In this Issue 2014 Child Advocacy Day Young Physician’s Council Legislative Update Early Childhood Partnership Missouri Pediatric Assoc. MSMA Advocacy Training
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Screening & Treatment of Post-Partum Depression Buzz About Baby Friendly Sr. Pediatrician’s Observation Newborn Screening Program Strong Moms, Happy Kids
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Spring/Summer 2014 Dear colleagues: While the winter has been a long and cold one, I trust the spring soon arriving will find each of you and your family members well. The spring also hosts two other important events. It marks the time in which the Missouri Legislature Robert Steele, MD, MBA,FAAP fully swings into gear. It Chapter President is also the time in which your board members meet for the annual spring meeting. I’d like to touch on these to both inform you of how your chapter is advocating for your patients and ask for your help. We had another successful Advocacy Day on March 5th at the state Capitol with 80 pediatricians in attendance interacting with their legislators on topics such as Medicaid reform, proposed legislation on bullying, and tobacco prevention. We all joked about how, for most of us, this is one of very few times during the year that we actually wear our white coats. The sea of ivory-clad pediatricians made a positive impression, but the work doesn’t stop there. You have fantastic advocacy leaders in Drs. Kristin Sohl and Sandy McKay. But they and their dedicated team cannot carry the water all on their own. We desire to continuously harness the collective expertise and passion of our chapter membership to advocate for those that cannot do so for themselves. Advocacy remains a central focus of the chapter. But it is by no means the only one. This winter, your Chapter began a strategic planning process focusing on the next 3-5 years. 1 PedsLines | Spring/Summer 2014
Members from the Board, executive committee, the state’s children’s hospitals, and at-large members gave their input during this process.
There were three central themes that emerged: 1) Support for the pediatrician 2) Child Advocacy 3) Broad membership engagement An action plan is now being developed and will be communicated to you shortly. But the bottom line is that this is your Chapter working for you and your engagement is crucial to our collective success. Having said all that, I must convey to you some important news regarding the leadership of your Chapter. After 17 years of practice in Missouri, I have accepted an administrative position as Senior Vice-President and Chief Strategy Officer at Arkansas Children’s Hospital. As such, I must resign my post as your current President. It has been my honor to serve on the Chapter Board and Executive Committee, and I will miss the friends and colleagues here. Per the ByLaws, your President Elect, Dr. Sandy McKay, will assume the role of President, Dr. Ken Haller will become PresidentElect, and the Secretary/Treasurer position will be filled by appointment from the current Board. Dr. Stuart Sweet will, of course, remain on the Executive Committee as Immediate Past President. I will look forward to watching the Chapter’s success from the South and wish all of you a fond farewell.
Robert W. Steele, M.D. President, MOAAP PedsLines | Spring/Summer 2014 1
Speak Up for Children!
2014 Child Advocacy Day at the State Capitol
L to R: Kelli Boelens, David Sonderman, Alison Curfman, Nicole Brossier, Sarah Garwood (St Louis Children’s Hospital)
On March 5, the Missouri State Capitol building was buzzing with white coats. Pediatricians from around the state came together for a common cause, proudly displaying buttons that read “Speak Up for Children,” a perfect tagline for the American Academy of Pediatrics Missouri Chapter’s annual Advocacy Day. Attendings, residents and medical students from Kansas City to St. Louis came prepared to speak directly with their legislators regarding some of the most pressing issues in Pediatrics, including Medicaid Expansion, Tobacco Cessation and Prevention and Bullying. It was an exhilarating experience, often finding conversation with Senators and Representatives in an elevator on their way to the floor. Legislators from both sides of the political spectrum graciously welcomed us and openly discussed the topics we are so passionate about. We explained the positive 2 PedsLines | Spring/Summer 2014
impacts passing legislation to expand Medicaid would have on improving the health of Missouri’s Children in hopes of shrinking the 4.4% of eligible children not currently enrolled in Medicaid. Many legislators recognized that tobacco use and exposure is a significant public health concern, especially for children. However, many were surprised to learn that Missouri ranks 50th of 51 states (including Washington D.C.) in tobacco prevention funding and has the 9th highest adult smoking rate. This allowed for great conversations regarding the steps our Representative and Senators can take to facilitate change and invest in the health of Missourians. We explained to Senator Jamilah Nasheed’s Chief of Staff, Eric Vickers, the severe impacts bullying has on children’s and adolescents’ physical and mental health. We advocated for
David Bowman, Rachel Ashworth, Brittany Blue, Stuart Sweet, Colleen Edge (St Louis Children’s Hospital)
Dr. Kristen Sohl, Aneesh Tosh, Clayton Butcher, Audrey Southard, Taylor Pancoast
the passage of a bill that would allow school officials to better understand the reasons why children bully others.
The day wrapped up with a birthday celebration for Dr. Baline Sayre and a new appreciation for the imperativeness that Pediatricians continue to advocate on all levels, and that no effort is too small.
A group from St. Louis Children’s Hospital met with Representative Jill Schupp, as she hurried back from voting on the floor, and she adamantly encouraged us to continue to advocate by developing a relationship with our legislators. She even asked that we write testimonies based on our expertise in Pediatrics, and reiterated that out “input very much matters.” Towards the end of the day, Representative Stephen Webber graciously took time to meet with us and explain the Affordable Care Act and its relationship to Medicaid Expansion to Missouri’s health in a manner we as physicians could easily understand.
Emily Paprocki, Jodie Amschler, Thuylinh Pham, Amanda Sommerville, Megan Ference, and Laura Plencner
Chris Lust, David Sonderman, Nicole Brossier, (SLCH)
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Amanda Musto
Dr. Amanda Musto is an intern at St. Louis Children’s Hospital. She grew up near Orlando Florida and has two little sisters who were her initial inspiration to be a pediatrician. She graduated with an undergraduate degree with a bachelor’s in science from the University of Notre Dame in 2009, and attended the University of Florida College of Medicine. Her interests are community advocacy and global health. During medical school she participated twice in a medical trip to an orphanage in Chiang Mai, Thailand.
