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APRIL 2019 / $5

CEO Tim Puthoff Joins Brookwood and Tenet Operations


By ann B. deBeLLIS

Physician Assistant Still going Strong after Knee Replacement at 76 Most people don’t continue working at the age of 76. And most people don’t get both knees replaced at the same time. And certainly, most people don’t return to work two weeks later, at any age ... 3

Home Dialysis Can Be Life Changing for End Stage Renal Patients End-Stage Renal Disease (ESRD), or permanent kidney failure, affects almost 750,000 people per year in the United States, and the patient population is increasing by five percent each year ... 7

Tim Puthoff returned to Alabama in January to serve as Chief Executive Officer for Brookwood Baptist Medical Center and Tenet’s Alabama and Tennessee Group. He is responsible for all strategic, operational and clinical activities at Brookwood Baptist Medical Center as well as providing oversight at all five hospitals in the Brookwood Baptist Health system and Tenet’s Tennessee hospital operations. For the past five years, Puthoff served as CEO of Houston Northwest Medical Center where he led Houston Northwest in significant growth, including increases in admissions, surgeries, and Emergency Department visits. Under his leadership, the hospital scored well above national averages in the AHRQ Culture of Patient Safety Survey. Having worked for Tenet previously, Puthoff is familiar with Brookwood and the Tenet systems. “I know what a wonderful facility Brookwood Baptist has been

Tim Puthoff, left, visits during a ‘CEO Coffee with the Community’ event.



Multistate Nursing License A New Option for Alabama? By Laura Freeman


Peggy Sellers Benson, RN, MSHA, MSN, NE-BC

Soon Alabama nurses will likely be able to choose one medical license that will allow them to practice in more than 30 states. Nurses in those states will also be able to practice in Alabama without the delay and added expense of buying a separate license here. The Senate Healthcare Committee passed SB37 in March and the full senate is expected to consider it in April. On the House side, the House Health Committee is expected to pass HB44 in early April, sending it on to the full House. If enacted, this legislation will approve participation in the Enhanced Nurse Licensure Compact (eNLC), which in turn could help to alleviate nursing shortages by making recruiting of temporary and travel nurses easier. It would also open up job opportunities for Alabama nurses, and could be particularly helpful in rural areas and (CONTINUED ON PAGE 4)

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Birmingham Medical News


Physician Assistant Still going Strong after Knee Replacement at 76 By martI weBB SLay

Most people don’t continue working at the age of 76. And most people don’t get both knees replaced at the same time. And certainly, most people don’t return to work two weeks later, at any age. But Bill Parker, Physician Assistant to Kenneth Bramlett, MD at Bramlett Orthopedics, is not most people. Parker graduated from the UAB Physician Assistant program in the second graduating class. After serving in the Air Force, he had been working as a scrub technician in South Carolina when he learned about the PA program in Birmingham. “The problem was, when I heard about it, the classes were starting the next Thursday,” Parker said. He interviewed with Margaret Kirklin (wife of John W. Kirklin, MD), was accepted into the program, and moved to Birmingham all within a week. He did not expect to be a PA for the rest of his career. The original plan called for him to use it as a stepping stone to medical school. “I enjoyed this work so much, I never even applied to med school,” he said. He has seen many changes for PAs over the years. “There was not much legislation about PAs in the 70s,” he said. “The state of Alabama left it to the hospital and doctors to decide what you could do, so we had a lot of autonomy in the early years.” Although his profession has seen many changes, he still enjoys going to work, and says he is not willing to retire yet, despite his double knee replacement earlier this year. He chose to have both knees replaced at the same time, and by the orthopedic surgeon he has worked with for 27 years. “There was no other person in this world I’d have do it,” he said. “Dr. Bramlett is brilliant, has done over 400 of these procedures, and is organized, disciplined and dogmatic about his surgery. When he finishes, it is right.” Parker wouldn’t recommend bilateral replacement to everyone. “It’s not a procedure I recommend unless they know what they’re getting into,” he said. “I put off the surgery as long as I could, eight

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Bill Parker (left) has been practicing with Dr. Kenneth Bramlett (right) for 27 years.

years after injuring a knee while jogging. It’s hard to go to work and pretend you’re fine when you are hurting. I couldn’t do it anymore, and both knees hurt. I knew exactly what to expect, and that makes a difference.” Two weeks later he was back at work. “I love going to work,” Parker said.

“None of the cases are the same. You can have two 220-pound ladies, but they’ll need different size knees. It keeps you wondering what you’ll see next. It’s like a Cracker Jack box. That’s what’s kept my enthusiasm about it. It’s not hard to get up and go into work. The people are great. We all know each other and can all

depend on each other.” He has focused his work somewhat over the past few years. “Paperwork is a time consuming job,” he said. “Seeing and educating the patient, doing the history and physical, following them every day on rounds, takes a lot of time. Dr. Bramlett came to me and asked me to just work in the operating room. “So now, I’m a hospital-based PA. I spend 99 percent of my time in the OR. I don’t find it to be drudgery. If I did, I would quit. But I’m definitely slowing down.” He may be slowing down, but he still exerts a great deal of influence in his profession. “I love to teach,” he said. “We’ve got bright kids coming out of the program today. I don’t know if I could have met the current criteria.” Perhaps his longest legacy, however, will be the Bill Parker Endowed Scholarship in Physician Assistant Studies. Three years ago he established the endowment fund which provides a $1500 scholarship to current or future students in the program. He hopes other PAs will follow suit and start an endowment fund of their own. “There are a lot of PAs out there who have been in practice for 20 to 25 years,” he said. “If I can do this, they can do it too. I wanted to do this for my school.”



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APRIL 2019 • 3

Multistate Nursing License, continued from page 1 near state lines where nurses may live in one state and work in another. When the question of whether to join eNLC first rose, the Alabama Board of Nursing couldn’t yet recommend it because many aspects of membership were yet to be defined. Now that guidelines and responsibilities are clear, benefits known, and a plan in place for covering expenses without increasing costs to nurses who choose an Alabama-only license, the board is giving the legislation its full support. “We are the only southeastern state that hasn’t yet joined the compact,” Alabama Board of Nursing Executive Officer Peggy Sellers Benson, RN, MSHA, MSN,

NE-BC said. “Membership would benefit both our nurses and our communities. “Nurses will be able to choose the license that best fits their career plans. Those who choose a Compact license will be able to practice in person and participate in telemedicine nursing in other member states. Nurse educators will be able to teach students in multiple states without having to purchase multiple licenses.” In addition to addressing local nursing shortages, the compact license would help to facilitate additional nursing support in disaster recovery. Consistent nursing standards required to qualify for a Compact license would also protect quality of care

for patients. “Nurses who are in military families or whose spouses are likely to be transferred will be able to seamlessly seek employment in any member state without having to obtain another license,” Benson said. Under Compact rules, nurses will apply for a multistate license in their home state. The Alabama Board of Nursing will be able to quickly verify licenses and backgrounds to expedite new hires for employers. As of now, Compact licenses will not be available for advanced practice nurses such as nurse practitioners and nurse midwives, as requirements and scope of practice regulations vary so widely from state to

CEO Tim Puthoff Joins Brookwood, continued from page 1 over the years, and I was excited for the opportunity to help lead a system that has such a prevalent role in the market,” he says. Puthoff plans to employ strategies specific to Brookwood Baptist and Tenet, but he will first take time to identify the needs of the health system. “It’s a bit early to talk about strategies because I am still learning about the organization,” he says. “Overall, I think we will continue to develop our primary care base. We have opportunities with the neurosciences, and we can be a leader in stroke care in the Birmingham area. I want us to continue to improve what I think is already the leading cardiovascular services in the city at Brookwood, Princeton and Shelby. I am excited about further development of that service line.” Infrastructure improvements are also on Puthoff’s list. “We are investing $80 million in our facilities which includes new equipment and renovations. We will see a lot of noticeable improvements in the Brookwood facility and other hospitals in the system,” he says. Projects nearing completion at Brookwood Baptist include the addition of a new

state-of-the-art electrophysiology lab, new linear accelerator for advanced cancer treatment, new 3T MRI, expansion of the hospital’s sterile processing area and renovations to the hospital lobby. Upcoming projects include the purchase of three new cardiac catheterization labs, expansion and renovation of the GI procedure area and a fully-renovated orthopedic and neurology patient floor. Adding to its capital investments and touching on Puthoff’s desire to be a leader in stroke care in Birmingham, Brookwood along with Shelby, Princeton and the Brookwood Freestanding Emergency Department recently deployed the RAPID imaging platform from iSchemaView, bringing the most advanced brain imaging software platform for identifying treatment options for stroke patients. RAPID is a new class of automated brain imaging software that allows doctors to quickly visualize reductions in blood flow to the brain and early signs of brain injury. “We are also working with our marketing and public relations staffs in an effort to be a more visible part of the Birmingham community from both a patient and pro-

vider standpoint,” Puthoff said. “We want people to know the Brookwood system and the great things we are doing in our hospitals.” Healthgrades, a leading online resource for comprehensive information about physicians and hospitals, has already recognized the Brookwood system’s accomplishments. It recently acknowledged Brookwood Baptist Medical Center’s excellence in Healthgrade’s 2019 Report to the Nation as one of America’s 100 Best Hospitals for orthopedic surgery and spine surgery. Brookwood Baptist Medical Center is the only hospital in Alabama to be recognized in both surgical categories for 2019. “There is a lot to be proud of at Brookwood,” Puthoff says. “Our patient satisfaction and overall quality scores are outstanding, and we will continue to work to improve in these areas. The care that is delivered in our organization is second to none in Birmingham, and we have a wonderful staff and a dedicated group of doctors. My priority is to build on the strong foundation we already have and to help grow our health system in the years to come.”

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state. These will need to be standardized before a multistate license will be available for these nursing specialties. Alabama-based travel nurse (name) is definitely looking forward to the new license that will allow her to practice in more than 30 states. Passage of this legislation by both houses of the legislature is expected to occur shortly. Any changes in status that occur after this issue goes to press and before the next issue will be updated in our online edition at www.

