnosed cases from 2001 – 2007 because of new advances in treatment options • More than half of patients diagnosed with Non-Hodgkin’s Lymphoma are now surviving the disease as a result of improved diagnosis and treatment • Personalized medicine or precision medicine is substantially improving outcomes for patients In closing, I want to get back to the concept of the value of a roundtable discussion and suggest that although

it is subjective and unique to each individual, the true value lies within the process of collaboration. Every single person at that table represents a different interest, yet it revolves around the common interest of improving and increasing the lives of people battling cancer. The key facts mentioned above are not incidental nor accidental, but rather the result of many years of hard work and dedication involving everyone from the scientists to the healthcare professionals, pharmacists, pharmaceutical companies, patients and grassroots advocacy organizations who fight for patient rights and advocate for equal access to care and medication. For CAPA, the value is being part of a discussion that puts patients first and puts PA representatives at every table. We are proud to be a valued stakeholder and contribute to such a meaningful discussion. 

Controlled Substances Education Course for PAs

6 Hour s Cat. I CME

Saturday, July 30, 2016 Marshall B. Ketchum University 2575 Yorba Linda Blvd Fullerton, CA Saturday, November 5th, 2016 Northern California Location is TBD

Wednesday, October 5, 2016 Renaissance Palm Springs (preceding CAPA Conference) 888 E Tahquitz Canyon Way Palm Springs, CA

by Sue Gilroy, PA-C; Director-At-Large

“We either make ourselves miserable, or we make ourselves strong. The amount of work is the same.”

— Carlos Castaneda

am resigned to exercise. After an adult lifetime of talking the talk, I walk the walk regularly… truly, walking. It amazes me how many people discount walking as a form of exercise—they expound on the virtues of tennis or bicycling or marathon running as “real” exercise forms and look on walking as a poor relation to anything aerobic. I salute those vigorous shapes pounding the pavement before dawn, trying to improve themselves and their performance times. Yet, look at photos of people walking and they are usually smiling, just enjoying the walk for what it is—a chance to slow down and see what is really around them, finding small delights in a neighbor’s garden or a funny bumper sticker on a parked car. We work so hard in healthcare that we often feel guilty for slowing down during our fitness regimens when walking. The exercise of walking requires more time to attain improvement-but you put one foot in front of the other, whether walking a path or climbing a mountain. The frustration of golfers with their games or runners with their times makes their fitness sound like a miserable experience—but we all are hoping to become stronger. My journey will just take longer—but I’m hoping to finish a bit stronger and with a smile. 

With CAPA’s efforts resulting in the successful passage of SB 337, effective January 1, 2016, PAs holding a certificate of completion from CAPA’s past or upcoming Controlled Substances Education Courses have mechanisms to reduce physician co-signatures from a mandatory 100% of Schedule II medical records down to 20%. JANUARY/FEBRUARY 2016

PAs in Primary Care by Ana Maldonado, MPH, DHSc, PA-C; Vice President

s PAs, we all know our generalist medical education permits us to function as clinicians, in collaboration with physicians, to provide patient care in a wide variety of medical specialties and healthcare settings (AAPA, 2015). To date, approximately 1/3 of PAs practicing in the U.S. are employed in primary care settings defined as family medicine, general medicine and general pediatrics. Subsequently, the distinction of primary care has broadened “PAs practicing in primary now to include emerging roles care have gained the such as hospitalist, distinction of providing oncology, psychiatry, geriatrics and other comprehensive, healthcare delivery coordinated care with innovations such as telemedicine and increased continuity retail medicine.

and accessibility for the patients they serve.”

In reviewing a recent article published on the NIH Public Access website, one of the questions posed was: To what extent do PAs contribute to effective, safe and efficient team-based primary care? The core of this question is to explore and identify the services PAs can perform within the context of a physician-PA primary care team that are demonstrated as beneficial to the practice, the patient, the employer and society (Hooker & Everett, 2012). Additionally, it is important to examine the recent shift and decreased percentage of PAs entering the practice of medicine in primary care due to the decrease in federal funding for PA education that once emphasized primary care and the deployment of PA graduates to underserved areas. Other significant influences include the high wage differentials for emergency medicine, dermatology, surgery and procedure-

CAPA NEWS

based roles. For those PAs that practice in rural areas of the US, there is some reported dissatisfaction with the longer hours, higher stress, poor reimbursement and erosion of scope of practice (Center et al, 2009). The Pros – Contributions of PAs to Primary Care PAs practicing in primary care have gained the distinction of providing comprehensive, coordinated care with increased continuity and accessibility for the patients they serve. Multiple studies have compared the scope of patient care services by PAs and physicians in primary care settings and have concluded that PAs can perform 85 -90% of the services traditionally provided by primary care physicians (Hooker, 2010). In a recent study of U.S. Community Health Centers, it was identified that a higher percentage of PA visits were focused on providing care for a patient with an acute condition (48%) compared with physicians (34%) and NP visits (33%). These acute conditions were typically injury, illness and comorbid conditions such as: hypertension, hyperlipidemia, diabetes, depression, obesity, arthritis, asthma, and chronic and obstructive pulmonary disease (Hing, 2010). Results from another study suggests that comprehensive primary care services provided in rural communities by PAs and physicians were not comparably different in terms of the prescribing, interpreting diagnostic studies, providing a wide range of services, referring patients and providing patient education. In terms of coordinated care, this level of care is generally viewed by primary care PAs as a function that is included within their clinical role. Specialist physicians have consistently reported their willingness to accept