Mentorship:
Mentorship, Leadership and Advocacy
The Young Physicians Council has recently developed three main pillars to describe the Council’s main efforts within the Chapter. The three pillars are Leadership, Mentorship and Advocacy. The YPC was established to increase young physician involvement in the Chapter and to serve as the Chapter’s “home” for medical students, residents, fellows, and early career pediatricians. The YPC encourages young physicians to take an active role within the Chapter to enhance their leadership and professional development. One way young physicians can become involved is through the YPC’s mentorship program. The mentorship program will pair young physicians with a senior Chapter member within their geographic region that have similar career goals and professional interests. Through the mentorship program, the Chapter hopes to enhance membership interaction, ease the transition from residency to early career, help achieve an adequate work-life balance, and enable young physician professional development. If you are either a young physician interested in a mentor or a senior Chapter member willing to be a mentor, please contact Maya Moody at mmoody@phcenters.com or Johanna Derda at jbderda@aap.net.
Leadership: The Young Physicians Council recently completed the annual residency program visits to each of the resident programs in the state. The Chapter 4 4 PedsLines PedsLines || Spring/Summer Spring/Summer 2014 2014
enjoyed having the opportunity to meet the residents and discuss the structure of the AAP and introduce the residents to Chapter and YPC projects. Through these visits we have welcomed two new resident YPC co-chairs: Lisa Hiskey from the University of MissouriColumbia and Hayley Friedman from Cardinal Glennon. We are excited to have them on board! The Chapter also sponsored two social “meet and greet” events for young physicians. The first was in St. Louis at Pi Pizzeria and the second was at Agave Mexican Restaurant in Columbia. Chapter members and young physicians were able to enjoy pizza and beer (or margaritas and nachos), get to know one another, discuss current topics in pediatric care and potential Chapter involvement. We look forward to next year’s visits!
Advocacy: Every year the national AAP Section of Medical Students, Residents, and Fellowship Trainees (SOMSRFT) picks an advocacy topic and encourages each program delegate to take information regarding that topic back to their residency programs and develop an advocacy project . This year, the Young Physicians Council has decided to follow suit and expand the SOMSRFT advocacy topic to young physicians in the Missouri Chapter. This year’s advocacy topic is firearm injury prevention, which has been a recent hot topic in the state of Missouri. The Young Physicians Council sponsored a Letter to the Editor in a local St. Louis paper
and also conducted a letter writing campaign to the Missouri legislature regarding firearm injury prevention and the preserving the physician’s right to ask about firearm ownership. The YPC has also offered to assist the residency programs in the development of their advocacy projects in hopes to alleviate some of the workload from an already busy resident schedule. This is the first year that the YPC has elected to lead an advocacy campaign, and although participation was mostly Council members, the YPC hopes to expand the campaign to all of the Chapter’s young physicians. The Missouri Chapter Young Physicians Council is excited to be growing in number and interests! If you are interested in joining the Young Physicians Council or would like more information, please feel free to contact Maya Moody at mmoody@phcenters. com.
Dr. Maya Moody, D.O. is a pediatrician at BJK People’s Health Center in St. Louis and also serves as the Young Physicians Council CoChair for the Missouri Chapter.
2014 Legislative Update
2014 MOAAP Child Health Advocacy Day The 4th annual MOAAP Child Health Advocacy Day was excellent success as pediatricians from across Missouri descended on Jefferson City to advocate for kids. Over 80 pediatricians from all regions of Missouri spoke to over 100 legislators on behalf of kids. The morning started with our executive leadership briefing the attendees on the key issues for the day. After the briefing, small groups of advocates spread throughout the Capitol educating legislators and advocating on behalf of children. Advocates focused on three topics: medication transformation, school bullying, and smoking prevention.
We urged legislators to move forward with Medicaid Transformation because: Children are three times more likely to be enrolled in Medicaid if their parents or guardians are eligible for enrollment. Under the ACA, parents, custodial adults, and childless adults living at less than 138% the FPL would be eligible. In turn, these adults will establish medical care and be more likely to seek out routine medical care for their children.
We urged legislators to address School Bullying by: Removing the ban on school officials asking alleged perpetrators why they bully in order to: 1. Restore local control 2. Allow districts to find out what works best for them. 3. Generate information on best practices that can be shared with other districts. Many groups had passionate discussions with legislators about the importance of child health and being proactive for Missouri’s kids. Following our legislative visits, Representative Stephen Webber (D46) addressed the Advocacy Day audience during lunch and encouraged each pediatrician to continue making individual connections with elected officials and to be available to them as a local resource. He stressed the importance of our voices as they debate topics important to child health. Many attendees described Advocacy Day 2014 has exciting, enlightening and encouraging. Many more described how they learned they could make a difference for kids in a way they never knew possible. We encourage you to attend Advocacy Day 2015 and join us as we stand up for children and give them a voice!
We urged legislators to take the lead in Smoking Prevention through: State-wide smoke-free legislation in workplaces, restaurants and bars. An over-the-counter license requirement, to reduce youth exposure to tobacco and e-cigarettes. An increase in the tobacco product excise tax, which currently ranks as the lowest in the country at $0.17 per pack. Using the tobacco settlement funds for their intended purpose: Tobacco prevention and cessation.
Kristin A. Sohl, MD, FAAP is the Director of Clinical Services, Thompson Center for Autism and Neurodevelopmental Disorders in Columbia, Missouri. She also serves as the Medical Director for the Thompson Center for Autism and Neurodevelopmental Disorders. Dr. Sohl is on the board of MOAAP and is the chair of the legislative committee.
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Early Childhood Education and Pediatric Health Care: Perfect Partners
M. Denise Dowd, MD, MPH, FAAP
An expanding body of knowledge, from distinct disciplines (neuroscience, behavioral science, sociology) calls for a re-evaluation of how and what we pediatricians deliver to maximize our impact on child health. The same body of knowledge is also informing current practices in early childhood education. Both disciplines recognize the
enormous impact of adverse childhood experiences (ACEs) on children’s health and ability to learn. The ACE studies provide firm evidence that events such as physical, sexual and emotional abuse, parental addiction, incarceration of a family member, and parental death significantly contribute to negative adult physical and mental health outcomes.1,2,3 Healthy brain development can be disrupted by activation of physiologic response to ACEs (toxic stress) with lifelong implications for both learning and physical/mental health. The American Academy of Pediatrics’, seminal policy statement and technical report on toxic stress, states that addressing exposure to ACEs requires embracing the ecobiodevelopmental model of child health.4,5 This implies forming new collaborations which reach beyond the clinic walls. One such collaboration is taking shape in Kansas City. Children’s Mercy Hospital (CMH) and Operation Breakthrough (OB), Missouri’s largest early Head Start program and provider of social
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services for the city’s most vulnerable families, have formed a unique partnership. This partnership has a clear, common purpose: to assure that our most vulnerable children have the opportunity to develop to their full potential.