HB44/SB38 Enhanced Nurse Licensure Compact (eNLC) Current law: • The Alabama Board of Nursing is not a party to the eNLC, and issues only single-state licenses. • 31 states currently participate in the eNLC. • Alabama is the only state in the Southeast not in the eNLC. Challenges under current law: • Employers report difficulty hiring travel or temporary nurses, due to unwillingness to obtain an Alabama license. • Rural hospitals have difficulty hiring nurses. • Alabama nurses report difficulty accepting out of state work, as they may not hold the proper license. • Alabama nurse educators must hold multiple state licenses, if they teach out-of-state students. HB44/SB38 would: • Enact the Nurse Licensure Compact, while protecting Alabama nurses. • Allow Alabama nurses to choose to have either a Compact or an Alabama-only license. • Allow hospitals to rapidly place travel nurses who hold a Compact license. • Allow nurses to easily transition across state lines to work flex positions in Alabama hospitals. Benefits • Expands access to nursing services in Alabama. • Enables nurses to provide telehealth services to patients across the country without having to obtain additional licenses. • Allows nurses to cross state borders and provide services in the event of a natural disaster. • Allows military spouse nurses to continue working, without having to obtain a new license when they relocate. • Facilitates online nursing education by reducing educators’ need for multiple licenses. • The eNLC also removes a burdensome expense for organizations that employ nurses and may bear the burden of multiple licenses.

North Alabama Medical Center Grows into its New Home By Laura Freeman

As the worldwide influenza epidemic of 1918 swept through Alabama’s Tri-Cities, young Eliza Coffee was one of the many who were lost. The area’s hospital was named in her memory. It served generations of residents over the next century, but after so many years and three decades since the last update, it was time for a facility that could bring 21st century healthcare to the area. “We promised the people of the Tri-Cities a new hospital. Getting approval on the certificate of need took a while, but that gave us time to focus on planning, which helped us build a better hospital,” Chief Operating Officer Michael Howard said. “We had conversations with our staff in every department. We asked people what would make their job easier. And we wanted to know what we could do to improve pa-

The new North Alabama Medical Center.

tient care. From physicians and nurses, pharmacy, dietary, housekeeping, and staff throughout the hospital, our frontline caregivers gave us some wonderful ideas that we took to our architect, Gould Turner Group, and our builder, Layton Construction.” From groundbreaking to completion, construction of the state-of-the-art facility took two years. As it progressed, the hospital staff spent long hours planning the logistics for moving patients in a convoy of ambulances from Eliza Coffee Memo-

rial Hospital and making sure everything was in place at the new medical center to welcome them. The big day came in December. The new North Alabama Medical Center opened its doors to begin serving patients from Florence, Muscle Shoals, Sheffield, Tuscumbia and border communities in Tennessee and Mississippi. “We had reserved 20 ambulances from Alabama and Mississippi for the whole day if needed, but everything went so smoothly that by 1:00 p.m. we were

getting the last of 135 patients comfortably settled in their new rooms,” Howard said. “The response from patients has been wonderful. They talk about how much larger and more comfortable the rooms are and how easy the hospital is to navigate. They are also happy about the technical advances and new capabilities that allow them to receive a broader range of care without having to travel far from home.” For the comfort of patients and their families, rooms are decorated with a feel that is more like a hotel than a hospital. In addition to a bedside recliner in every room, there is also a sleeper sofa so family members who stay with patients can get a better night’s rest. “Our doctors are happy because their patients are happy,” Howard said. “They also like the layout and easy navigation (CONTINUED ON PAGE 6)

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APRIL 2019 • 5

Clinical Labs Beware: Review Your Marketing Arrangements By JIm hooVer

On October 24, 2018, Congress enacted the Eliminating Kickbacks in Recovery Act of 2018 (EKRA). EKRA is part of the “Support for Patients and Communities Act,” comprehensive legislation designed to address the opioid crisis. Although the Act is aimed at the use/ abuse of opioids and the business practices of recovery centers, it contains some very important and potentially game changing legislation. The most substantive change brought about by EKRA relates to certain business practices that some clinical labs currently use. EKRA prohibits certain compensation arrangements with employees and contractors. The statute prohibits a clinical lab from paying compensation to employees or contractors that is based on: (1) the number of individuals referred to a particular recovery home, clinical treatment facility or laboratory; (2) the number of tests or procedures performed; or (3) the amount billed to or received from, in part or in whole, the health care benefit program from the individuals referred to a particular recovery home, clinical treatment facility or laboratory. Thus, compensation formulas for employees that use a percentage of collections or

number of specimens are now prohibited. This change is important because under the AKS, clinical laboratories and other providers are permitted to pay bona fide employees compensation based on revenues generated from their marketing activities. The OIG has even indicated in several Advisory Opinions that providers could pay independently-contracted sales agents percentage-based compensation so long as the arrangement contained adequate safeguards to address so-called “suspect factors.” The prohibition of paying employees based upon a formula that takes into account the amount of business generated by the employee should cause laboratories to review and change their compensation practices since these compensation arrangements are widely-used, and now are no longer protected. Another game changing provision of EKRA is that the statute applies to all payors. This means it applies to services that are paid by commercial insurers in addition to services paid by Medicare and Medicaid. Unlike the Anti-Kickback Statute (“AKS”) that only applies to federal payors, EKRA applies to commercial payors as well. Obviously this is much more expansive than the AKS and may have a significant impact on clinical labs if a lab carves out arrangements for fed-

eral healthcare benefit programs. Clinical labs should examine their business practices as they relate to commercial payors if the labs have carved out arrangements specific to commercial payors. Finally, EKRA currently applies to all clinical laboratories. The definition of “clinical labs” used by EKRA is the definition contained in 42 USC 263a, which is extremely broad. Rather than confining the definition of “clinical lab” to toxicology labs which would satisfy the legislative purpose of the opioid crisis and business practices of recovery centers, the definition actually includes all clinical labs. Consequently, the reach of the definition of “laboratory” is significantly broader than the purpose of the Support for Patients

and Communities Act and, as currently drafted, applies to every clinical laboratory. Accordingly, all clinical laboratories are subject to EKRA’s reach. While there is a possibility the definition of clinical lab will be interpreted to apply only to toxicology labs, it is far from certain. Consequently, any/every clinical laboratory needs to be aware of the new legislation and examine its business practices and compensation arrangements immediately. Jim Hoover is a partner at Burr & Forman LLP practicing in the Health Care Industry Group.

North Alabama Medical Center, continued from page 5

The lobby of the North Alabama Medical Center has a modern feel.

that allows them to move quickly to where they need to be. And we are getting great reviews on the technology upgrades that allow our surgeons to do a wider range of more advanced procedures so they can do more to help their patients close to home.” The center has increased ER rooms from 21 to 36, and operating rooms from 10 to 15. “One of those rooms is a rare hybrid that includes imaging to assist in cath lab and other vascular procedures,” Howard said. “We have excellent radiology and imaging technologies overall, including two CT scanners and two MRIs. A new O-arm is being put to good use assisting

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Birmingham Medical News

in brain and spinal procedures. As you might imagine, these advances in our capacities are helping us attract new physicians, nurses and patients. We’re seeing increases in transfers coming to us from small outlying hospitals.” Location is another plus for the new medical center. “We are in Florence by the river, up on a hill where we are easy to find. Being near the crossing of two major traffic arteries makes it easier to get here in an emergency.” The medical center participates in training for medical students and is working toward setting up a residency program. Its new facilities also offer space for continuing education for staff as well as health education for the community. “With the new conference facilities and auditoriums, we’ve been able to do several seminars for our physicians and staff and wellness seminars on topics such as diabetes education for the community. We have childbirth and new baby classes, and more planned,” Howard said. “There is so much potential here and built-in room to grow.”

Home Dialysis Can Be Life Changing for End Stage Renal Patients By ann B. deBeLLIS

End-Stage Renal Disease (ESRD), or permanent kidney failure, affects almost 750,000 people per year in the United States, and the patient population is increasing by five percent each year. The state of Alabama is fifth in the nation for kidney disease with 11,000 people currently on dialysis and 1,600 waiting for a kidney transplant. The most common causes of ESRD in our state and region are diabetes and hypertension, but researchers have identified genetic causes for kidney diseases, according to physicians Harold Giles, MD and Jeffrey Glaze, MD, both with Nephrology Associates in Birmingham. “We are identifying some genetic causes that were previously labeled as hypertension,” Glaze says. “One of those is a genetic variant called APOL-1 gene mutation. It causes kidney failure in African Americans and is likely a reason that many young people develop kidney failure. “Studies are underway to identify treatment options for this problem, because currently there are none. Polycystic kidney disease is also genetic and is responsible for about four percent of people

Harold Giles, MD, examines a patient with kidney disease.

who are on dialysis. Currently, there are treatments that have been shown to slow the progression of the disease but that

aren’t necessarily curative.” There are five stages of kidney disease based on a person’s glomerular filtration rate (GFR), a test that determines how well the kidneys are functioning. “The GFR measures the filtration ability of the kidneys, and as it declines, the patient will progress through the stages of kidney disease,” Glaze says. “Stage five is a GFR of less than 15, and that’s when most people end up on dialysis.” Once a patient is diagnosed with kidney failure, the options are dialysis or a kidney transplant. “I believe the best option for these patients is a transplant, because it is associated with the highest rates of survival,” Giles says. “Home dialysis is the next best choice.” Although home dialysis has been available since the 1960s, for a number of years most patients went to a dialysis center for treatment. “In the past decade, there have been upgrades and changes to the way patients do home dialysis which has made it easier and more successful for patients. The technology has simplified dialysis in such a way that it is available for more patients,” Glaze says. There are two types of home dialysis therapy – peritoneal dialysis and hemodialysis. Both are equal in results, so pa-