patient referrals from primary care PAs and have expressed a general satisfaction with the appropriateness and timeliness of the referrals (Simekens, 2009). Continuity of care is another provision of care that enhances the patient-clinician relationship and is denoted as a central feature of primary care. In recent studies exploring the self-reported continuity of care related to patient satisfaction, it was demonstrated that there were no differences in types of providers (PA/NPs or doctors) when distinguished by the patient. This particular study suggested that it is the continuity of care and not the type of provider that was associated with higher patient satisfaction (Fan, 2005). As shown by empirical evidence, PAs can improve access to care to underserved patients and open access practices. In a study of primary care providers in California and Washington, PAs demonstrated a greater productivity for providing care to the underserved. PAs ranked first or second in both states (compared to MDs, NPs and midwives) as the providers with the highest proportion of the profession practicing in rural areas, health professional shortage areas and vulnerable population areas (Grumbach, 2008). The Cons – Why Not Primary Care as a PA? A number of studies have identified factors that discourage the recruitment and retention of PAs in primary care practices. The disparity in pay and benefits when compared with specialty practices has presented a barrier for many PAs (and physicians) entering the workforce to provide primary care services.

In rural primary care practices the lack of medical equipment, technological advancement and pharmacy availability has been a source of frustration for ruralpractice PAs. Additionally, social and professional isolation deters some PAs from entering and/ or continuing in primary care practices. In summary, although the practice of medicine for PAs in primary care can be rewarding and provide enhanced autonomy, scope of practice and involvement in community health. To date, the barriers for many outweigh the benefits. For some PAs, the diversity and complexity of a primary care practice with lessened acknowledgement of worth, both economically and professionally, are significant deterrents to practice. Yet, the need for PAs in primary care grows. Let us examine, as citizens, how to bridge this gap in order to respond socially and professionally to the needs of our healthcare seek-ing communities. The upcoming debates in this election year will no doubt include a polarized discussion regarding the provision of primary healthcare in the U.S. Let us, as PAs, whether we practice in specialties or primary care, vocalize the significance of our profession and the need for PAs to participate on the frontlines of healthcare delivery.  References: American Academy of Physician Assistants. AAPA Physician Assistant Census Report: 2009, Alexandria, VA: American Academy of Physician Assistants 2009:1-15. Center, R. G., Bazemore, A., Bennett, K., Dodoo, M. S., Legagneur, C., Petterson, S., ...

& Xierali, I. (2009). Specialty and Geographic Distribution of the Physician Workforce--What Influences Medical Student and Resident Choices?. Robert Graham Center. Fan, VS, Burman, M, McDonell, MB, Fihn SD. (2005).Continuity of care and other determinants of patient satisfaction with primary care. Journal of General Internal Medicine. 20(3):226-233. Grumbach, K., & Mendoza, R. (2008). Disparities in human resources: addressing the lack of diversity in the health professions. Health Affairs, 27(2), 413-422. Henry, L. R., Hooker, R. S., & Yates, K. L. (2011). The role of physician assistants in rural healthcare: a systematic review of the literature. The Journal of Rural

Health, 27(2), 220-229. Henry, L., & Hooker, R. S. (2008). Autonomous physician assistants in remote locations: Perspectives from the communities they serve. J Physician Assist Educ, 19(1), 34-37. Hing, E., Hooker, R. S., & Ashman, J. J. (2011). Primary healthcare in community health centers and comparison with office-based practice. Journal of community health, 36(3), 406-413. Simkens, A. B., van Baar, M. E., van Balen, F. A., Verheij, R. A., van den Hoogen, H. J., & Schrijvers, A. J. (2009). The Physician Assistant in General Practice in the Netherlands. The Journal of Physician Assistant Education, 20(1), 30-38.

The Professional PA Continued from page 3

rather a healthcare professional that has a backbone founded in rigorous education, national certification and continuing medical education. When treating patients, PAs are not just “assisting” the physician, but rather are team members contributing in ways that enrich the patient’s healthcare experience. PAs are both complementary and necessary in California’s healthcare system. One such process to review is the required Delegation of Services Agreement. The written agreement between the PA and physician is outlined in both law and regulation. CAPA has heard from members that all of the formal written documentation that must be in place for PA practice can disincentivize PAs in the

healthcare system. Often it is mentioned that NPs lack these document requirements and their relationship with physicians is perceived as much easier, making them potentially more employable. The American Academy of PAs’ model legislation has removed a recommended formal written document between the physician and PA. Although a formal document remains required in California, there may be ways the documentation can be simplified and streamlined. The PA professional is an important team member in California’s healthcare workforce. As PAs are further integrated and expand access to high quality care, we must continue to review and examine the processes and barriers that exist that may inhibit the full potential our profession can provide.  JANUARY/FEBRUARY 2016