A Model in Development While CMH has sponsored a primary care clinic, housed in the same building as the OB Center, since 1995, it is only in the last 18 months that earnest collaborative planning has taken place involving both leadership and front line staff of both organizations. Leadership at CMH called upon two senior staff members, one a nurse (Donna O’Malley RN, PhD) and one a physician (Denise Dowd, MD, MPH, FAAP), to assess the current functioning and recommend ways to foster a more productive partnership. Several elements of the partnership were, fortunately, in place. A clinical team led by medical director, Keri Hubbard, MD, FAAP was operating the clinic five days per week. Dr. Hubbard and staff routinely performed several key functions among them: primary and acute care, meeting Head Start health requirements, educating OB staff as well as daily rounds in Head Start classrooms to assess children’s medical needs and address staff concerns. A series of listening sessions identified better communication as an important goal. A leadership team composed of key CMH and OB stakeholders underwent formal strategic planning and began to meet regularly. To
increase overall communication, a combined OB-CMH staff advisory team, was instituted, as was a weekly e-email update on Partnership progress. A variety of needs have risen to the top that the advisory team is tackling. They include: both adult and child mental/behavioral health care, on-site sick child care, coordination of social services, and joint care models and staffing. With so many of the children of OB and the CMH clinic facing adversities , their needs are incredibly complex. This exacerbates the need for effective communication and coordination among frontline staff. Parents of children at OB were also solicited for input. While there are a small number of parents who volunteer at OB, increasing parent participation is a top priority. Parents have provided insight on how to increase utilization of the clinic on-site and other operational issues at OB. They also provide much needed feedback on utility and appropriateness of parenting materials. A parent task force has been suggested to increase parent involvement and increase utilization of services provided through the CMH-OB partnership.
Increasing Momentum Drs. Hubbard and O’Malley provide the day-to-day leadership on-site to carry forward the ideas developed by the leadership team and help mitigate the challenges that arise in bringing together two larger organizations with very different administrative structures. The stakeholder’s group has quickly grown beyond general pediatrics and now includes CMH psychologists, child abuse pediatricians, emergency physicians and developmental pediatricians. The mental and behavioral health needs of the children and their families served are many and new ways of assessment and delivery of services are being explored. Outcome evaluation is being planned that will require health, education and social service input.
The fact educators and pediatricians serve the same children and families highlights the logic of working together effectively. The major lesson learned thus far is summarized by project Director, Donna O’Malley, “This work is dependent on positive and trusting relationships. Pediatric health care providers and early childhood educators have an incredible opportunity to intentionally join together to benefit children”. For more information please contact Donna at domalley.cmh.edu.
REFERENCES 1. Felitti, V; Anda, R; et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998; 14 (4). 2. Anda RF, Felitti VJ, Bremner JD, Walker JD, Whitfield C, Perry BD, et al. The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci. 2006 [cited 2009 Aug 21];256(3):174-86. 3. Harvard Center on the Developing Child: “Toxic Stress: The Facts.” (http://developingchild.harvard.edu/topics/science_of_early_ childhood/toxic_stress_response/). Accessed March 4, 2014. 4. Garner AS, Shonkoff JP. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. 2012;129: e232-e246. 5. Garner AS, Shonkoff JP. Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health. Pediatrics 2012;129: e224-e231.
A National Model? Through the connection between Drs Dowd and O’Malley and the Head Start National Center on Health (housed within the American Academy of Pediatrics), funds were secured to develop a short documentary on the work of the Partnership. Focusing on the impact ACEs have on families, the video, Breaking Through , tells the compelling story of parents who – in spite of their own exposure to ACEs – have recognized the need for support for their children. They have turned to OB for that support and have taken advantage of the Head Start program and related services, but also the partnership OB now has with CMH. 7 PedsLines | Spring/Summer 2014
M. Denise Dowd, MD, MPH, FAAP
Dr. Denise Dowd is an attending physician in the emergency department of the Children’s Mercy Hospital in Kansas City, Missouri and is Director of Research for the Division of Emergency and Urgent Care there. She is professor of Pediatrics at the University of Missouri-Kansas City and adjunct Professor at the University of Kansas. She is chair of leadership team for the American Academy of Pediatrics/Department of Justice sponsored project, Medical Homes for Children Exposed to Violence and is a primary author for the AAP’s firearm injury prevention policy statement.
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Missouri Pediatric Foundation The Missouri Pediatric Foundation, INC was incorporated as a 501©(3) corporation in 2002 for the purpose of receiving and distributing charitable gifts for disadvantaged children, to promote children’s health issues and to support medical students and pediatric residents in their advocacy efforts. The foundation is governed by a Board of Directors consisting of the three past presidents and the MOAAP. The current board consists of Drs. Tom Tryon, Claudia Preuschoff and Stuart Sweet as well as Johanna Derda, the Executive Director of the Missouri Chapter of the AAP. The foundation has been able to grant seed money for the first two Lobby Days in Jefferson City, a tradition that has
grown stronger every year and is now a self-sustaining annual event pairing groups of residents with pediatricians who have previous lobbying experience with the purpose of speaking with their elected representatives at the Capitol in Jefferson City about issues that affect children and children’s welfare. The foundation was initially funded by various grants that the chapter operated but as grant funding has become less available the foundation has been able to remain financially strong due to the generosity of pediatricians and their contributions. We would like to grow the foundation and I would like to encourage each and every one of you to consider contributing to our Pediatric Foundation. Contributions to the
Missouri Pediatric Foundation are tax deductible. Please make checks payable to the Missouri Pediatric Foundation and send to Johanna Derda, 1537 B Cedar Ridge Place, Jefferson City, MO 65109-1909
Claudia Preuschoff, MD FAAP Past President of MOAAP
MSMA Advocacy Training Workshop
Drs. Lisa Hiskey, Ken Haller and Maya Moody I’ve always fancied myself a budding activist. Throughout my education I’ve participated in fundraisers, political campaigns and community education events. I’ve pronounced my opinions in bold bumper stickers and Facebook posts. I’ve dreamt of the changes I 8 PedsLines | Spring/Summer 2014
could make in the world. On medical school graduation day I walked across the stage with building excitement, ready to don my long white coat and add my voice to the cacophony sounding in legislator’s ears. “They will hear me”, I thought, “they will pay attention to what I have to say. I’m a doctor now, after all. I’ve passed a lot of tests. That has to count for something”. I was right – kind of. Education and experience are important. Reallife examples, facts and figures are important. But I failed, initially, to realize that numbers on a pamphlet are sometimes just numbers, no matter who hands out the information. I needed strategy. On January 18th of this year, I received just that. I attended
the MSMA advocacy training workshop in Jefferson City, MO and found myself simultaneously humbled and giddy. I learned wonderful tips to help keep my cause in legislator’s thoughts. I was taught how to frame information so that it becomes important to each person in the audience. I practiced paring down enormous topics into two minute bursts of speech that have more effect than hours of reciting statistics. Basically, I learned how to be effective. I learned how to advocate. I’ve always fancied myself a budding activist…now I have a foundation from which to grow. Lisa Hiskey, DO Resident Physician University of Missouri Women’s and Children’s
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Screening and Treatment of Postpartum Depression in an Academic Pediatric Primary Care Clinic
by Elizabeth A. Rhyne, PNP,
families. Our experiences with women having PPD and its childhood consequences prompted us to pursue routine screening for PPD in all newborns. As healthcare providers in a pediatric medical home, we have many opportunities to see, and therefore screen, mothers for PPD in the immediate postpartum period. The American Academy of Pediatrics (AAP) recommends that primary care providers screen mothers for PPD in outpatient clinics at regular intervals13. However, the American Congress of Obstetrics and Gynecology (ACOG) does not recommend universal screening1. These conflicting recommendations and the barriers that our mothers face, lead to under recognition and treatment of PPD.