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tients can choose which type they prefer. Each patient is trained in one of the two Nephrology Associates centers, located in Birmingham and Anniston, before beginning dialysis at home. Peritoneal dialysis uses the lining of the abdomen to filter waste from the bloodstream. It uses the blood vessels in the lining of the peritoneum to naturally filter and clean the blood. Dialysate fluid is circulated into the peritoneal cavity either manually or by using a PD dialysis machine called a cycler. The fluid then absorbs the waste, toxins and excess fluid from the blood, which are removed when the dialysate is drained. The in-and-out process is repeated several times a day using fresh dialysate. Home hemodialysis is basically the same process that is used in a dialysis center, but it is done with slightly different equipment. It involves blood and needles and may require a partner for each treatment. During home hemodialysis, the blood is filtered outside the body through a dialyzer or “artificial kidney” to remove unwanted waste, toxins and excess fluids. Hemodialysis uses dialysate solution to remove unwanted substances from the blood. Clean, chemically balanced blood is then (CONTINUED ON PAGE 12)

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APRIL 2019 • 7


Ending the Allergy March by Jane


“Each rising generation is appearing to be more allergic than the next,” says John Anderson, MD, an allergist with Alabama Allergy. Between 1997 and 2011, the prevalence of food allergies in children rose by 50 percent, equaling about two in every classroom, according to the Centers for Disease Control (CDC). Allergies first John Anderson, MD begin at birth, but symptoms start most often with atopic dermatitis, also called eczema, at around six months to a year. “That doesn’t mean

all allergies start then. It can start later,” Anderson says. “But atopic dermatitis is historically looked at as the entryway to that allergic march — that pattern where kids start with eczema and then later have allergy asthma and allergic rhinitis.” When researchers first looked at the allergic march, food allergies were not part of that picture. But now the combination of eczema and food allergies is seen as a predisposition to allergic rhinitis and asthma later. “Not all kids showing those symptoms will have respiratory conditions later,” Anderson says. “But if you’re looking for predictors, early onset and severity of atopic dermatitis and food allergies, if they are a persisting problem, are clues that a child will grow into other disease states.” Often the eczema and food allergies

will fade in late childhood at around 10 to 14 years of age. “We think that the role of the skin as a barrier might have something to do with the initial allergic reactions,” Anderson says, which is why some kids’ symptoms fade and do not progress along the allergic march. Before a child ever orally contacts a food, their skin may come in contact with it. “That touching is an opportunity for the immune system to survey what’s around it and the start of either becoming allergic to it or tolerant,” Anderson says. Studies on peanut allergies in children—the most common food to trigger anaphylaxis, a potentially fatal allergic reaction — have shown that the white blood cells that govern the allergic reactions, called lymphocytes, displayed markers



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proving they had been on the skin. “That showed that the skin had touched a protein of peanut and that the skin was the point of initial exposure to the allergen for those children,” Anderson says. “This was the great folly of our allergy experiment,” Anderson says. “We told parents not to give peanut butter to kids until they were three years old, because we did not think at that time that cutaneous sensitization was a cause.” Now allergists believe oral ingestion lessens the risk of a reaction and breaks that allergic march, at least for peanut. “One reason for this is the immune system that traffics through the gut and the mouth is perhaps more engineered for creating tolerance to food,” Anderson says. The five-year LEAP study, that ended in 2013, tested the early oral introduction theory by intentionally feeding peanut for over a year to 500 infants ages 6 months to a year prone to allergic risk factors, like eczema. “It showed that early introduction prevented the development of peanut allergy,” Anderson says. Five years later, 81 percent fewer of those children had manifested a peanut allergy compared to the control group, which had avoided peanuts completely during that time. Today, allergists suggest parents of infants showing no allergic risk factors regularly introduce peanut butter at home. But if they show a history of eczema or egg allergy, then they should talk to their doctor and decide if an allergist should be part of the conversation. “As groundbreaking as this is, it hasn’t changed the allergic march. Kids are still getting other food allergies, atopic dermatitis and asthma down the line,” Anderson says. “We’re still searching for more meaningful interventions to change the course entirely. And there are things coming down the pipeline that could that.” One option is the current development and usage of biologics — drugs tailored to the individual that block specific signals that normally trigger allergic reactions. “Those could then be used to halt or alter this atopic path,” Anderson says, along with other options being explored, such as probiotics and introducing the most common allergic foods in infancy — cow’s milk, wheat, and soy. “We know small studies show just applying moisturizer to a child’s skin helps to prevent atopic dermatitis. How simple is that?” Anderson says. “This is something that could have broad implications and needs more study.” Anderson says the microbiome of all the germs around us needs to be better understood, because the common cluster of symptoms in the allergic march — atopic dermatitis, food allergy asthma, and allergic rhinitis — are occurring in more numbers than genetics can explain. “The microbiome has been altered by our lifestyle changes, and we need to learn more about what has changed,” he says. “Then we can intervene in our microbiome to restore our tolerant nature to the proteins within our food and our environment. That’s in its early stages.”


Allergen Immunotherapy By Jane Ehrhardt

Allergen immunotherapy (AIT), also known as allergy shots, have been around for over 100 years. This treatment not only creates a long-term tolerance for a specific allergen, but can stop both the development of new sensitivities and the allergic march. “If you can catch it early, allergy shots put up a wall against allergic rhinitis progressing into allergic asthma,” says Carol Smith, MD, allergist with Birmingham Allergy & Asthma. “I don’t think a lot of people know that’s possible, because they don’t think of asthma as being related to their allergies.” AIT is also the Carol Smith, MD only treatment to alter the immune mechanism of the allergic disease on a long-term basis. “It works by decreasing the response to common things that the body sees as foreign,” Smith says. “It decreases the T-helper 2 (Th2) response and stimulates IL-10 and TGF-β expression cells, while increasing the blocking antibodies, particularly the immunoglobin IgG4. “This may block the interaction between allergen and IgE, creating an inhibitory effect. We always assumed that there was some sort of antibody that blocked the allergy response, but we didn’t know until the last ten years. Now we know it’s IgG4.” Smith says that confirmation did not necessarily change things in AIT, but it did open the door to looking at new things including the administration route for the allergens. “We’ve had allergy shots since the beginning, but now we have sublingual tablets,” she says. The tablets, held under the tongue until dissolved, began receiving FDA approval for various airborne allergens in 2014. The advantage is that treatment with sublingual tablets has a lower chance of anaphylaxis compared to allergy shots, and they do not require an office visit. “The tablet is felt to be almost as effective as subcutaneous shots, but it has a drawback,” Smith says. “They only have tablets for grasses, dust mite and ragweed. So if you have pollen sensitivities, you’re better off taking allergy shots.” More recently, clinicians have used skin patches to administer the needed dosing. “Epicutaneous patches don’t work well for aeroallergens, but do show promise for food allergies” Smith says. The mechanisms for altering the immune system differ for each allergen designation. But in food allergies, the patch could be ideal, because the treatment must be continuous. “You’re developing a sustained tolerance to the food. You can’t ever stop your treatment,” Smith says. “If you stop, you lose all desen-

sitization.” For the patches, their time may soon come. A review of the literature in 2018, published in the Journal of Translational Medicine, found eight placebo-controlled, double-blind patch trials, covering grass pollen rhinoconjunctivitis, cow’s milk allergy, and peanut allergy. The studies showed high safety and adherence to the patch. The peanut allergy patch may even hit the market soon. Last fall, the FDA nixed the first patch to treat peanut allergies for children, because it lacked “sufficient detail regarding data on manufacturing procedures and quality controls.” But the maker, DBV Technologies, has stated that because the FDA’s concerns did not pertain to the safety or efficacy of the patch, they will be able to gather the needed data and resubmit their application this fall. Another new way to administer allergens is currently in clinical trials. It utilizes the traditional shots but places them into the lymph nodes. “It would probably be painful, but it would give you the benefit a whole lot faster—like days versus years,” Smith says. Because the lymph nodes are the source for both IgE, which causes the reactions, and the IgG that blocks the reaction, injecting the lymph nodes creates a faster, purer route for the allergen. A different protocol using the traditional subcutaneous injections can also shorten the initial part of the treatment span. Called rush, the typical weekly doses are condensed into one day by being delivered every 30 minutes. The allergist generally administers extra medication prior to the allergy shot treatment, such as an antihistamine and steroid. “This is to block all these receptors,” Smith says. “That’s what allergists do is push people to the edge of their tolerance. That’s why the expertise of an allergist is needed.” That one-day treatment equals about the first four months of weekly visits, followed by the usual allergy shot regime. “After the single-day treatment, patients come weekly for another 15 to 20 weeks until they hit their goal dose, after which they come monthly for three to five years,” Smith says. “Then they can stop.” The Rush protocol is for people who need to get their allergic reactions under control faster or who don’t have time to come in weekly. “People who work outdoors who have anaphylactic reactions to stings benefit from the Rush protocol. It can also be helpful for someone who has terrible spring allergies and wants to build up some tolerance before spring comes,” Smith says. “The point is that allergen immunotherapy works well,” Smith says. Plus research and applications are now on the horizon for easier and shorter administration. “AIT may have been around forever,” she says, “but it is still the only therapy we have available to alter the immune mechanism of allergic disease long-term.”