Basic Info on Concussions by Cherri Penne-Myers, PA-C; Director-At-Large

as anyone seen the movie Concussion yet? This movie highlights the problems with the sport of football. It is raising public awareness about the dangers of football-related head trauma. We should all know that football is not the only sport where head trauma can lead to a concussion. Concussions occur in contact and collision sports, including: ice hockey, soccer, wrestling, diving, lacrosse, field hockey, gymnastics, cheerleading, skiing, basketball, baseball, boxing, swimming, surfing, track, pole vault, rugby, equestrian, softball, water polo, bowling, volleyball and motocross to name a few. Concussions do not always mean the individual is “knocked out.” A change in mental status as a result of direct or indirect head trauma can also indicate a concussion. What is a concussion? There are four different organizations that currently have definitions for concussions. Review Table 1. National Collegiate Athletic Association (NCAA) listing below. This brings us to the challenge: how to respond when parents of

adolescents and teens ask a provider’s advice on whether their child/teen should participate in contact sports. First and ultimately, it is up to the parent to make the best informed decision of whether their child/teen should participate in a contact sport. As providers, it would be nice to be able to give parents data to help them make informed decisions regarding contact sports.

one of the largest pediatric facilities in the U.S. This hospital has a research division that keeps track of sports-related injuries. The statistics in this study can be eye-opening to parents with teens participating in contact sports. There are some alarming concussion statistics. Here are just a few:

NCAA has a graph showing the classification of concussion of some sports. See Figure 3 called Impact Expectation by Sport on the following page. One fact I learned was the frequency of concussions is higher in females in certain contact sports such as soccer. Recently, the United States Soccer Federation has taken a major step in an attempt to reduce concussions among youth soccer players, adopting a policy that bans players under 11 from heading the ball and reducing headers in practice for 11 to 13 year olds. See the table on the following page: High School Sports Injury Rates by Sport: 2011-12, provided by the Nationwide Children’s Hospital located in Columbus, Ohio. Nationwide Children’s Hospital is

•

There are between an estimated 1.6 and 3.8 million sports-related concussions in the United States every year.

•

The Centers for Disease Control (CDC) concluded that sports concussions in the United States have reached an “epidemic level.”

•

The Sports Concussion Institute estimates that 10 percent of high school athletes in contact sports suffer a concussion each season.

•

According to the CDC, during 2001-2005 children and youth ages 5 -18 years accounted for 2.4 million sports-related emergency department visits annually, of which 6 % (135,000) involved a concussion.

Table 1. Concussion Definitions

American Academy of Neurology

American Medical Society for Sports Medicine

Zurich

NCAA

Pathophysiologic disturbance in neurologic function characterized by clinical symptoms induced by biomechanical forces, occurring with or without LOC. Standard structural neuroimaging is normal, and symptoms typically resolve over time.

A traumatically induced transient disturbance of brain function and involves a complex pathophysiological process. Concussion is a subset of mild traumatic brain injury (MTBI) which is generally self-limited and at the less-severe end of the brain injury spectrum.

A brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces.

A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.

CAPA NEWS

•

For young people ages 15- 24, sports are the second leading cause of traumatic brain injury behind only motor vehicle crashes.

Did you know that California has a law regarding concussions: Assembly Bill 25, signed in 2011. AB 25 requires California school districts to immediately remove an athlete from a school-sponsored activity if the student is suspected of sustaining a concussion or head injury. Students are prohibited from returning to activity until they are evaluated by and receive written clearance from a licensed healthcare provider. In July 2014, another piece of legislation was signed into law: AB 2127 Interscholastic sports regarding full-contact football practices (concussions and head injuries). California law was amended to mandate completion of a graduated return-to-play protocol of no less than seven days, and, in response to growing concern about the long-term effects of repetitive head impacts,

limits practice to two 90-minute full-contact practices in football per week during the pre-season and regular season and banning off-season practices altogether. In 2013, the American Medical Society of Sports Medicine took a position on concussions and developed the Signs and Symptoms of Concussion. It covers four areas: Physical, Cognitive, Emotional and Sleep. See Table 4 on page 18: When should a parent seek emergency care? Children’s Hospital of Orange County recommends if a child or teen displays any of the following symptoms, a parent should seek immediate medical care at an emergency department: •

Changes in alertness and consciousness

•

Convulsions or seizures

•

Muscle weakness on one or both legs

Figure 3. Impact Expectation by Sport

•

Persistent confusion

•

Remaining unconscious

•

Repeated vomiting

•

Unequal pupils

•

Unusual eye movements

•

Walking problems

•

Fuzzy vision

•

Double vision

•

Balance problems

Also, it is important to know there is something called “Delayed Concussion.” This occurs when the child or teen does not show or develop symptoms right after the injury. Symptoms can appear hours or days later. Remember to be alert for possible delayed symptoms. There is a relatively new tool now being used with contact sports. It is Continued on page 18