Article submitted by Elizabeth Rhyne, SLU Postpartum depression (PPD), the most common medical problem encountered in new mothers, affects up to 13-20% of all women in the postpartum period. Higher rates, approaching 40-60%, have been reported in low-income mothers and parenting teens1. Despite the frequency of this condition, PPD is not readily identified in women with newborn children. Additionally, screening women for PPD is not routinely recommended. Urban, low income mothers are more likely to experience PPD, but less likely than women of higher income to seek treatment11. Common obstacles these women face include: overcoming the stigma of mental illness, transportation to and from offices, and lack of insurance coverage for mental health services. PPD poses a significant health problem for both the mother and the child. Women with PPD can have feelings of lack of self-worth, thoughts of harming self (or newborn child), irritability, insomnia, and problems bonding with their child. Infants of affected mothers are at risk for developmental and behavioral problems, excessive crying, poor future academic performance.2 Danis Pediatrics at SSM Cardinal Glennon Children’s Medical Center in St. Louis, Missouri, provides primary medical care for many children from the surrounding urban neighborhoods with a high concentration of low-income 10 PedsLines | Spring/Summer 2014
In 2012, Danis Pediatrics developed The Happy Mothers, Healthy Families (HMHF) program to screen all women presenting to the clinic at their child’s newborn and subsequent office visits. This program was funded by a grant from the St. Louis City Maternal, Child and Family Health Coalition with the intent to screen all mothers for PPD and provide on-site treatment. Mothers who reside in the city are eligible to enroll, and may receive on-site treatment, whereas women outside of the city limits are referred to local mental health services. Our multidisciplinary team includes pediatricians, nurse practitioners, social workers, a psychologist, and a project coordinator. HMHF treatment includes on site counseling, follow-up phone contacts, and therapeutic text messaging. We utilize the Edinburgh Postnatal Depression Scale (EPDS) to screen mothers for PPD. This screening tool has been validated for use among low-income populations through 12 months postpartum.3 In our practice, all mothers are given the 10-item multiple choice questionnaire at well child visits from 1 week to 6 months of age. A score of ≥ 10 on the EPDS identifies mothers at risk for PPD. Mothers identified as having a greater risk for PPD are referred to counseling services available within our clinic, or provided resources for local support and counseling services outside of our medical home. Social workers in Danis Pediatrics assist with managing immediate case management needs, including issues with housing, unemployment, transportation, or access to care.
Inclusion criteria for the program include residence within St. Louis City, English-speaking, and a score of ≥ 10 on the EPDS. If mothers do not meet these criteria, we are able to offer some limited counseling services and assist with referrals to local resources. For mothers enrolled in the program, depression severity is defined via the Beck Depression Inventory (BDI-II).4 The BDI-II and EPDS are followed during therapy to gauge progress with counseling and texting services. Counseling services include cognitive behavioral therapy (CBT), the gold standard for PPD treatment, and motivational interviewing, a proven treatment modality that helps guide behavioral change. Follow up treatment includes telephone calls and text messaging. Text messaging provides mothers with instant supportive services. Messages include themes of support, education, and motivation, many with the option to receive a call from a team member within 24 hours. Examples of text messages: supportive, “Your goal today is to take some time for YOU. Get some rest while your baby is resting!”; motivational, “Change is not easy. Keep up the good work!”; educational, “With appropriate diagnosis, evaluation and treatment, postpartum depression is a very treatable condition”. It is an innovative, adjunct therapy to CBT to help bridge the common barriers that our mothers face in receiving treatment for PPD. Preliminary data indicates that 65% of mothers have text messaging capable phones and that mothers perceive text messaging to be a helpful way to deal with PPD treatment. As of February 1, 2014, 55 mothers from St. Louis City, who would have otherwise gone without treatment, have enrolled in HMHF. We have screened 3028 times with 219 mothers identified as at risk for PPD. Of those, 60% have resided within St. Louis City. 90% of our mothers enrolled in HMHF have opted to receive the text messaging services. Many mothers cite the connection that they have established with the HMHF program, which is pronounced when many of the participants have very little support otherwise. Specific comments have included that the messages “bring a light to their day” and makes them feel that “someone was there” for them. While studies indicate that for most women, PPD will improve on its own, counseling based directly in the pediatric medical home and adjunct therapeutic text messaging has the potential to improve the symptoms more quickly and subsequently decrease the number of required therapy visits. In spite of the barriers, identifying this common condition should not be ignored. The negative effects on mother and 11 PedsLines | Spring/Summer 2014
baby are serious problems that can occur in early childhood. We recognize the ease of universal screening but may have difficulty with referrals. Increased recognition of this problem may lead to greater availability of mental health services. 1. Earls MF. Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice. Pediatrics. 2010;126(5):1032-1039. 2. Chaudron LH. Postpartum depression: what pediatricians need to know. Pediatric Rev. 2003;24(5):154-161. 3. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782-786. 4. Beck AT, Steer R, Brown G. Manual for the Beck Depression Inventory- II. San Antonio, TX: Psychological Corporation; 1996. 5. Stockwell MS, Kharbanda EO, Martinez RA, Vargas CY, Vawdrey DK, Camargo S. Effect of a Text Messaging Intervention on Influenza Vaccination in an Urban, Low-Income Pediatric and Adolescent Population. JAMA: The Journal of the American Medical Association. 2012;307(16):1702-1708. 6. Strandbygaard U, Thomsen SF, Backer V. A daily SMS reminder increases adherence to asthma treatment: a three-month follow-up study. Respir Med. 2010;104(2):166-171. 