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Severe Asthma Disparities

Study Finds Social Determinants Impact ED Usage By CINDY SANDERS

Racial disparities between asthma prevalence, severity and morbidity have been well documented in numerous scholarly journals. A recently published article in the Journal of Allergy and Clinical Immunology (JACI) drilled down on emergency department utilization between self-reported black and white patients, finding that while self-reported black patients were more than twice as likely to visit an ED, those disparities disappeared when factoring out social determinants and related environmental exposures. The research, published in JACI on Jan. 8, stemmed from the National Heart, Lung and Blood Institute’s Severe Asthma Research Program (SARP). Lead author Anne M. Fitzpatrick, PhD, RN, an associate professor of Pediatrics at Emory University School of Medicine, explained SARP is a consortium of invesAnne Fitzpatrick, tigators at institutions PhD, RN across the country who have been granted funding to build the knowledge base related to severe asthma. “Each investigator has their own unique interest, but together we make a really great partnership,” she noted. “By pooling our resources and creating a shared group of individuals, we can now answer questions we wouldn’t be able to answer on our own.” Fitzpatrick added that while asthma is common, severe asthma is less so. “We think about 5 percent of asthma patients have severe asthma,” she said. That relatively small patient sample made it difficult for any single researcher or team to gain enough critical mass to make the clinical determinations that can be achieved by looking at a larger patient pool through SARP. In her clinical practices, Fitzpatrick said she had observed black patients utilizing the ED to care for asthma significantly more often white patients. However, she continued, before the national study through SARP, it was hard to know if that usage pattern was specific to Atlanta or the Southeast or held true nationally. Looking at entrance to the health system through the ED along with a prescription for steroids, which indicates a severe asthma episode, Fitzpatrick said researchers thought they would get a straightforward answer to the question of why self-reported black patients used the emergency department more frequently than self-reported white patients for severe asthma. “What became immediately apparent,” she continued, “is that it was like comparing apples to oranges. Almost every baseline characteristic we looked at between black and white patients was different.”

A laundry list of economic and social variables – from increased environmental exposures to decreased access to resources – factored into a patient’s ultimate arrival at the ED for asthma treatment. Once inverse probability of treatment weighting was used to balance for these variables, Fitzpatrick said the difference in ED usage ceased to be statistically significant. “I think the encouraging thing about our results is they are not pointing to genetics or biology,” Fitzpatrick continued. “That’s a good thing because we can design interventions,” she added of addressing the root causes of the disparities. She added that while ED usage was the primary outcome studied, secondary outcomes included use of inhaled corticosteroids, physician office visits for asthma and asthma-related hospitalizations. “Outpatient visits for asthma were much less in black patients,” she said, adding the study found black patients were 43 percent less likely to see a physician or other provider for asthma care in the community. “It tells us our efforts toward outpatient management of asthma are not sufficient.” Noting the black patients in the study tended to be more economically disadvantaged than the white participants, Fitzpatrick said social determinants loom large. “These medications for asthma are expensive, and there are very few generics,” she said. “These are real world problems,” Fitzpatrick continued of trying to decide between using limited resources to care for your children or purchase your inhaler. She noted the nature of asthma also adds to the problem. “Asthma is one of those diseases where some days you feel really good, so you skip your medicine. It’s like a perfect storm,” she continued. “You feel okay, but inflammation is actually building up.” The SARP findings have opened the door to many more questions. Does more time need to be spent on health literacy and disease education? Can access to care and affordability of medicines be improved? Is there a cultural mistrust of the health system? What are the best ways to reach the target audience for improved outpatient management? What steps should be taken to address environmental factors? This initial ED usage report came from the first year of observation of 579 participants ages six and older. Follow-up reporting from SARP investigators will continue over the next few years. While this new report doesn’t offer specific solutions to the larger issue of disparities, Fitzpatrick said it’s a first step to further study. Knowing the role of social determinants on ED utilization allows other investigators, public health officials and policymaker to look for specific interventions to address the non-biological factors exacerbating severe asthma. “It’s good because we can do something about it,” she concluded.

The Biggest Threats to Public Health Opioid Abuse, Anti-Vax Movement, Antibiotic Resistance Loom Large By CINDY SANDERS

of the list,” stated Schaffner. Opioid addiction William Schaffner, and misuse have been MD, a professor of mediwell documented across cine in the Division of all socioeconomic levInfectious Diseases and els, ethnicities, reliof preventive medicine in gious beliefs and ages. the Department of Health While some areas of the Policy for Vanderbilt Unicountry have been hit versity School of Medicine, harder, no community has devoted his career to has escaped the crisis. public health and disease Statistics from the Naprevention. A Yale gradutional Institute on Drug ate and Fulbright Scholar, Abuse show just under he earned his medical 17,000 deaths from drug degree from Cornell Unioverdose in 1999. By versity and completed his 2017, that number had fellowship in infectious disjumped to 70,237 with ease at Vanderbilt before Dr. William Schaffner, a noted authority on public health and infectious disease, 47,600 of those overdose being commissioned in the frequently speaks on his field of expertise. deaths involving opioids U.S. Public Health Service in some form. as an epidemic intelligence In addition to the immediate human service officer with the Centers for Disand international media outlets on a range toll caused by misuse, Schaffner said there ease Control and Prevention in Atlanta. of public health topics. Recently, during a are far-reaching consequences that are After completing his tour of duty with the break in a CDC meeting he was attending, only beginning to be understood. Opiate CDC, he returned to Nashville and the Schaffner took time to speak with Medical addiction, he continued, has a wide range faculty of Vanderbilt. News and share thoughts on his three top of downstream implications from family Schaffner, who sits on numerous napublic health threats. disruption to increasing a user’s risk for tional committees and is a current board an array of infectious diseases. The latter, member and past president of the NaThe Opioid Crisis he noted, has caused ethical dilemmas for tional Foundation for Infectious Diseases, “The crisis regarding opioid use and providers and payers. has become a ‘go to’ expert for national abuse … that’s got to be right at the top

In particular, Schaffner pointed to a spike in infective endocarditis, an infection of the interior heart lining, that has been attributed to opioid abuse. The heart infection can be treated with antibiotics or through surgery, depending on severity and response to medication. However, treatment is very expensive … but failure to treat is fatal. Adding to the conundrum is the very real chance the infection could reoccur with continued drug use. “It’s also true that many of these people don’t have any insurance or insufficient insurance, and so this creates a financial stress on the institutions – the hospitals,” Schaffner said of covering treatment options. “This has precipitated the creation of ethical committees who try to interact with the patients who are affected,” he continued. Schaffner noted these committees have, in many cases, agreed to one surgical treatment if required … but only one … and that the patient must agree to go into a drug treatment program as a condition of having the surgery. Schaffner said these programs were created out of desperation and compassion, but “nobody has really had a chance, yet, to evaluate how successful the programs are.” (CONTINUED ON PAGE 12)

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The Biggest Threats to Public Health, continued from page 11 Anti-Vax Movement While Schaffner said there could be legitimate discussion points regarding vaccination laws, he noted scientifically debunked fears shouldn’t be the driving force behind the anti-vax movement. “There is zero evidence that vaccines cause autism,” he stated bluntly. Schaffner’s lifelong work has focused on the prevention of infectious disease, including the effective use of vaccines in both pediatric and adult populations. A widely regarded expert on the subject, he has been a member of numerous advisory

committees that have established national vaccine policies. “One of the discussion points has to do with compulsion … the obligation that every child who goes to school or preschool has to be vaccinated,” he said, adding that some people who believe in the effectiveness of vaccines have a problem with the ‘compulsion’ part of the process. However, he said, “Before we had these school immunization laws – with a full-court press on the part of pediatricians, family doctors and public health professionals – at a stretch, 70-72 percent

(of children) were immunized. That left a quarter of all children unvaccinated.” Schaffner continued, “After the laws, compliance was in excess of 90 percent.” He added it takes a high compliance rate to eliminate a disease. In fact, he continued, vaccinations have historically been so effective in the United States that the country has become a victim of its own success. A significant number of parents of young children who refuse to vaccinate have never seen the true toll of measles, whooping cough or even chickenpox … all of which can be deadly.

Home Dialysis Can Be Life Changing for End Stage Renal Patients, continued from page 7 returned to the body. “There is no clinical study that says one method is better than the other. From an outcome standpoint they are equivalent. What’s better is the one that is most suited for each individual patient,” Glaze says. Giles agrees that it is the patient’s choice, but regardless of which method they choose, home dialysis can be satisfying. “Many patients think they can’t do home dialysis, but I see a lot of people who are happy not having to go to a medical facility for care,” he says. “If you go to a center for dialysis, you will have to go 13 times a month and sit for an average of four hours per treat-

it functions more like the kidneys. It is easy to do and gives the patient a gentler form of therapy with less fatigue so that they can be more independent and spend less time in a medical facility.” Glaze believes that home dialysis can improve the quality of life for patients. “Except in rare circumstances, these patients will be on dialysis for the rest of their lives unless they get Jeffrey Glaze, MD, and patient discuss treatment options. a kidney transplant Glaze says. “Home dialysis allows people to continue with their lives, going ment. It is tiring and a more intense to work and having a family life. It doesn’t cleaning that can lead to intolerance alter their lives as much as going to a cenof the procedure,” he says. “Home ter for dialysis.” dialysis is done more frequently so

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“We need to do better telling these stories,” said Schaffner. “It’s become apparent we have to constantly educate.” He pointed out vaccination laws come from states rather than the federal government and that all states have voted to enact some form of mandatory vaccines. With only Nebraska having a unicameral legislature, he continued, “That means the merits of school immunization laws had to be debated 99 times and voted on and then signed into law by governors … and every state has it. This is a premier, elegant exercise in democracy.” As for those who bristle against mandates on principle, Schaffner pointed out, “We’ve compelled people to go on the green and stop on the red.” Sometimes, he said, rules have to be in place for the greater good, particularly when protecting those who cannot be vaccinated against infectious disease. “Today, we have so many children who are immunocompromised,” he noted. “I believe all of us in a society have a responsibility not only to our own children but to those in our community who are too frail to be vaccinated. We have an obligation to protect them.”