High School Sports Injury Rates by Sport, 2011-12

NATIONAL HIGH SCHOOL SPORTS-RELATED INJURY SURVEILLANCE STUDY

High

Contact & Collision Impa

Baseball* Basketball* Cheerleading Diving*

Rugby Skiing Soccer* Wrestling*

Equestrian* Gymnastics* Softball* Water Polo*

tion

pecta

ct Ex

Contact

Field Hockey* Football* Ice Hockey* Lacrosse* Pole Vault*

Limited Contact

Low

Bowling Cross Country Fencing Golf Rifle

Rowing Swimming Tennis Track & Field Volleyball

Boys’ Swimming Girls’ Swimming Girls’ Swimming Cheerleading Boys’ Track Boys’ Baseball Girls’ Track Girls’ Volleyball Girls’ Gymnastics Girls’ Lacrosse Boys’ Basketball Girls’ Softball Boys’ Soccer Girls’ Field Hockey Girls’ Basketball Boys’ Ice Hockey Boys’ Wrestling Boys’ Lacrosse Girls’ Soccer Boys’ Football

Injury rate is “per 1,000 Athletic Exposures” Figures include practice and game/competition rates. Full report available at http://www. nationwidechildrens.org/cirp-rio-study-reports

*2010 Sports

JANUARY/FEBRUARY 2016

Basic Info on Concussions Continued from page 17

a neurocognitive test called ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing). It was developed in the early 1990s by doctors Mark Lovell and Joseph Maroon. It is a 20-minute test that has become the standard tool used in comprehensive clinical management of concussions for athletes from age ten through adulthood. Currently, the school districts that use it have athletes who participate in contact sports with high concussion risk do a baseline assessment prior to the athlete starting the sports season. It is recommended that a baseline test be completed every other year. Should the athlete ever have a concussion or head injury, the ImPACT test is repeated. This helps aid in the decision process to determine when the athlete can return to play. While the test provides helpful information for trainers, doctors and coaches, it does not measure the severity or degree of a concussion. Side

note: One weakness of baseline neurocognitive testing is that an honest answer is not required when the athlete is being tested. There are some athletes that purposely try to make a low score in order to make it more likely he will be able to “pass” the test in an event they may have a concussion during the season.

play (i.e.: competition) sooner than 7 days after evaluation by the healthcare provider who made the diagnosis of concussion. See the link below of the CIF concussion protocol. There are normally seven stages to the return to play as covered in the link below.

There are return-to-academic and return-to-play plans should a child/ teen have a concussion.

Just as there are return-to-play guidelines, there are also return-toacademics guidelines. Per NCAA, “The hallmark of return-to-learn is cognitive rest immediately following concussion, just as the hallmark of return-to-play is physical rest. Cognitive rest means avoiding potential cognitive stressors such as school work, video games, reading, texting and watching television. The rationale for cognitive rest is that the brain is experiencing an energy crisis, and providing both physical and cognitive rest allows the brain to heal more quickly.”

For those who would like more training regarding concussions, the CDC has online training for healthcare providers: http:// www.cdc.gov/headsup/providers/ training/index.html As part of AB 2127, mentioned earlier, California Interscholastic Federation (CIF), which governs high school sports in California, requires a student that has suffered a concussion cannot return to

www.capanet.org/concussions

Table 4. Signs and Symptoms of Concussion: AMSSM 2013 Position Stand Physical

Emotional

Sleep

• Headache

• Feeling mentally ‘foggy’

• Irritable

• Drowsiness

• Nausea

• Feeling slowed down

• Sadness

• Sleep more than usual

• Vomiting

• Difficulty concentrating

• More emotional

• Sleep less than usual

• Balance problems

• Difficulty remembering

• Nervousness

• Difficulty falling asleep

• Dizziness

• Forgetful of recent information and conversations

• Visual problems • Fatigue • Sensitivity to light • Numbness / tingling • Dazed • Stunned

Cognitive

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• Confused about recent events • Answers questions slowly

National Collegiate Athletic Association has suggested guidelines for return-to-academics: •

If the student-athlete cannot tolerate 30 minutes of light cognitive activity, he or she should remain at home or in the residence hall.

•

Once the student-athlete can tolerate 30-45 minutes of cognitive activity without return of symptoms, he/ she should return to the classroom in a step-wise manner. Such return should include no more than 30-45 minutes of cognitive activity

at one time, followed by at least 15 minutes of rest. •

The levels of adjustment needed should be decided by a multi-disciplinary team that may include the team physician, athletic trainer, faculty athletic representative or other faculty representative, coach, individual teachers and psychologist. The level of multi-disciplinary involvement should be made on a case-by-case basis.

the provider arm parents with invaluable information on the types of contact sports and level of possible concussions, detecting a concussion by signs and symptoms, when to have the child/teen evaluated, making sure the school’s sports department offers baseline ImPACT tests prior to start of the season of the child/teen’s sport, the need for a repeated ImPACT test prior to going back into competition following a concussion and guidelines for return-toacademics and competition. 