7. Terry M. Text messaging in healthcare: the elephant knocking at the door. Telemed J E Health. 2008;14(6):520-524. 8. Krishna S, Boren SA, Balas EA. Healthcare via cell phones: a systematic review. Telemed J E Health. 2009;15(3):231-240. 9. Cole-Lewis H, Kershaw T. Text messaging as a tool for behavior change in disease prevention and management. Epidemiol Rev. 2010;32(1):56-69. 10. Jordan ET, Ray EM, Johnson P, Evans WD. Text4Baby: using text messaging to improve maternal and newborn health. Nurs Womens Health. 2011;15(3):206-212. 11. Abrams, L and Curran, L. “And you’re telling me not to stress?” A grounded theory study of postpartum depression symptoms among low-income mothers. Psychology of Women Quarterly. 2009;33: 351-362. 12. Connelly, C et al. Pediatric health care providers’ self-reported practices in recognizing and treating maternal depression. Pediatric Nursing. 2007; 33 (2): 165-172. 13. American Academy of Pediatrics (AAP), “Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice”. Pediatrics. Published online October 25, 2010
Elizabeth A. Rhyne, PNP, joined the physician practice of Saint Louis University School of Medicine, as a pediatric nurse practitioner, in the Department of Pediatrics, in May 2012. She has been a PNP since 2006, and a pediatric nurse since 2000.
Elizabeth A. Rhyne, PNP
Ms. Rhyne earned her Bachelor of Science in nursing from Saint Louis University School of Nursing and her Masters of Science in nursing from the University of Missouri– St. Louis. She will pursue her PhD in Public Health Studies at Saint Louis University in the fall of 2014.
Ms. Rhyne is affiliated with SSM Cardinal Glennon Children’s Medical Center and has clinical expertise in general pediatrics. Her research interests include postpartum depression as well as promotion and support for breastfeeding mothers.
The Buzz About Baby Friendly It seems that you hear about breastfeeding everywhere you go these days. Whether it’s Pope Francis promoting breastfeeding in churches or supermodel Gisele Bundchen posting a photo of breastfeeding her one year old daughter on her instagram page, breastfeeding is in the spotlight. Not surprisingly, there seems to be a renewed emphasis on promotion and support of breastfeeding in the medical community as well. One current “hot topic” is whether a hospital should go “Baby Friendly”. What, are we “baby hostile”? So, what’s the big deal about “Baby Friendly” anyway, and why should we care??? In 1991, the World Health Organization (WHO) and UNICEF (United Nations Children’s Fund) developed the Baby Friendly Hospital Initiative (BFHI). This is a global program instituted to encourage and recognize hospitals and birthing centers that offer an optimal level of care for infant feeding and mother/ baby bonding. An international program, it only received modest attention in the United States with 172 hospitals becoming certified over the 17 years of the Baby Friendly USA’s existence. However, in the last several years, the climate has changed. Over the last 10 years, a tremendous amount of research on breastfeeding has been published, showing compelling evidence of its impact on child and maternal health. The AAP’s 2012 Statement on Breastfeeding and the Use of Human Milk includes a chart of meta-analysis of the research 12 PedsLines | Spring/Summer 2014
noting previously recognized effects on decreasing the incidence of otitis media, asthma, and gastroenteritis, but also significant health effects on decreasing the incidence of necrotizing enterocolitis by 77%, type 2 diabetes
Breastfeeding”, urging hospitals to “accelerate implementation of the Baby Friendly Hospital Initiative” as a key point under Action 7.
The CDC has also weighed in. Since 2007, the CDC has issued the mPINC (Maternity Practices in Infant Nutrition and Care) survey 10 Steps to Successful to all hospitals and birthing Breastfeeding” centers who provide maternity 1) Have a written breastfeeding policy that is care in all 50 states and territories. routinely communicated to all health care (See this website for Missouri’s staff. data: 2) Train all health care staff in the skills http://www.cdc.gov/ necessary to implement this policy. breastfeeding/pdf/mPINC/ 3) Inform all pregnant women about the states/mPINC2011Missouri.pdf ). benefits and management of Missouri has a composite rating breastfeeding. of 66 out of 100 which ranks us 4) Help mothers initiate breastfeeding as #36 in the nation. We’re not within one hour of birth. exactly leading the pack. 5) Show mothers how to breastfeed and As of January, 2014, the Joint how to maintain lactation, even if they are Commission for Hospital separated from their infants. Accreditation has begun using 6) Give infants no food or drink other than exclusive breastfeeding rates as breast milk unless medically indicated. part of its core measurements for 7) Practice rooming in; allow mothers and accreditation. CMS (Centers for infants to remain together 24 hours a day. Medicare and Medicaid Services) is 8) Encourage breastfeeding on demand. now using exclusive breastfeeding 9) Give no pacifiers to breastfeeding infants. rates for quality indicators, 10) Foster the establishment of breastfeeding which we all know is linked to support groups and refer mothers to them reimbursement. Obviously, our on discharge from the hospital or birthing national governing bodies are center. taking the health implications of breastfeeding quite seriously. by 40%, and obesity by 24%. No doubt about it, those are impressive numbers. With the striking implications for public health, our governmental agencies have been promoting education and support for breastfeeding. Surgeon General Regina Benjamin in 2011 released her “Call to Action to Support
With the emphasis not only on initiation of breastfeeding, but breastfeeding exclusivity, the Baby Friendly Hospital Initiative is a valuable tool for achieving improved support of initiation and sustained breastfeeding. BFHI is structured around the “10 Steps to Successful Breastfeeding” and adherence to the International Code of Marketing of Breast Milk Substitutes.
achieve designation this year as well. For hospitals who are interested in improving breastfeeding support, initiation, and continuation, but are not sure they are ready to go the full BFHI route, a good first step is the “Missouri Show Me 5”. This designation incorporates 5 of the “10 steps” and may offer an effective path to an incremental adoption of evidence-based maternity care practices. The website for this program is:http://health.mo.gov/living/ families/wic/breastfeeding/showme5.php.