Antibiotic Resistance Schaffner rounded out his top three public health threats with the growing issue of antibiotic resistance. “We’re overusing antibiotics … not only in medicine but in raising cattle, chickens and hogs,” he said. “We have to be much more disciplined in our use of antibiotics wherever we’re using them.” While medicine has been making efforts to curb overuse for two decades, Schaffner said the field still isn’t where it needs to be. Doctors, he pointed out, are human, too. Sometimes it’s easier to give in to the tenth demanding patient of the day. Instead, however, he asked prescribers to talk about symptom relief, which is really what patients want. “You have a viral infection rather than bacterial, but here’s what we can do to help you feel better,” he suggested of an approach. In light of the rise of ‘super bugs,’ Schaffner said curbing overuse is critical. “Slowly but surely, the main thing that’s happened is our options have been restricted,” he continued of trying to fight the increasing number of drug-resistant bacteria. The Medical Community Role While the healthcare community has direct actions that can be taken to address these top public health threats, including in-office education about vaccinations or limiting prescriptions for opioids and antibiotics, Schaffner said there is an even larger role to play. He pointed out providers have an authoritative voice and can share important insights outside the clinic setting. Even those who don’t prescribe can speak up at a cocktail party or school event to correct misinformation. “Medical societies need to say, ‘Yes, we’ll get behind and support these public health efforts,’” he continued. Ultimately, Schaffner concluded, “We all have a potential to get involved.”


Alabama Health Plan Updates Underway Rehab Beds a Key Consideration By Laura Freeman

Managing change is not a simple task. In addition to the pace of advances in health care, there is the continually shifting uncertainty of what will happen next in coverage. Combine that with a growing and changing population already dealing with challenges to access, and it isn’t surprising that the list of requested changes in the Alabama Health Plan is getting longer. After reviewing the situation, Governor Kay Ivey decided that, rather than trying to address issues in a patchwork fashion, the state really needed a comprehensive update to the Alabama Health Plan. One revision that is being closely watched involves changes in how additional rehabilitation beds are approved. In contrast to facilities that are not regulated by the State Health Planning and Development Agency (SHPDA) and do not have to file for a certificate of need before adding rehabilitation beds, hospitals and rehabilitation hospitals are regulated by multiple agencies. They have to file for a certificate of need in a process they contend takes too long to allow them to respond to patient needs, is too expensive and too unpredictable. A current case in point is Spring Hill Medical Center in Mobile. Attorney David Belser has been representing the hospital in an attempt to add seven inpatient rehabilitation beds to its 11-bed unit. “For some time now, we’ve been forced to turn away 30 percent of the patients seeking inpatient rehabilitation David Belser due to lack of beds,” Belser said. “Many patients are sitting in our own emergency room or in an acute-care bed, but they must be transported to another facility due to lack of capacity. There are only three hospitals in Region Six that offer inpatient rehab and are qualified to care for more complex cases that require hospitallevel services. Both the Mobile Infirmary and Thomas Hospital agree that there is a pressing need for more inpatient rehab beds.” Another concern is that patients may have to stay in an acute care bed longer while waiting for placement, which could add to their costs and reduce the number of beds available to other patients. In some cases, depending on health coverage, patients with needs that qualify for inpatient rehabilitation with costs at least partially covered worry about having to choose between a facility not covered by their insurance, or going home until they can find an alternative. “After the lengthy application process, we met with regulators in the fall to discuss our request for adding more inpatient rehab beds,” Belser said. “At that time they tabled the request pending revisions to the Alabama Health Plan that are underway in the Health subcommittee. We had planned to attend the March meeting, but that was

canceled due to lack of a quorum. We hope they will meet in April and we will be able to learn more about our request and any progress on revising the state health plan.” Even after the effort and expense of staff time and legal fees, if additional inpatient rehab beds are approved for Region Six, that doesn’t mean Spring Hill will receive any of them. “Additional beds are granted by region, not by hospital, so the process begins again,” Belser said. “We have to apply for those beds, and other hospital can apply for them, too. We have to hope we are granted enough beds that we will be able to care for the patients we are now turning away.” Representative April Weaver chairs the House Health Subcommittee that is working to revise the different aspects of the Alabama Health Plan to write updates they will recommend. “We have completed the revisions for several sections,” Weaver said. “The committee is still working on a few sections, including inpatient rehab. Representatives from related industries April Weaver have been present at our subcommittee meetings and have been given the opportunity to offer comments. We are working with SHCC (Statewide Health Coordinating Council) to receive updated data. The committee members will

have an opportunity to review the data when it becomes available. At the last meeting the subcommittee requested that they meet to discuss and report back. I expect that update will also be given at the next meeting.” Understandably, other facilities that offer rehabilitation services are likely to want to see their concerns reflected in revisions that are under consideration. Alabama Nursing Home Association spokesman John Matson said, “There are more than 100 community-based rehab centers operated by nursing homes in Alabama and there are rehab beds available in every state health planning region. We are proud of the work our physical, speech and occupational therapists do to treat thousands of patients every year. The Alabama Nursing John Matson Home Association is on record supporting inpatient rehab beds for patients who need hospital-level acute care combined with intensive therapy. Because Alabama already has more inpatient rehab beds than called for in the State Health Plan, we’re working with members of the State Health Coordinating Council and the Alabama Hospital Association to gather data needed to better understand future patient needs so that we can make an informed decision.” Belser said, “For inpatient rehabilitation beds, a 60/40 rule applies. A require-

ment is that at least 60 percent of our beds must go to patients who have a condition or co-morbidity that requires an inpatient level of care during rehabilitation. For up to 40 percent of the other patients, choosing a hospital setting may be a matter of personal preference, convenience in location or in not having to transfer by ambulance or personal car, or for some, possible health coverage requirements that may apply. “We’re hoping that the updated Alabama Health Plan will help to remedy current shortages and streamline the process for growing demand in the future as our population grows.” Proposed changes to the CON process, which are yet to be considered, would allow hospitals with rehab bed occupancy of 80 percent or more for 90 consecutive days to request approval of up to 10 additional beds to expedite response to shortages. When all aspects of the health plan have been addressed by subcommittees, they will be reviewed by the full SHCC. Any edits will be made and the plan will be sent to the governor for review. When the governor approves the updated plan, it will be sent out for public comment. After comments are returned, SHCC will finalize the revisions and the new Alabama Health Plan will take effect. Any breaking news related to revisions in the state health plan that occurs after this issue goes to press will be updated in our online edition at

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This Chair Rocks: A Manifesto Against Ageism by Ashton Applewhite; c.2019, Celadon Books; $26.99; 289 pages There’s another candle on your birthday cake. Whatever. Your back hurts, your knees hurt, and it was hard getting up this morning, then you lost your glasses and ten minutes looking for them. One stupid candle won’t make you feel enlightened but in This Chair Rocks by Ashton Applewhite, you’ll see how to grow older without aging. Ashton Applewhite Ashton Applewhite hates the way we talk about people over 50. Specifically, she hates “the elderly” and “seniors” because those terms have generally bad connotations. Instead, she suggests we change our language to “olders,” because the word “emphasizes

that age is a continuum.” Aging, you see, is what she knows – not just because she’s sixty-something, but because she writes about the subject. She knows there are lots of myths about aging, and that the truth is better than we think. A mere three percent of Americans over age sixty-five live in nursing homes, for one, and most of them “can think just fine,” which means they don’t have any problems with dementia. Most olders, in fact, remain active, independent, and enjoy fashion, dating, sex, and travel. To think differently is indulging in ageism. Once you know how to spot ageism, Applewhite says, you can combat it. Forgetting that olders are still consumers is ageism. Howling that nearretirement-age employees take jobs from younger workers is ridiculous – and ageism. Getting shamed for needing a wheelchair is ageism. Being scolded for wearing something you love but that someone has decided is “too young for you”… ageism. Absolutely.

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Furthermore, says Applewhite, your brain is probably fine. Cognition declines to a certain extent in older years, but aging enhances thought processes and besides, younger people forget things too. You can keep your brain sharp by working your body. Remember that aging is not a disease, and you shouldn’t be ashamed of it because “sixty isn’t the new forty, but it is a new sixty.” Oh, and those aches? You shovel, you garden, you walk, you dance. Maybe the aches came from living. Your next birthday is arriving soon, and you’re not sure whether to dread it, admit to it, or lie about it. You’re not sure what to think, but after reading This Chair Rocks, you’ll know exactly. Author Ashton Applewhite is, as you can imagine, a proponent of embracing your years, an action that she shows is beneficial in many ways for both quality of life and longevity.

Those are happy words for the person who seizes their existence and wrings every ounce from it. They are a shout-out to anyone who uses a hearing aid or wheelchair without embarrassment, and a comfort to those who struggle to ignore the “shouldas” that other people fling. They’re advising words of the MYOB sort: enjoy your years because whose business is it what you do? That’s counsel that could turn your thinking around, or it could make a great 50th Birthday gift to someone with dread on their mind. This Chair Rocks proves that getting older is icing on the cake.

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New Access Standards for Veterans to Receive Community Care By Colin Luke

Earlier this year, the Department of Veterans Affairs (“VA”) proposed new access standards for community care as part of the implementation of the MISSION Act, which President Trump signed into law last June. One goal of the MISSION Act is to provide veterans with greater access to medical care by allowing them to use private care outside the VA system. Although several confusing avenues currently exist for veterans to qualify for outside care, the new access standards would consolidate and simplify the process by basing eligibility on average drive times and appointment wait times. For primary care, mental health and non-institutional extended care services, the VA is proposing that veterans who must drive an average of 30 minutes for services, or who must wait longer than 20 days for an appointment, may seek care with an eligible community provider. For specialty care, the VA is proposing more stringent standards – a 60-minute drive time or a longer than 28-day wait to obtain an appointment. Veterans will also have access to urgent care that gives them the choice to receive certain services when and where they need it. The new access standards are

set to go into effect in June. According to the VA’s Fiscal Year 2019 Budget Submission, community care accounted for around $9.7 billion in 2018. Under the new access standards, the VA expects the number of veterans eligible for community care to almost triple. Of the $66 billion the VA spent on health care services in 2018, excluding community care, $38.5 billion went to ambulatory services, $14 billion went to inpatient care and $8 billion went to mental health care. The remainder went to prosthetics, dental care, and rehabilitation. With the expansion of access for veterans, a larger portion of these services will likely be supplied by community care providers. Under the MISSION Act, the VA is required to establish networks to ensure veterans get access to community care from eligible providers. Eligible community care providers include providers who participate in Medicare, aging and disability resource centers, federally qualified health centers, and centers for independent living. Unlike prior community care programs which failed to make timely payments to providers (e.g., Veteran’s Choice Program (“VCP”)), the VA will be required to reimburse services under a prompt payment standard (i.e., within