The resources and information included in this article should help

CAPA is always diligent when monitoring legislation. Provider neutral language is something we strive for when appropriate. In the case of SB 2127, it is appropriate and we closely monitored the bill throughout the legislative process to ensure that licensed healthcare provider was included in the bill. Excerpted from California Assembly Bill No. 2127 CHAPTER 165 [Approved by Governor July 21, 2014. Filed with Secretary of State July 21, 2014.] An act to amend Section 49475 of, and to add Section 35179.5 to, the Education Code, relating to interscholastic sports. AB 2127, Cooley. Interscholastic sports: full-contact football practices: concussions and head injuries. SEC. 3. Section 49475 of the Education Code is amended to read: (1) An athlete who is suspected of sustaining a concussion or head injury in an athletic activity shall be immediately removed from the athletic activity for the remainder of the day, and shall not be permitted to return to the athletic activity until he or she is evaluated by a licensed health care provider. The athlete shall not be permitted to return to the athletic activity until he or she receives written clearance to return to the athletic activity from a licensed health care provider. If the licensed health care provider determines that the athlete sustained a concussion or a head injury, the athlete shall also complete a graduated return-to-play protocol of no less than seven days in duration under the supervision of a licensed health care provider. The California Interscholastic Federation is urged to work in consultation with the American Academy of Pediatrics and the American Medical Society for Sports Medicine. b) As used in this section, “licensed health care provider” means a licensed health care provider who is trained in the management of concussions and is acting within the scope of his or her practice.

Cutting Into Orthopedics: An Orthopedic Review Saturday, April 16, 2016 Marshall B. Ketchum University 2575 Yorba Linda Blvd Fullerton, CA 2 Hrs of Cat. I CME & 4 Hrs of SA-CME CAPA Member: $180 Non-Member: $310 Student: $90 This course is for PAs who are looking to improve their orthopedic knowledge base – regardless of their practice setting. This 1-day course offers a comprehensive review of common knee, hip, shoulder, elbow and spine pathology along with hands-on exam techniques. Attendees will also learn more about injection therapy, common pediatric disorders and common medical orthopedic problems.

www.capanet.org JANUARY/FEBRUARY 2016

Tune Into Safety for Hearing-Impaired Patients Mrs. S comes to a busy medical office with signs and symptoms of a urinary tract infection. While teaching her about her newly prescribed medications, her physician assistant (PA) realizes she hasn’t heard any of the instructions. What should the PA do?

Courteously and empathetically listen to your patient and watch the nonverbal responses for signs of misunderstanding. If the patient misunderstands something, correct him or her in a respectful way.

Looking into hearing loss Hearing loss, the most common sensory deficit in humans,1 diminishes quality of life and impairs the ability to communicate in everyday life. An estimated 30 million Americans age 12 and over experience bilateral hearing loss, or about 12.7% of the U.S. population.3 Researchers predict greater numbers of Americans with hearing loss as the population ages.3 Cardenas-Valladolid et al. found that hearing-impaired older adults taking multiple medications had double the risk of nonadherence when compared with others without hearing loss. Legal concerns Safe care depends on good communication between PAs and patients. Legally, PAs have an obligation to do whatever it takes to effectively communicate with patients who are hearing impaired. Without good communication, patients and caregivers can encounter these barriers to safe patient care: • Patients misunderstand important information. • Informed consent for treatment isn’t provided. • Medication regimens aren’t followed.5 Always rely on a trained language interpreter, if available, or an assistive device or strategy approved for use in your facility. Care strategies First and most important, ask hearing-impaired patients for their preferred methods of communication.5 In a clinic or outpatient setting, the message can be conveyed with posters, appointment screen messages, and flyers.6 In an inpatient facility, admission procedures include hearing assessments.7 Ask how the patient prefers to communicate; for example, by lip reading, language interpreters, written information and notes, voice recognition software, or a combination.5,6 Encourage your hearing-impaired patients to wear hearing aids (if available) and learn sign and/or lip-reading strategies.6 Be aware, however, that lip reading is inaccurate and shouldn’t be relied upon as a communication vehicle.5 PAs can take continuing-education classes that focus on the care of hearing-impaired patients. Even when using a language interpreter, face your patient, position yourself on the same level, and make direct eye contact. Keep bright lights on you, not your patient. Speak directly to the patient, not into a computer screen, and avoid interrupting the patient. As much as possible, keep extraneous noise and distractions to a minimum.6-8 Speak clearly and distinctly, but not too slowly or in an exaggerated way. Never shout. Preface main conversation topics with your patient’s name. Eliminate medical jargon whenever possible; use short words and short sentences. Talk about one topic at a time, and before changing topics, ask your patient to repeat to you what he or she understands. When misunderstandings occur, explain things in a different way rather than saying the same phrase over and over.8