These “10 Steps” have been endorsed by major maternal/ child health authorities such as the AAP, AAFP, Academy of Breastfeeding Medicine, CDC, USBC, and the Surgeon General. The International Code on Marketing Breast Milk Substitutes was adopted by the WHO in 1981 and recommends restrictions on the marketing of breast milk substitutes, infant feeding bottles, and teats (or pacifiers as we know them here in the US). Specifically, provisions in this code restrict advertising breast milk substitutes to families, free samples in the health care system, and gifts to health workers. (See this website for the complete document: www.who.int/nutrition/ publications/code_english.pdf ) Currently, in Missouri, we have only one facility, Hannibal Regional Hospital, who has received the Baby Friendly designation, but they won’t be lonely for long. Hopefully, in the next year, we will see several more Missouri hospitals join Hannibal in earning this designation. Barnes-Jewish Hospital in St. Louis, Truman Medical Center-Hospital Hill in Kansas City, and the University of Missouri- Women’s and Children’s Hospital in Columbia are all part of the Best Fed Beginnings program, a nationwide quality improvement initiative to help hospitals improve maternity care and increase the number of “Baby Friendly” designated hospitals in the United States. This program is supported by the CDC and run in close partnership with Baby Friendly USA. The goal is for hospitals in the program to achieve Baby Friendly status by September, 2014. My home institution, Mercy Hospital Springfield, is also independently on the path to Baby Friendly, and we hope to 13 PedsLines | Spring/Summer 2014
So, what’s the bottom line? Current research is conclusive and compelling on benefits of breastfeeding and the risks of not breastfeeding. Major maternal/child medical organizations (e.g. AAP, AAFP, ACOG) support breastfeeding, and our governmental organizations (e.g. Joint Commission, CDC, Surgeon General) promote breastfeeding. As pediatricians in Missouri, we have an amazing opportunity to improve our breastfeeding rates, impact maternal/child health, and even make our facility administrators happy by assuring accreditation and hitting quality indicators!
Tamara McAlister Fusco, MD, IBCLC, FAAP, FABM, is a practicing pediatrician with the Mercy System in Nixa, MO. She is the medical director for the Family Resource Center and Lactation Services at Mercy Hospital Springfield. Dr. Fusco received her medical degree from the University of Arkansas for Medical Sciences and completed a pediatric residency with Tulane University in New Tamara McAlister Fusco, MD, Orleans. After practicing in Alaska IBCLC, FAAP, FABM, where she was the Alaska AAP CBC, she has lived in Missouri for the last 13 years. She became certified as a lactation consultant in 2012 and was inducted as a Fellow in the Academy of Breastfeeding Medicine in 2013. She is the current co-chair of the Greater Regional Ozarks Breastfeeding Coalition and is a member of the Missouri Breastfeeding Coalition. Recent activities in breastfeeding medicine include collaboration in the formation of a regional breast milk depot, local research on microbial causes of breast pain in lactation, and didactic lectures to MSU PA students. Dr. Fusco is married to Evan Fusco, MD, MHA, an emergency medicine physician and associate medical director with Mercy Care Management. She is the mother of twin teenage sons and a 9 year old daughter. In her personal time, she enjoys traveling, scuba diving, and reading.
A Senior Pediatrician’s Observation Today’s column will address two issues. Hopefully, the first will become a regular feature: remembering deceased or impaired Pediatricians who have played an important role in Missouri Pediatrics. Please provide information regarding any Pediatricians you would like to see mentioned in later editions. Dr. Georg Soto died last year and had the well-deserved reputation of being one of the sharpest diagnosticians to ever practice Pediatrics in the St. Louis area. I recently saw a senior adult Cardiologist, and George had cared for all his children. He went on and on about how great a diagnostician George was. He attributed it to his unusual dedication to keen observation, always observing the nuances of both wellness and disease, filing everything away in his super-computer (his mind) and then noting even the most subtle variation from the expected findings. Most important, he exclaimed: “They are not training doctors like George anymore!” So, this is a challenge to all readers, young and old. Please, prove him wrong!
Blaine Sayre, MD
The next physician is Dr. Frederick Peterson, past President of our State AAP Chapter and a Pediatric leader for many years. Although Fred has excellent cognitive preservation, he has developed multiple physical disabilities that have confined him to a nursing home indefinitely. He would love to hear from old friends (or brand new ones). Contact information is: Dr. Fred Peterson, Delmar Gardens of Chesterfield, 14855 N. Outer 40 Rd., Chesterfield, Mo. 63017, Phone #: 636/536-3678. This time of year with the Missouri legislature in session our thoughts naturally turn to advocacy. Everyone knows the history of the American Academy of Pediatrics. Our founder, Dr. Abraham Jacobi, was a very assertive social activist in general, and a child advocate in specific. The Academy was founded to promote the health and well being of children, not to protect the interests of Pediatricians. This is unique among medical organizations, and it is the underlying reason the Academy has been effective. A great illustration of this took place a few years ago when I was in Washington for the AAP legislative training. At that time, there was a “tort reform” bill before Congress which was focused on limiting the amount of non-economic damages one could seek for a medical injury, much as we 14 PedsLines | Spring/Summer 2014
are seeing in Missouri today. When I went to Representative Lacey Clay’s office, the receptionist immediately identified me, erroneously, as one of the endless stream of physicians, some in white coats and some in suits, who were coming in to promote “tort reform”, but of course they were perceived— to put it mildly—as there to serve their own self interests. Speaking as a former common person, and one whose unique qualification understands the dynamic interface between poverty and ignorance, few things are more disgusting than seeing a group of self-serving physicians promoting their own welfare. Representative Clay’s office radiated this from the reference. Once I was meeting with his aide in charge of health matters (a very well-educated recent graduate of Washington University’s School of Social Work). I assured her that: “I don’t give a damn about tort reform” and proceeded to tell her about the Academy’s agenda for promoting child health. When I looked up, there were tears in her eyes, and when I asked why she was crying, she expressed that I had been the only doctor in that session who was not addressing the needs of doctors. She was convinced that I was there only to promote my own interests. There were good repercussions: Representative Clay put a nice entry into the Congressional Record regarding my efforts, the aide sent her sister to volunteer at our office, Lacey became my “favorite Congressman”, and I became his “favorite Pediatrician”; he spoke at the funeral of our administrator the following year, etc. But the downside is that Representative Clay was already a self-described “dedicated Progressive” and will always vote on the correct side of any child health issue. The big question is: can this approach ever convince a “swing legislator” to come down on the correct side of child health issues? The answer: it can never hurt. As I write this, we are preparing for our annual Child Health Advocacy Day in Jefferson City. As all readers know, currently in Missouri the #1 item that would benefit the health and well-being of Missouri’s citizens in general and children in particular is Medicaid expansion. Every other proposed or planned item pales in comparison to this item. My plan: Propose that opposition legislators “become part of the solution and not the problem.” My example: Senator Bond who is now walking the halls of Missouri’s Capitol spreading that message—reform Medicaid by joining up, then fix all those terrible flaws. I shall try to carry this a step forward suggesting that if the legislator has any high aspirations, this is a unique opportunity to join hands with Senator Bond and be seen as a problem solver. It is a chance to continue saying how terrible Medicaid is, while showing you to be that problem-solver that EVERYONE will support, i.e., just like Senator Bond. I’ll let you know next time if I have any success!