45 calendar days upon receipt of a clean paper claim, or 30 calendar days upon receipt of a clean electronic claim). Providers who wish to provide services for veterans must contract with their region’s Community Care Network (“CCN”) administrator. The CCN is a set of contracts awarded to as many as four private sector contractors who are tasked with developing and administering six regional networks of high-performing licensed health care providers. To date, contracts for regions 1-3, which include the East, South and Midwest, have been awarded to Optum Public Sector Solutions, Inc., a subsidiary of UnitedHealth. Following the deployment of the CCN, the selected contractor in each region will begin contracting with providers. However, until the CCN is deployed nationwide, providers who meet certain eligibility requirements can partner with TriWest Healthcare Alliance’s community care network, the VCP administrator during the transition. Under the VCP, community providers must meet these eligibility requirements: • Accept Medicare rates; • Meet Medicare Conditions for Coverage and Conditions of Participation or other criteria established by the VA;

• Be in compliance with all applicable federal and state regulatory requirements; • Have same or similar credentials as VA staff; • Submit a copy of the medical records to the TPA for medical care and services provided to Veterans for inclusion in the VA record; and, • Be eligible according to the U.S. Department of Health and Human Services Office of Inspector General Exclusion Program. The Veteran’s Choice Program will statutorily sunset after June 6, 2019, so providers should be cognizant of potential changes in provider eligibility standards as the MISSION Act takes effect. Colin Luke is a partner and Practice Group Leader for Healthcare Compliance and Operations in the Birmingham office of Waller Lansden Dortch & Davis LLP.

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Birmingham Medical News

APRIL 2019 • 15

Healthcare Staff: Are You Prepared for an Active Shooter? By tereSa FIeLdS, deBBIe FrankLIn, marIe howatt, and LISa rawLInGS

We have heard a lot from the media on active shooter events throughout the U.S., but how many of these include healthcare facilities? The Homeland Security and the FBI define “active shooter” as “an event where one or more persons actively engage in killing or attempting to kill people in a populated area.” Statistics show active shooter incidents involving healthcare facilities are less common than other events, but they can occur, so planning may save lives. Because hospitals are open to the public with many entrances and exits,

securing the building presents specific challenges. Hospitals serve some vulnerable populations, such as the elderly or handicapped. Many are unable to run from the situation which places them at higher risk. According to a John Hopkins study on hospital shootings, many took place outside the building or near the entrances, so metal detectors could not have prevented these events. The same study indicated that from 2000 to 2011 there were 154 hospital-based shootings. 30 percent of these occurred in emergency departments. What have you done to train staff on Active Shooter events? Hospitals are

required by CMS to include workplace violence education into Emergency Preparedness planning and training. However, clinics and other healthcare organizations may also need to initiate training. In developing plans, you should first assess for safe areas and exits. Have an emergency number to activate local law enforcement. With any active shooter situation, be aware of your environment and any possible dangers. If possible, look for at least two of the nearest exits whenever you are in any facility. According to the U.S. Department of Homeland Security and the FBI, should you be involved in an Active Shooter event, remember run,

hide, fight. Run: • Have an escape route and plan in mind; make sure patients and visitors are safe • Leave your belongings behind • Keep your hands visible • Call 911 when it is safe to do so Hide: • Hide in an area out of the shooter’s view – preferably in a locked area if you cannot exit the facility • Block or lock entry doors to your hiding place and if there are any windows shut shades and turn off lights • Silence cell phones Fight • Only fight as a last resort if you are confronted directly by the shooter and if your life is in imminent danger • Attempt to incapacitate the shooter by throwing objects at the shooter, use a fire extinguisher if nearby

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Additional Safety Tips: • Keep all unnecessary exterior doors locked (personnel may enter by badge, key, or code only) • ID checks for visitors entering and sign-in processes • Do not share any entry codes with others • Do not prop locked doors for any reason • Practice situational awareness - pay more attention to who is around you and what they are doing • Knowing how many personnel can hide in any given area is important • Practice knowing exits and situational awareness everywhere you go • Identify potential triggers in your department (waiting, lack of feeling informed, history of violence, etc.) • Install metal detectors at entrances, especially in the emergency department

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New EPA Rule Requires Health Care Facilities to Evaluate Federal Compliance By Hayley Scheer, J.D., LL.M. Health Law

The United States Environmental Protection Agency (“EPA”) regulates pharmaceutical hazardous waste. Under the EPA, unused and disposed of pharmaceuticals are evaluated, managed and disposed of as potential “hazardous waste” under the Resource Conservation and Recovery Act (RCRA) Regulations. The RCRA establishes procedures and standards for hazardous and solid waste material management and disposal. Under the RCRA, solid waste includes “solids, liquids and gases and must be discarded to be considered waste.”1 When a health care facility has unused pharmaceuticals, it will commonly send the drugs to what is called a “reverse distributor” or dispose of the drugs at the facility. A reverse distributor is defined as “any person that receives and accumulates prescription pharmaceuticals that are potentially creditable hazardous waste pharmaceuticals for the purpose of facilitating or verifying manufacturer credit.”2Once a reverse distributor receives unused pharmaceuticals, it will then determine whether the drugs can be shipped back to the manufacturer for a credit. If the product cannot be resold, the distributor will dispose of the pharmaceutical under proper environmental regulations. Under prior federal standards, a pharmaceutical was not considered a “waste” under the RCRA until it was officially discarded, after the reverse distributor determined it was unusable. This operation line allowed health care facilities to ship all unused prescription and non-prescription pharmaceuticals to a reverse distributor without having to consider whether any of those products were considered hazardous wastes under federal law. However, on December 11, 2018 the EPA signed a new rule, effective six months from its signing, that now holds all unused pharmaceuticals are considered “waste” before a reverse distributor makes any determination. The Management Standards for Hazardous Waste Pharmaceuticals and Amendment to the P075 Listing for Nicotine now requires health care facilities, including hospitals, clinics, pharmacies and long-term care facilities, to identify all unused pharmaceuticals as discarded waste before they leave the facility, compelling facilities to abide and report under RCRA waste standards. Under the new rule, the health care facility must now follow RCRA protocol and management standards of all hazardous and non-hazardous waste in regard to its unused prescription pharmaceuticals. Among other requirements, all health care facilities that dispose of hazardous prescription pharmaceuticals are required

to register with the EPA, and must separate hazardous pharmaceuticals from nonhazardous pharmaceuticals. Additionally, health care facilities are prohibited from flushing any hazardous waste down the sink or toilet (also known as “sewering”). The rule establishes new standards for healthcare facilities and reverse distributors that require specific training to all relevant personnel, including storage, labeling, recordkeeping, reporting and off-site shipment of discarded pharmaceuticals under the RCRA. The EPA proposes that the new rule will simplify the management of hazardous waste pharmaceuticals generated at health care facilities, improve compliance of the RCRA, and will reduce the risk caused by hazardous waste pharmaceuticals that are flushed down the sink or toilet. The EPA contends that healthcare workers and pharmacy employees lack the understanding of RCRA hazardous waste management requirements, which results in thousands of tons of hazardous waste material to be flushed into the local surface water every year. The final rule’s goal is to “establish cost-saving, streamlined standards” for health care facilities to properly handle and dispose of hazardous waste pharmaceuticals in an environmentally friendly manner.3 This new rule requires all health care facilities to implement educate its employees on RCRA requirements. In addition, healthcare facilities must ensure that they have the proper capacities to manage and dispose of hazardous and non-hazardous pharmaceuticals under the RCRA, which must be done within one year of being determined a waste. There are several exemptions from the rule that should be noted: all FDA-approved nicotine replacement therapies, such as patches or gum are exempt from hazardous waste disposal requirements. Additionally, any controlled substance regulated by the DEA and any regulation medications collected during drug take-back programs are exempt as well. Non-prescription pharmaceuticals will continue to be evaluated by the reverse distributor as to their waste status. Healthcare facilities that fall under the EPA’s new rule should take extra measures and care to

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ensure complete compliance by the rule’s effective date in June 2019. References 1 Resource Conservation and Recovery Act (RCRA) Overview, United States Environmental Protection Agency (July 9, 2018), https://www.epa. gov/rcra/resource-conservation-and-recovery-actrcra-overview. 2 Frequent Questions about the Management Standards for Hazardous Waste Pharmaceuticals and Amendment to the P075 Listing for Nicotine Final Rule, United States Environmental Protection Agency (Nov. 13, 2018), 3 Rule Summary, Final Rule: Management Standards for Hazardous Waste Pharmaceuticals and Amendment to the P075 Listing for Nicotine, United States Environmental Protection Agency (Jan. 30, 2019), See MANAGEMENT STANDARDS FOR HAZARDOUS WASTE PHARMACEUTICALS AND AMENDMENT TO THE P075 LISTING FOR NICOTINE PAIN, No. EPA-HQ-RCRA-2007-0932, E.P.A. (2018). Hayley Scheer, J.D., LL.M. is an attorney who practices health law with Cabaniss, Johnston, Gardner, Dumas & O’Neal.

Assessing a possible location change of a well-established practice is incredibly overwhelming! Consulting with the Veritas team proved a great source of guidance and support for our practice’s decision to make such a move. Veritas was able to assess our present location and our current needs and then help plan for our vision of the future; all the while allowing our physicians and staff to remain focused on patient care. Veritas worked diligently to translate and negotiate the terms of our new lease agreement ensuring a smooth and successful transaction.