If using a technology-enhanced communication device, make sure you’re thoroughly familiar with how it works and continuously evaluate its quality, usability, and effectiveness. Put important information in patient handouts. Here’s where voice recognition software (speech to text) can be very helpful. Clearly dictate words into the microphone, show the on-screen written transcript during your conversation and dictation, and give related printouts to your patient. With all written information you share, consider carefully the patient’s literacy level and language skills. If you work in a clinic or outpatient facility, encourage hearingimpaired patients to book and confirm appointments electronically through text messages, secured online website scheduling, or e-mail. Also, instead of calling hearing-impaired patients from the waiting room, use a visual call system display using their first name and last initial or walk over to them and escort them to the exam room. Don’t violate patient privacy by speaking loudly within the hearing range of others. Having patient safety strategies for specialty populations is important for all healthcare organizations. A well-written policy that can be used by managers and employees to respond to hearing impaired patients will help organizations function at their highest capacity to provide excellent patient care and customer service. Following these policies and documenting the care you provided may protect you from being named in a lawsuit. REFERENCES 1. Deuster D, Matulat P, Schmidt CM, Knief A. Communication skills for interviewing hearing-impaired patients. Med Educ. 2010;44(11):1130–1131. 3. Lin FR, Niparko JK, Ferrucci L. Hearing loss prevalence in the United States. Arch Intern Med. 2011;171(20):1851–1852. 5. National Association of the Deaf. Questions and answers for healthcare providers. 2013. http://nad.org/issues/health-care/providers/questions-andanswers. 6. Tidy C. Dealing with hearing-impaired patients. Patient.co.uk. 2014. http:// www.patient.co.uk/doctor/dealing-with-hearing-impaired-patients. 7. UW Medicine. University of Washington Medical Center. Culture clues: communicating with your head-of-hearing patient. 2012. http://depts. washington.edu/pfes/PDFs/HardOfHearingCultureClue.pdf. 8. UCSF Medical Center. Communicating with people with hearing loss. 2015. http://www.ucsfhealth.org/education/communicating_with_people_with_ hearing_loss. This risk management information was provided by Healthcare Providers Service Organization (HPSO), the #1 provider of professional liability insurance for over 1 million healthcare professionals, and is now offering the same quality coverage, financial strength and level of service to Physician Assistants. The professional liability insurance policy is administered through HPSO and underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an email to service@hpso.com or call 1-800-982-9491. www.hpso.com.

Students Students Students Students Students Students Congratulations to the 2016 CAPA Scholarship Winners! the PA profession at the community and national level. Congratulations to Jennifer DeMoss for being selected as the 2016 Ray Dale Memorial Scholarship recipient! May Ray Dale’s legacy be kept alive through your actions.

Jennifer DeMoss, PA-S

As a member of CAPA, AAPA, NCCPA and AFPPA, she continually encourages fellow PA students and practicing PAs to get involved with their professional organization and with CAPA’s Political Action Committee (CAPA PAC). Her future goals are to continue to pursue her interest in politics and the legislative process, become part the CAPA PAC, attend town hall meetings and advocate for

His summer goal includes taking a trip to Mexico to help build a house for a family in need as he continues to strive to serve as a mentor and role model through his community service projects. Congratulations to Steven Bayer for being selected as the 2016 Community Outreach Scholarship recipient! Best of luck with all your community service endeavors.

he Ray Dale Memorial Scholarship is awarded to a PA student who is in good academic standing and pursues activities that promote the PA profession. This year the recipient’s actions and goals truly embrace the passion of promoting the PA profession, both locally and nationally. Chosen by PAEA to be a PA student fellow at the 2nd Annual Student Health Policy Fellowship, she traveled to Washington, D.C. where she advocated for the PA profession at the national level. Upon her return to California, she presented the importance of advocating for the PA profession and shared her knowledge of how to promote the PA profession on the legislative level to fellow PA classmates and faculty. Locally, she serves as the Class Historian for her school’s PA Student Society and as a Peer Student Member along with having been a Student Ambassador in 2014 and Lead Student Ambassador in 2015 at CAPA’s Annual Palm Springs Conference.

he serves as President of the PA Student Society and has organized a day of “Random Acts of Kindness” with his fellow classmates.

Steven Bayer, PA-S

The Community Outreach Scholarship is awarded to a PA student who is in good academic standing and has demonstrated community outreach and other philanthropic activities as a student. This year, the student recipient’s passion for community outreach and philanthropic activities began many years prior to becoming a PA student. Growing up in a small rural town, he did what it took to help his community thrive. Whether it was cleaning up trash at the local park or rebuilding a house for someone who lost theirs in a fire, he was there to lend a helping hand. He was also involved in feeding the homeless at the Denver Rescue Mission and helped repair a home that was destroyed in a storm as part of his active involvement with Habitat for Humanity. Currently, as a PA student, he continues to be involved with community service activities such as participating in food banks and health fairs, making and delivering food to the homeless community and educating 5th graders about body systems. His involvement at his school is apparent:

Aivi Phung, PA-S

The Ruth Webb Minority Scholarship is awarded to a minority student demonstrating good academic standing and pursuing activities to promote the PA profession. This recipient’s desire to educate, inspire and assist others to become PAs started when she, herself was on the road to becoming a PA. During her undergraduate education, she and her classmates formed a Pre-PA student association to help other students learn about the PA career. On several occasions she spoke at local middle schools and high schools in her community to inform students about the PA profession. As the CAPA and AAPA representative for her PA class, she is a strong advocate Continued on page 22

JANUARY/FEBRUARY 2016

Students Students Students Students Students Students The Power of Compassion by Emily McCoy, PA-S; Student Representative

Robert McCoy, MD and daughter, Emily McCoy, PA-S

CAPA NEWS

ach of you probably has at least one person you consider your role model. That someone that inspired you to go into medicine, someone you wanted to be just like. Since I was a young girl that someone has been my dad. He would come home in his cool navy blue scrubs and always have an interesting story for us at the dinner table. On some weekends, he would take me with him to round on his patients in the hospital. It was one of my favorite things to do with him because not only did I get to see where my dad went to work every day as a general surgeon, but also how he cared for his patients. As I got older and showed an interest in medicine, I was lucky enough to be able to observe him more with his patients. With his witty sense of humor and unwavering compassion, he was the first person who showed me the value of a good bedside manner.

diabetes or how to manage asthma, the process also involves learning how to be a “PA.” Distinguishing from the learning you received through textbooks and lectures, this specific type of learning is done through modeling or what medical sociologist, F. Hafferty has called the “informal” or “hidden curriculum of medical school.” To explain, in clinical rotations you will find role models, such as your preceptors, that you can emulate and model yourself after.