Participants at the 2014 MOAAP Child Advocacy Day in Jefferson City
FROM THE SMALLEST OF CHILDREN TO THE BIGGEST OF CHALLENGES. For outstanding clinical outcomes, refer your patients to one of the Best Children’s Hospitals as recognized by U.S. News & World Report . Our highly trained doctors, nurses and specialty staff are nationally known for providing high-quality, multidisciplinary care for children of all ages—from outpatient subspecialty care to the most complex procedures. Learn more about how we transform outcomes every day at childrensmercy.org/transform. For admissions, consults or transports, call 1-800 GO MERCY (1-800-466-3729).
Mercy 140718 Physician-Pedsline Ad-v6.indd 1
15 | Spring/Summer 2014 B A I PedsLines LEY LAUER MAN Children’s Mercy Warady Nephrology ad Mercy140718 Pub: Missouri AAP Pedsline Color: 4-color Size: 7.5" x 4.75"
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The Missouri State Newborn Screening Program: The Role of the Pediatrician
Newborn screening refers to screenings performed on newborns shortly after birth to protect them from the dangerous effects of disorders that otherwise may not be detected for several days, months or even years. Missouri law requires all babies born in the state to be screened for certain genetic, metabolic, and endocrine disorders. Whether a baby is born in the hospital or at home, the newborn screen should be collected between 24 and 48 hours of age regardless of feedings. A small sample of blood is collected from the baby’s heel and placed on a special filter paper. The filter paper, or blood spot card, is then sent to the Missouri Department of Health and Senior Services State Public Health Laboratory. After the blood spot cards reach the Missouri State Public Health Laboratory, they are then screened for over 60 disorders. In Missouri, a baby is diagnosed approximately every other day with one of the disorders for which the department screens. Early screening paired with timely follow-up can provide these babies with the medical care and treatment they need to allow them to grow and develop as healthy as possible. Undetected and untreated, these disorders can cause severe injury to the brain, organs, or nervous system, and can result in death. Since symptoms are not generally noticeable at birth, the only way to find these disorders before permanent damage occurs is through newborn screening. The goal of the Newborn Screening Program is to prevent serious health problems through early screening. As pediatricians, you can play an important role in achieving 16 PedsLines | Spring/Summer 2014
this goal by educating new and expectant parents about the value and importance of newborn screening. Although parents should have received information prenatally, it may be a good idea to take a moment during the first well visit to provide a brief overview of newborn screening and why it is important. Newborn screening educational materials for new and expectant parents are available from the Department of Health and Senior Services. An excellent newborn screening educational video is also available free of charge from the Save Babies Through Screening Foundation, http://www. savebabies.org/video.html. The Missouri Newborn Screening Program wants parents to make sure their babies get tested and that they take follow-through very seriously if tests come back positive. Sometimes a few words of wisdom from their healthcare provider can make all the difference for parents. Pediatricians should verify that a newborn screen was collected and results have been received for every baby within their care. If inaccurate contact information or the wrong primary care provider was provided on the blood spot form, the newborn screening follow-up staff may have difficulty contacting the primary care provider or the parents in the case of an abnormal screening result. A good way to ensure the newborn screen was collected is to discuss the newborn screening results with parents during their baby’s well visit. By incorporating this discussion into routine care, pediatricians can ensure the newborn screen was collected and make certain that the parents understand the results. Occasionally, a baby may be found to have not had a newborn screen. The Missouri Newborn Screening Program recommends a newborn screen for these babies regardless of age. Although newborn screening is most beneficial when collected at 24 to 48 hours of age, there is no age at which it is “too late.” Because of the fact that some of the disorders for which we screen can show no signs or symptoms for months or even years, it can still be very important to have the newborn screen collected outside of the newborn period. For more information regarding Missouri’s Newborn Screening Program or to obtain educational materials, please contact the Department of Health and Senior Services, Bureau of Genetics and Healthy Childhood at 800-877-6246 or 573-751-6266.