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Birmingham Medical News

APRIL 2019 • 17

Controlling Physicians’ Online Identities By Georgina Perry, CPA, CMPE

Like customers in most other industries, patients are turning to the internet to learn about physicians before seeking treatment. The following tips will help your practice manage your physician’s online identity in order to maximize the benefit and reduce the risks associated with online information. Social media is the most commonly used form of content sharing. If your practice and physicians have not

joined in yet, now is the time. Facebook reaches over 1.2 billion users daily. That population is too big to ignore. Creating a Facebook business page is an easy way to participate in this online community. A Facebook business page gives your practice a homepage to list basic contact information, provide directions, and share articles online. Patients and other fans can like your page or check in when they visit, as well as leave reviews about their experiences. Those reviews are

then pushed to various physician ratings sites. Facebook ranks very high in search engine results, meaning the more activity you have on Facebook, the easier it is for users to find your page through an online search. Most businesses, including medical practices, have a website. These sites are a common destination for finding correct business listing information such as a phone number, address and provider names as well as medical content and

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other information. While websites are costly and time-consuming to establish and maintain, they serve as a credible source of online information, which can be controlled by the practice. You can easily monitor your online presence by setting a schedule for reviewing your practice’s website and search engine results. This will help you ensure your information is accurate on an ongoing basis. You can also utilize listing management services from companies like Yext, which pulls all of your business listing information found on a long list of websites together in one place to compare the results. Physician ratings sites are one online facet that is somewhat unique to the healthcare industry. Many practices are surprised to find their physicians have accounts on multiple ratings sites. Additionally, they are often unsure how the information got there. Physician information is compiled on ratings sites in a variety of ways. For example, Heathgrades pulls information from physician licensing boards and creates a profile for each physician. This site also pushes physician information and ratings to other secondary ratings sites. Another popular ratings site is RateMDs. Physician accounts on this rating site are created by the patients. These independently generated profiles are where the surprises lie. The information from the licensing board could be out of date. Information provided by the patient could be incomplete or incorrect. However, most ratings sites will allow the physician to claim his or her own profile. By claiming the profile, you gain the ability to edit content and respond to comments and ratings. A physician’s online identity is important because search engines are the new Yellow Pages. An online search yields much more than a phone number. Physicians need to know the information patients are using to make provider selections, so they can control the information as much as possible. Georgina Perry, CPA, CMPE is a Healthcare Consultant, Kassouf & Co., P.C.

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Weightlifting Could Improve Cognition Resistance exercise, such as weightlifting, benefits cognitive abilities like attention, reasoning and memory, according to a new study from UAB. “This study is an important step in understanding the relationship between physical health and cognitive and mental health,” said Daniel Mirman, PhD, associate professor in the UAB College of Arts and Sciences’ Department of Psychology. “The benefits of exercise are well-established. We want to know more about how this type of exercise affects emotions and cognition.” The study, published in Psychological Research, was a meta-analysis. The

results were integrated from more than 20 published papers to assess the bigpicture evidence that resistance exercise programs improve cognitive health as well as physical health. Four primary analyses were carried out to assess

Study: Low-carb Diet Provides Relief from Knee Osteoarthritis A study conducted at UAB, published in Pain Medicine, shows a low-carbohydrate diet was more effective in reducing pain intensity than a low-fat diet in adults ages 65-75 suffering from osteoarthritis. Researchers also found the low-carb diet decreased serum levels of the adipokine leptin and a marker of oxidative stress. The randomized controlled pilot study of 21 adults (nine males, 12 females) tested the efficacy of low-carb and low-fat dietary intervention. Study particpants were asked to follow one of the two dietary interventions or continue to eat as normal for a period of 12 weeks. Functional pain, self-reported pain, quality of life and depression were assessed every three weeks. Serum from before and after the diet intervention was analyzed for oxidative stress. To test functional pain, researchers asked participants with knee pain to stand from a sitting position a number of times, walk a set distance, and then tested their knees for pain response by repeated stimulation “Our work shows people can reduce their pain with a change in diet,” said Robert Sorge, PhD, lead author of the study. “Many pain medications for pain cause a host of side effects, whereas this diet may provide additional benefits such as reduced risk for heart disease, diabetes and weight loss.” “Opioids may work well for short-term severe pain. But they have limited usefulness over the long term and, in some cases, perform no better than over-thecounter drugs,” Sorge said. The advantage of a change in diet is that it can be done without long-term anti-inflammatory use or prescription medications, and it can be tailored to taste and preferences. “Diet will never cure pain, but our work suggests it can reduce it to the point where it does not interfere with daily activities to a high degree,” Sorge said. Diets such as the Mediterranean diet (a partial low-carbohydrate diet) have been shown to reduce inflammation in arthritis patients and self-reported pain in osteoarthritis and rheumatoid arthritis. This previous work supported Sorge’s hypothesis that, by lowering the intake of refined carbohydrates, oxidative stress would decrease and functional pain would be improved. However, diet intervention studies to date have focused exclusively on self-reported pain, and not assessment of functional pain, which Sorge believes may be a better indicator of efficacy.

the effects of resistance exercise on cognitive outcomes, including composite cognitive scores, screening measures of cognitive , measures of executive function and measures of working memory. The results showed a positive effect of resistance training on composite cognitive scores, cognitive screening measures and measures of executive function, but no effect on measures of working memory. This may be due to the cognitive demands of resis-

tance training, which requires planning and focusing on the details of lifting weights and body positioning. This form of attention training may explain why overall cognition and executive function are improved while working memory is not improved. The meta-analysis also showed that the effects of resistance exercise on cognition are highly variable, which is an important question for future studies. The role of exercise duration, frequency and intensity will be a key topic to address.

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Birmingham Medical News

APRIL 2019 • 19

UAB School of Medicine in Elite Group in NIH Funding How did UAB Accomplish This? In the past five years, the UAB School of Medicine has climbed 10 places on the National Institutes of Health research funding rankings, from 31 in the nation to 21. Total NIH funding during that period rose from $133,264,288 in 2013 to $234,390,799 in 2018. “Over the past five years, UAB has been part of an elite group of eight academic medical centers that have experienced more than $100 million in net NIH funding growth,” said Selwyn Vickers, MD, dean of the medical school. The School of Medicine (SOM) created a systematic plan following the arrival of Vickers as dean in 2013 to boost NIH funding by concentrating on several key components.

for Clinical and Translational Science, the Center for AIDS Research, the Antivirial Drug Discovery and Development Center, and the O’Neal Comprehensive Cancer Center. UAB launched the Multi-PI Program in 2015, which fosters collaboration by creating a funding mechanism to encourage faculty to work with researchers in other disciplines on a common goal. The School of Medicine funded four collaborative projects in 2015. The research teams were able to produce significant preliminary results and jointly publish that data, priming the pump for securing large, collaborative NIH grants. “The intent is to fund a cadre of faculty who have complementary research interests,” said Etty Benveniste, PhD, senior vice dean for Basic Sciences. “The first four we funded were successful at leveraging our initial investment into larger NIH grants. We have funded eight more since then, with more in the pipeline.” The return on investment for the initial round of funding was 19 to 1. “A small investment by the school on

Science Through Synergy One way to quickly move up in funding rankings is to secure large, collaborative grants, and UAB has seen success there. The NIH provided $45 million to UAB to lead the Southern Network of the All of Us Research Program, a national effort to promote genomic medicine. Other large grants were awarded to the Center


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UAB School of Medicine, continued from page 20 the front end often results in a much larger return on the back end with multiyear NIH funds,” she said.

One Grant is Good. Two Grants are Better. An additional target in leadership’s crosshairs is the bread and butter of NIH funding — the R01 grant. “Most faculty have an R01 grant,” Benveniste said. “These are the primary funding sources to establish and equip a laboratory. So a target for growth is to help an investigator get a second R01 grant.” In 2016, the school launched a mechanism to achieve this goal, with internal funding available to allow investigators to do the necessary preliminary studies and acquire the data needed to apply for a second R01. Eleven investigators were funded in 2016, with a grant of $50,000 per year for two years. Five more received funding in 2017 and six in 2018. “Those funded in 2016 have been largely successful,” Benveniste said. “They are wrapping up now, and the investigators are now using their newly acquired data to apply for new, additional R01 grants. So far, the return on investment for this initiative is 16 to 1.” Along with seed money, the SOM has provided bridge funds drawn from state investment in UAB to help researchers keep their projects going while in the midst of the NIH funding process. More than 40 faculty have received bridge funding since 2015, and more than 70 percent of them have ultimately secured NIH funding. Clinical Side Steps Up Recognizing the importance of seed funding, the school created the Academic Enhancement Fund to provide the necessary resources in 2014. “The fund was created with the support of the clinical enterprise of UAB Medicine, from UAB Health System leadership, UAB Hospital, and the clinical chairs,” said Robert Kimberly, MD, senior associate dean for Clinical and Translational Research. “These funds are central to our ability to compete on a national stage for the NIH grants that can be transformative, not just for UAB, but for the people of our communities.” “That, of course, is the ultimate goal,” said Anupam Agarwal, MD, executive vice dean of the SOM. “Can we, through science, make a meaningful difference in the lives of the people of Alabama?” More Scientists, More Dollars Another strategy to boost the number of research dollars coming into the university is to boost the number of researchers at the university. That can mean attracting new faculty, and hanging onto the ones already here. And the faculty is growing. The number of principal investigators at UAB has climbed from 259 five years ago to 323 at

the start of 2019, an increase of nearly 25 percent. “The older medical schools at the top of the NIH funding list have more faculty than we do, so it stands to reason that they pull in more research dollars,” Agarwal said. “But we’re growing. For example, five years ago the Department of Medicine had just five Career Development Awards from NIH. Now we stand at 29.”