During the first year or so of PA school, you are taught how to take a detailed history, perform a physical exam and create a differential diagnosis list for your patients. You eventually develop an eagerness to get out there and take a H&P, suture up your first laceration or diagnose a patient’s ailment correctly. But one thing that isn’t explained in textbooks is the importance of a good bedside manner. While most of PA school education is about the essentials of clinical care, such as how to treat

Ultimately, she wants to work as a PA in one of the many critically underserved healthcare facilities in America. For the past five years, she has spent her afternoons helping at a diabetes clinic in an underserved community where she was able to see first-hand some of the daily struggles the patients faced and their limitations to accessing care since many of them spoke little to no English. Her fluency in Vietnamese helped her communicate with these patients

As a second year PA student in clinical rotations, my advice to you is to remember to be open to learning,

accept criticism and continue to better yourself and the way you take care of patients. Realize that not only does your bedside manner encompass your medical knowledge and personality, but your capacity to understand the patient and convey your concern for them.  Reference: Chen M.D., P.W (2009, January 29). The Hidden Curriculum of Medical School. Retrieved from http:// www.nytimes.com/2009/01/30/ health/29chen.html

Congratulations to the 2016 CAPA Scholarship Winners! Continued from page 21

for PAs. She believes it is of the utmost importance that the PA profession is promoted because PAs play a pivotal role in improving healthcare in America.

and assisted them in taking the necessary steps to receive the medical treatment they needed. Being in such a setting increased her drive to advocate that every patient deserves compassionate and comprehensive care. Congratulations to Aivi Phung for being selected as the 2016 Ruth Webb Minority Scholarship recipient! We wish you much success in all of your endeavors. 

Welcome New Members

Local Groups

November 3, 2015 through February 11, 2016 Porscha Adams, PA-C Albert Ahoy, PA-S Lindsey Alkema, PA-C Robert Allen, PA-C Arthur Amanfo, PA-C Ayleigh Amaya, PA-C Anthony Ambrosino, PA Rhonda Ardelean, PA Edward Arias, PA-C Amanda Asaro, PA-C Karen Atkinson, PA-C Robert Baker, PA-C Karissa Bartholme, PA-C Alisa Beal, MS, PA-C Rodney Beaty, PA-C Matthew Biasca, PA-S Rebecca Boyle, PA-C Faye Branum, MPAS, PA-C Benjamin Brenner, PA-S Meghan Bristyan, PA-C Antonio Brown, PA-C Christina Brown, PA-C Jennifer Brown, PA-C Paul Brylewski, PA-C Jeffrey Bulger, PA-C Antoinette Busalacchi, PA-C Celeste Callinan, PA-C Lauren Campagna, PA-C Mark Canet Erin Carmody, PA-S Gloria Carrasquel, PA-C Brandy Carrillo, PA-C Marissa Carrillo, PA-C Patricia Castillo, PA-C Brenda Cean, PA-C Ileana Cervantes, PA-C Melanie Chan, PA-S Pamela Chan, PA-C Robert Chavarin, PA-C Tom Chow, PA-C Alkiesha Collins, PA-C Ellen Corn, PA-S Jonathan Corrigan, PA-C Chris Dambroso, PA-S Benjamin Davis, PA-C Philip DaVisio, PA-C Paulina De La Rosa, PA-C Matthew DeBenedetto, PA-C Jessica Der, PA-C Tina Di Marco, PA-S Danielle Dorey, PA-C Karla Dos Santos, PA-S Michael Duncan, PA-S Amanda Edmonson, PA Sara Ehrensberger, PA-C Allicia Elias, PA-C Tiara Esani, PA-C Eric Esparza, MS, PA-C Rita Estanol, PA-C Desiree Evans-Claassen, PA Chad Eventide, PA-C Amy Farabaugh, PA-C Trevor Fewins, PA-C Tatiana Fields, PA-C