Share Pregnancy & Infant Loss Support By Debra Cochran, BSN, MA Share Pregnancy & Infant Loss Support is a national not for profit organization with headquarters based in St Charles, Missouri. Our primary mission is to provide care, sup-port and resources to families who have suffered the death of baby in pregnancy, by still birth or in the first few months of life. Share was founded in 1977 by Sr. Jane Marie Lamb in Springfield, Illinois, and moved its headquarters to St. Charles in 1991. Today, Share provides support to bereaved families through the national office as well as nearly 80 chapters operating in 29 states through-out the country and internationally. These Share chapters operate through partnerships with hospitals as well as trained support group facilitators to provide comprehensive long term support to bereaved families from the time of loss through the journey of grief that follows. Share’s goal is to assure that no one walks through this tragic experience alone. As we know the CDC statistics reflect that one in four pregnancies ends in loss, we recognize the need for the services Share provides is continuous. Of these losses, over 900,000 occur early in pregnancy, before 20 weeks gestation, and many of the women experiencing this type of loss never enter into the Labor and Delivery suites of a hospital. Therefore, we are finding it increasingly important to assure that obstetrical offices, clinics and outpatient surgery facilities are prepared with our information, resources and an easy means to connect their patients with Share support when this crisis occurs. Our secondary mission is to educate and equip professionals, caregivers and community members to care for the bereaved. We have provided training and resources for all of the Share Chapter leaders and other professionals who care for grieving parents. Our training is valuable for all of those who care for the bereaved, but essential for those who desire to start and maintain a Share Chapter. Currently there are only a handful of Share Chapters outside the St. Louis metro area, non in Springfield and non in Kansas City. 17 PedsLines | Spring/Summer 2014
We know this means there are many bereaved parents in our state suffering through this tragedy without the support they need for healthy outcomes. We know that parents never “get over” the loss of a child, no matter their age. We also know many of the documented consequences of unresolved or complicated grief such as PTSD, depression and anxiety only serve to inflict additional suffering on these families. We know that Share can make a difference in these outcomes for your patients. We want to provide you, your patients and your office staff with the best resources available when this tragic loss occurs. We would like to be a trusted resource for you and your staff to refer your patients when the need arises. Please know that we welcome any questions you may have, and would value any conversations regarding Share and our mission. You may visit our website at www.nationalshare.org for additional information about the support we provide. Our catalogue of resources and information about upcoming training sessions can be accessed as well. Share exists to serve the needs of bereaved families and the professionals who care for them. We welcome your contact and are willing to arrange opportunities to connect with you, your office staff and/or professional group. We look forward to helping increase the support available to your patients and their families through Share. Visit http://www.nationalshare.org/sharing-caring.html to download a brochure. Debbie Cochran BSN, M.A. joined the Share staff as Executive Director in May of 2013. Her career includes various health care leadership positions and 12 years of health policy experience. She considers it a privilege to lead an organization that cares for families through such an intimate and personal experience. PedsLines | Spring/Summer 2014
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Strong Moms, Happy Kids
Over two years ago, I became a member of the Intimate Partner Violence Workgroup at Children’s Mercy Hospital in Kansas City, Missouri. I have always had an interest in intimate partner violence, and after completing my residency in general pediatrics, I was determined to create a program that would help victims become more knowledgeable on routine child healthcare topics, establish primary healthcare providers for themselves and their children, and have our volunteers act as mentors. Strong Moms, Happy Kids was created in order to achieve these goals. We are comprised of a group of volunteers from all different backgrounds, medical and non-medical, from Children’s Mercy Hospital in Kansas City, Missouri. We were graciously awarded the CATCH grant through the AAP in 2013 and were able to implement our program. We have primarily served two shelters in the Kansas City metropolitan area. Each month, we spend the first half of our sessions discussing a specific child healthcare topic, such as disciplining your child, respiratory infections and hand hygiene, or adolescent health. We also review the importance of immunizations and help provide resources to facilitate establishing a primary care provider at each session. During the second part of our sessions, we engage in an arts and crafts project with clients and use the time to act as positive role models and get to know them better. Each session is supervised by a physician who has completed a residency in general pediatrics. 18 PedsLines | Spring/Summer 2014
We are not the only ones who are teachers. All of our volunteers, myself included, have learned a great deal through our sessions with these victims. They have great strength and courage in leaving their abusive partners. In their stories are determination, an ability to overcome the most difficult challenges, and insight into the barriers they have faced in accessing routine healthcare for themselves and their children. Even though they may recognize the importance of routine healthcare for themselves and their children, pursuing this can be hard when safety is a concern. In order to seek appropriate healthcare for themselves and their children, victims of intimate partner violence often times have to begin by getting to a safe place. Even after victims get to a safe place, life in shelter is still a difficult transition to adjust to. It is hard to leave nearly everything behind and start over. As our grant period comes to an end, we would like to continue to raise awareness about intimate partner violence in all areas including the workplace and community and hope to continue to recruit more members to our volunteer group to serve other intimate partner violence shelters in the community. We hope to continue to be a positive influence on victims of intimate partner violence and help them establish a medical home by familiarizing them with resources available in their community. Our volunteers act as mentors to victims to promote positive attitudes regarding health and general well-being.
Dr. Pooja French is a general pediatrician at Children’s Mercy Hospital in Kansas City. She is the recipient of a CATCH grant, “Strong Moms, Happy Kids” and is a volunteer with Big Sisters and Brothers. Dr. French received the Clark W. Sealy award for demonstrating excellence in primary care. Pooja French, MD
Dr. Joseph Parks Guides MO HealthNet Dr. Parks serves as the Director of MO HealthNet, Missouri’s Medicaid authority in Jefferson City, Missouri. He also holds the position of Distinguished Research Professor of Science at the University of Missouri – St. Louis and is a Clinical Assistant Professor of Psychiatry at the University of Missouri, Department of Psychiatry in Columbia. He practices psychiatry on an outpatient basis at Family Health Center, a federally funded community health center established to expand services to uninsured and underinsured patients in central Missouri. He previously served for many years as Medical Director of the Missouri Department of Mental Health and as President of the Medical Director’s Council of the National Association of State Mental Health Program Director. He also previously served as Director of the Missouri Institute of Mental Health at University of Missouri St Louis and as Division Director for the Division of Comprehensive Psychiatric Services of Missouri Department of Mental Health. Dr. Parks has authored or coauthored a number of original articles, monographs, technical papers, and reviews on Behavioral Health services delivery and policy. He is the recipient of several Leadership awards including from the University of MO - Columbia , Department of Psychiatry (2006); Missouri Hospital Association (2009 & 2011); Missouri Primary Care Association (2012) and Missouri Chapter of Mental Health America (2011). He has also received Innovation and Quality Improvement awards including from American Psychiatric association (2006), URAC (2008); SAMHSA Science and Service Award (2008).; Missouri Governor’s Award for Quality and Productivity (2011); and the Missouri Governor’s Pinnacle Award for Quality and Productivity (2012).
MO Department of Social Services Seeking Pediatric Physician Consultant
Missouri Department of Social Services is seeking a full-time Pediatric Physician Consultant within the MO HealthNet Division (MHD), Evidence-Based Decision Support Unit. The purpose of MHD is to purchase and monitor health care services for low income and vulnerable citizens of the State of Missouri. This position requires responsible and highly skilled and complex physician consultant work on a professional, supervisory, and administrative level involving responsibility for Medicaid, Children’s Division, and Division of Youth Services functions of substantial scope and complexity. The position is located in Cole County. Please visit http://www.dss.mo.gov/hrc/jobs/ to view the full announcement. DSS IS AN EQUAL OPPORTUNITY EMPLOYER 19 PedsLines | Spring/Summer 2014
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