Sharpening the Science Kimberly points to another program, housed in the Center for Clinical and Translational Science, that helps researchers fine-tune their plans. “Investigators can bring their research hypothesis to CCTS, and we organize a panel of peers to review the idea and offer feedback,” Kimberly said.” CCTS has enabled 260 panels since 2017, and Kimberly says investigators who have taken advantage of the program have a success rate in garnering NIH grants that is four times that of the national success rate. UAB’s investment in new burgeoning fields in medicine is also paying dividends. The Hugh Kaul Precision Medicine Institute, the Informatics Institute, Proton Therapy Center and the UAB-HudsonAlpha Center for Genomic Medicine are in cutting-edge fields. All present opportunities for researchers to expand their horizons. The Future “We are currently 21st in NIH funding, and we anticipate moving to somewhere between 15th and 20th over the next three years,” Agarwal said. “We need to have at least 10 departments within the top 10 in their field. We have six now, so we have work to do.” Agarwal says continued funding growth is critical for every pillar of AMC 21, the Health System and School of Medicine’s strategic plan to be the preferred academic health center of the 21st century. A Rising Tide The School of Medicine does not operate in a vacuum. UAB has enjoyed a stream of accomplishments that have touched every facet of the university. Overall research funding to UAB topped $500 million in 2018, and the university just completed its largest fundraising campaign ever — a $30 million naming gift for the O’Neal Comprehensive Cancer Center put the Campaign for UAB over $1 billion. Total NIH funding to all schools within UAB reached nearly $300 million. “Each entity at UAB builds off the efforts and successes of our colleagues across this great university,” Vickers said. “It is the collaborative spirit of UAB that builds partnerships across campus, and the success of each school helps us all reach our goals.”

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Birmingham Medical News

APRIL 2019 • 21


Bogard to Chair Health Law Section of Alabama State Bar

Butler Named Dean of UAB School of Health Professions

Howard Bogard, a partner with Burr Forman, was recently appointed to serve as chair of the Alabama State Bar Association’s (ASB) Health Law Section. The Health Law Section of the ASB is open to members of the plaintiffs and defense bar who are involved in the health care Howard Bogard industry, including but not limited to various state and federal issues such as Medicare fraud and abuse, payment problems, merger and acquisition of health care entities, antitrust, fiscal management, peer review, provider malpractice, individual rights and Supreme Court actions. Bogard is the practice group leader of the Burr Forman Health Care Practice Group and also serves as the firm’s chief HIPPA compliance officer. His area of focus involves corporate and regulatory health care matters, including Stark and Anti-kickback and False Claims Act compliance, facility and professional licensure matters, HIPAA, physician practice formation, joint venture arrangements, mergers and acquisitions, certificate of need issues, Medicare and third-party audits and investigations, corporate compliance, and contract negotiations.

The University of Alabama at Birmingham has named Andrew J. Butler, MPT, MBA, PhD, dean of the UAB School of Health Professions following a national search. Butler joins UAB from Georgia State University, where he is a professor of physical therapy Andrew J. Butler, MPT, MBA, PhD and associate dean for Research. Butler received his PhD in motor control from the University of Iowa. He was a postdoctoral fellow at Iowa, at Texas Women’s University in Houston and at Heinrich-Heine University in Germany. Prior to joining Georgia State in 2012, he was a faculty member in the Department of Rehabilitation Medicine at the Emory University School of Medicine.

BCBS Promotes Williams Blue Cross and Blue Shield of Alabama has promoted Tyler Williams to Vice President, District and Consumer Sales. Williams has been with Blue Cross for 15 years. During his tenure, he has served as a Marketing Representative, Tyler Williams an Account Executive in Large Group Sales, District Sales Manager

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in the Montgomery District Office, and as Director of District and Consumer Sales. Williams has served on the boards of the Montgomery Chamber of Commerce and the State of Alabama Fellowship of Christian Athletes. He is a 1994 graduate of The University of Auburn at Montgomery.

Grandview Names Employee of the Year Trussville resident Hai Nguyen was recently named Grandview Medical Center’s 2018 Employee of the Year. Mrs. Nguyen is a registered nurse. She has been employed by Grandview for three years and works in SurgiHai Nguyen cal Services. Prior to joining Grandview, she worked in geriatric care and also as a home health nurse.

Number of Premature Babies Born to Single Mothers Decreases Thanks to Partnership The number of premature births in Jefferson County has decreased thanks to the Nurse-Family Partnership, a program run by the University of Alabama at Birmingham School of Nursing and the Jefferson County Department of Health. The program, which has been in the Birmingham area for a year, connects nurses who support pregnant mothers having their first baby. The nurses from the UAB School of Nursing provide weekly or biweekly home visits during pregnancy and throughout the first two years of the child’s life. The program is designed so the nurse and mother develop a strong relationship. The focus is on the first-time mother’s personal health, quality of caregiving and life course development — inspiring long-lasting change that benefits both the mother and child. It has been used around the country for nearly 40 years, including in Montgomery and Tuscaloosa, with great success. The program has grown to Walker County and will soon expand to Fayette County to provide care for mothers in rural areas. Interviews with the nurses and mothers are available with notice.

Fayette Medical Center and its Long Term Care Facility among Top in US

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22 • APRIL 2019

Birmingham Medical News

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FMC achieved a five-star rating from the Center for Medicare and Medicaid Services. FMC is one of only of five hospitals in Alabama and one of 293 nationwide to receive this rating, placing FMC in the top 6.5 percent of the nation’s hospitals. The rating is based on mortality, readmissions, patient experience, effectiveness of care, timeliness of care, and efficient use of medical imaging. In addition, FMC Long Term Care ranked in the top six percent of similar facilities in the US for resident satisfaction based on a survey of residents.

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Moul Joins Birmingham Orthopedics & Spine Specialists Rebecca Moul, DO has joined Birmingham Orthopedics & Spine Specialists. Moul is board certified by the AOBOS. She specializes in orthopedic surgery, Arthroscopy and sports medicine. Moul received her undergraduate degree from St. Bonaventure Rebecca Moul, DO University in New York. She earned her doctor of osteopathic medicine degree from Philadelphia College of Osteopathic Medicine in Philadelphia, PA. She completed her internship and residency in orthopedic surgery at Memorial Hospital in York, PA, and a fellowship in Arthroscopy and Sports Medicine with New Mexico Orthopaedic Associates in Albuquerque, New Mexico. Moul is a member of the American Academy of Orthopaedic Surgeons, the American Orthopaedic Society for Sports Medicine, the American Osteopathic Academy of Orthopedics, the American Osteopathic Association, and the Arthroscopy Association of North America.

Luther Joins Grandview Medical Staff Michael Luther, MD has joined the medical staff of Grandview Medical Center. Luther is board certified in Family Medicine. He is in practice with Grandview Medical Group Primary Care in Homewood. Luther received his undergraduate degree Michael Luther, MD from the University of Alabama and earned his medical degree from the University of Alabama School of Medicine. He completed his residency at the Tuscaloosa Family Practice Residency Program. For the last eight years, Luther has practiced family medicine in Albertville, Alabama. He is a member of the American Academy of Family Physicians.

UAB Graduate Programs Ranked among Nation’s best Master’s in Health Administration Ranked No. 1

U.S. News & World Report graduate school rankings once again showcase the strength of graduate and professional programs at UAB. UAB programs in the schools of Health Professions, Nursing, Medicine, Engineering, Education and Public Health and the College of Arts and Sciences are highly ranked in the 2020 U.S. News Best Graduate School Rankings. One UAB program, the Master’s in Health Administration in the School of Health Professions, received the No. 1 ranking as best in the country. “Attaining the most prominent position from the most-respected rank-

ing publication is a result of 50 years of dedication from our faculty, staff and partners and 50 years of success from our students and alumni,” said Harold Jones, PhD, dean of the School of Health Professions. The UAB School of Nursing boasts five programs ranked in the top 10 in the nation, and three others in the top 20. Two programs hold the No. 6 spot: Nursing Administration and Clinical Nurse Leader. Nurse Practitioner: Pediatric Primary Care is No. 8, while Nurse Practitioner: Family is No. 9. Adult Gerontology: Acute Care holds the No. 10 position. The program in Adult Gerontology: Primary Care is ranked No. 12, Doctor of Nursing comes in at No. 16, and Master’s in Nursing holds the No. 18 spot. “We are thrilled that, of the eight graduate specialties ranked by U.S. News & World Report, the UAB School of Nursing has five in the top 10 and one in the top 20,” said Doreen Harper, PhD, RN, FAAN, dean and Fay B. Ireland Endowed Chair. “Excellence in nursing also is measured by the care we provide patients, especially those in underserved areas; the leadership role we play in the translation of novel and cost-effective care models; and the development of nurse leaders who are helping forge creative change to advance health.” The School of Medicine moved two spots up in both the research and primary care categories, with a ranking of No. 30 in Medical Schools: Research and No. 35 in Medical Schools: Primary Care. The Department of Anesthesiology is ranked No. 20. Two programs, internal medicine and obstetrics/gynecology, are ranked No. 22. Surgery is ranked No. 23. “It is gratifying to be recognized by U.S. News & World Report for our research and clinical expertise,” said Selwyn Vickers, MD, senior vice president

and dean of the medical school. “We’ve also seen impressive gains in other metrics, such as NIH funding.”

Hindman Named CNO at Princeton Robbie Hindman has been named Chief Nursing Officer (CNO) of Princeton Baptist Medical Center. In addition, she serves as Group CNO of Tenet Health’s Alabama and Tennessee operations. Hindman joined the Brookwood Baptist Health family in 2000 as the Executive Director of Operations of Walker Robbie Hindman Baptist Medical Center and was later named CNO in 2012. Prior to joining Brookwood Baptist Health, Hindman was with the DCH System in Tuscaloosa. During her tenure, she opened one of the facility’s first home health agencies. Hindman obtained her bachelor’s degree in Nursing from Mississippi Uni-

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versity for Women and her master’s degree from Faulkner University. She has served on the Nursing Board Selection Committee of Bevill State Community College and the Birmingham Regional Emergency Medical Services System (BREMSS) Board.

North Harbor Pavilion Recognized North Harbor Pavilion at Northport Medical Center has been recognized for providing outstanding patient experience. Press Ganey, a health care performance improvement company, presented its 2018 Guardian of Excellence Award to honor facilities who sustained performance in the top five percent of its 33,000 clients. North Harbor was honored for being in the 95th percentile in patient experience as measured in patient satisfaction surveys. North Harbor offers adult and senior adult inpatient psychiatric treatment.

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