Patrick Fink, PA-C Ellen Fink, PA-C Robin Fraser, PA-C Esther Gayoba, PA-C Jayson Gesulga, PA-C Benjamin Gilbert, PA-C Ana Goldberg, PA-C Alison Gracom, PA-C Britanie Grandinette, PA-C Kathleen Grant, PA-C Holly Green, PA-C Brett Groh, PA-C Jan Guy, PA-C Kelly Hall, PA-C Nancy Hamler, PA-S Chelsea Hardesty, PA-C Chelsea Hartwig, PA-C Steven Hauswirth, PA-C Heidi Heal, PA-C Emerald Henault, PA-S Rachel Henn, PA-C Dorothy Hollingsworth, PA-C Mary Holmes, PA-C Alexis Holverson John Hosley Linda Hudson, PA-C Melissa Hutton, PA-C Bianca Iglesias, PA-C Jennifer Inglet, PA-C Chris Jensen, PA-C Joshua Johnson, PA-S Michael Johnson, PA-C Lindsey Kelley, PA-S Kathryn Kincel, PA-C Benton Kinney, PA-C Jodie Konigsberg, PA-C Mary Kreshon, PA-C Kaitlen Laine, PA-C Carie Lam, PA-C Shawn Lies, PA-C Kristina Liner, PA-C Allison Little, PA-C Jesirey Locquiao, PA-C Cindy Luo, MA, PA-C Crystal Maciel, PA-C Sakshi Madan, PA-S Evan Mangubat Sharon Marcarelli, PA-C Ian Marks, PA-C Susan McKim, PA-C Eileen McNulty, PA-S Erynn Meier, PA-C John Miles, PA-C Jessica Miller, PA-C Amalia Moreno, PA-C Erin Morgan, PA Sarah Nace, PA-C Lisa Nakhleh, PA Vivian Nguyen, PA-S Jane Nguyen, PA-C Thucdoan Nguyen, PA-C Annie Nicol, FNP, PA Julie Niedens, PA-C Lucy Ortega, PA-C

Mike Otte, PA-C Chelsea Parsoneault Corinne Petterson, PA-C Pamela Piacente, PA-C Lottie Pierce, PA-C Stella Plukchi, PA-C Oana-Diana Popescu, PA-S Alexander Porto, PA-C Caitlin Pray, PA Jennifer Price, PA-S Elisabeth Quick, MS, PA-C Rashpal Raj, PA-C Sagar Rana, PA-S Kristine Rebiero, PA-C Erika Reyes, PA-C Susan Rhoads, MPA, PA-C Carlos Rodriguez, PA-C Raafat Rokes, PA-C Carola Romero, PA Summer Ross, PA-C Megan Sadakane, PA-C Silvia Salas, PA-C Erin Salcido, PA-C Russell Sandberg, MD Mary Santos, PA-C Chelsea Sapp, PA-S Marina Sarwary, PA-C Michael Schmies, PA-C Amanda Schradermeier, PA-S Brandy Scott, PA-C Angela Segovia, PA-C Priyanka Shah, PA-S Melody Simanian, PA-S Brittany Stewart Stephanie Straley, PA-C Belinda Sun, PA-C Rashida Taher, PA-S Lisa Tanimune, PA-C Katherine Thompson, PA-S Kelly Tran Lynette Tschabold, PA-C Sung-Min Um, PA-C Andrew Valenzuela, PA-C Georgianna Vasilas, PA-S Megan Veale, PA-C Christine Vera, PA-C Wa Vue, PA-C Anabelle Walker, PA-C, MPAS Emily Wang, PA-C Andrea Wanless Jessica Warner, PA-S Gina Weaver, PA Anjali Wilkerson, PA-C Ryan Paul Wingco, MMS, PA-C William Winter, PA-C Tim Wootten, PA-C Natasha Wright, PA-C Anna Zakasovskaya, PA-C Jie Zhuang, PA-S

Redding Area PA/NP Alliance P.O. Box 993515, Redding, CA 96099-3515 Summer Ross, PA-C; (530) 225-6194 summerlynn712@gmail.com Contra Costa Clinicians Association Brian Costello, PA-C contracostapas.com San Francisco Bay Area Physician Assistants (SFBAPA) www.sfbapa.com, Martin Kramer, PA-C; (415) 433-5359 220 Lombard St., Apt. 118, San Francisco, CA 94111-1155 mkramersf@hotmail.com Bay Area Mid-Level Practitioners Rose Abendroth, PA-C; (650) 697-3583, Fax: (650) 692-6251 rosepard@aol.com Matt Dillon, PA-C; (650) 591-6601 mattdillon42@hotmail.com Bay Area Non-Docs Linda O’Keeffe, PA-C; (650) 366-2050 lindapac@aol.com Northcoast Association of Advanced Practice Clinicians John Coleman, PA-C; (707) 845-6008 streetdrag49@sbcglobal.net Stanislaus County NP/PA Network Brian Cormier, PA-C; (209) 605-4966 briancor@verizon.net www.nppanetwork.org Stockton Midlevels Roy Blanco, PA-C; (209) 623-8580 stocktonmidlevels@gmail.com Central Coast Nurse Practitioners & Physician Assistants Kris Dillworth, NP ccnppa@yahoo.com Sharon Girard, PA-C; (305) 803-1560 ccnppa@yahoo.com Orange County Hung Nguyen, PA-C nhy52@yahoo.com San Diego Area Mercedes Dodge, PA-C info@sdpasociety.com www.SDPASOCIETY.com.

Correction: In the November/December 2015 issue of the CAPA News there was an error in an article entitled, “The PA Profession: A Worldwide View.” When referencing South America, the article talked about Walter Susulu University (WSU). WSU is in South Africa. The most up-to-date reference on this topic is: Nadia Cobb et al 2015, Findings from a Survey of an Uncategorized Cadre of Clinicians in 46 Countries. JANUARY/FEBRUARY 2016

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