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FOCUS TOPICS PUBLIC HEALTH • DISPARITIES & SOCIAL DETERMINANTS

Your Middle TN Source for Professional Healthcare News

PHYSICIAN SPOTLIGHT PAGE 7

Consuelo Wilkins, MD ON ROUNDS

Public Health Happens in the Community … Not Just the Clinic Public health is the bedrock on which the healthcare system we have today has been built. The purpose of public health is to protect and improve the health of people and their communities ... 5

Threats to Public Health

Opioid Abuse, Anti-Vax Movement, Antibiotic Resistance Loom Large By CINDY SANDERS

William Schaffner, MD, a professor of medicine in the Division of Infectious Diseases and of preventive medicine in the Department of Health Policy for Vanderbilt University School of Medicine, has devoted his career to public health and disease prevention. A Yale graduate and Fulbright Scholar, he earned his medical degree from Cornell University and completed his fellowship in infectious disease at Vanderbilt before being commissioned in the U.S. Public Health Service as an epidemic intelligence service officer with the Centers for Disease Control and Prevention in Atlanta. After completing his tour of duty with the CDC, he returned to Nashville and the faculty of Vanderbilt. Schaffner, who sits on numerous national committees and is a current board member and past president of the National Foundation for Infectious Diseases, has become a ‘go to’ expert for national and international media outlets on a range of public health topics. Recently, during a break in a CDC meeting he was attending, Schaffner took time to speak with Medical News and share thoughts on his three top public health threats. (CONTINUED ON PAGE 4)

A New Vision for Safety Net Care

Indigent Care Stakeholders Look to Leave No One Behind Last month, the Indigent Care Stakeholder Work Team, formed by Meharry Medical College President and CEO James E.K. Hildreth, PhD, MD, unveiled their vision for a revamped safety net healthcare system that leaves no one behind ... 6 Follow us on Twitter

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Healthcare icon Dr. William Schaffner was inducted into the Tennessee Health Care Hall of Fame in 2018.

Covering Kids

Tennessee Sees Increase in Uninsured Children By MELANIE KILGORE-HILL

coverage between 2016 and 2017 lived in states that have not expanded Medicaid coverage to parents and other low-income adults, with the uninsured rates of children increasing at almost triple the rate in non-expansion states than in states that expanded Medicaid. Tennessee was among nine states that experienced statistically significant increases in their rates of uninsured children.

A recent study by the Georgetown University Health Policy Institute Center for Children and Families found a startling trend related to the growing number of uninsured children in the United States. According to the Nov. 2018 report, the number of uninsured children in the U.S. has increased for the first time in nearly a decade. The data showed an estimated 276,000 more children were uninsured in 2017 than 2016. Furthermore, the report found three-quarters of children who lost

Tennessee’s Kids

Kinika Young, director of Children’s Health for the Tennessee Justice Center, said Medicaid expansion helps get insurance

(CONTINUED ON PAGE 10) (CONTINUED ON PAGE 4)

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Pivotal Clinical Trial Investigates New Technology for Managing Uncontrolled Hypertension Uncontrolled hypertension is a leading risk factor for cardiovascular disease related morbidity and deaths. Hypertension is now so widely prevalent that the World Health Organization has declared it a global public health crisis that affects one billion people worldwide. An estimated 360,000 deaths per year in the United States have hypertension as the primary or a contributing cause. Despite the existence of effective antihypertensive drugs and diligent By Brian primary care oversight, arterial Jefferson, MD hypertension remains a critical challenge Interventional for many patients, even when combined with significant lifestyle changes. In fact, Cardiologist 50 percent of patients with high blood Centennial Heart pressure do not meet treatment goals, TriStar Centennial and nonadherence is high which creates Medical Center a pressing unmet need for new forms of treatment. TriStar Centennial Heart and Vascular is currently enrolling patients in a pivotal clinical trial to determine the safety and effectiveness of an investigational renal denervation device (RDN) used to help lower blood pressure in patients with uncontrolled hypertension. TriStar Centennial Heart and Vascular is the only site in the region where the Spyral HTN trial is available. It is an innovative tool that may prove effective for treatment of uncontrolled hypertension. Uncontrolled hypertension is blood pressure ≥140/90 mm Hg despite treatment with optimal doses of three different antihypertensive drugs, one of which should be a diuretic. Uncontrolled hypertension also is defined in instances where an individual’s blood pressure is at target levels but four or more antihypertensive drugs are required. Those with uncontrolled hypertension have double the risk of cardiovascular events than those without uncontrolled hypertension. Research has shown that the kidneys play an important role in managing high blood pressure. Sometimes, however, the nerves that control the kidneys become over-active and lead to high blood pressure. Renal denervation is an investigational therapy that consists of a minimally invasive procedure. Using active energy, overactive nerves that lead to the kidneys are adjusted from within each renal artery, potentially helping to balance overactive signaling. The patient is mildly sedated while the cardiologist performs the procedure in a single session by inserting a catheter into the femoral artery to access the nerves in the walls of the renal arteries. Controlled radio-frequency energy is administered in short bursts to ablate the targeted nerves. The Spyral HTN trial is randomized, controlled and blinded to study the effectiveness of the technology versus placebo. An 80-patient pilot study of the device published last year demonstrated clinically relevant reductions in both office and 24-

hour systolic blood pressure. Notably, those blood pressure lowering effects were observed not only throughout the daytime, but also during the nighttime and early morning periods when heart attack and stroke risk due to hypertension are highest. Blood pressure during sleep is the most significant predictive marker of cardiovascular disease morbidity and mortality, and reduction in asleep blood pressure is associated with highly significant reduction of cardiovascular disease risk. While the efficacy of anti-hypertension medications can fluctuate throughout the day, this pilot study resulted in the important observation that renal denervation is “always on.” To be eligible, patients must be between the ages of 20 and 80 and have uncontrolled hypertension with systolic readings between 150-180 mm Hg and diastolic readings above 90 mm Hg. Participants will be required to attend regular check-ups, wear an ambulatory blood pressure monitor, and agree to discontinue their blood pressure medications through their 3 month follow up period. After the 3 month follow up period, subjects may resume pharmacological blood pressure therapy in consultation with their doctor in order to obtain optimal blood pressure control. The screening process for enrolling in the trial is about a month long and involves monitoring blood pressure and medication compliance. The investigational procedure itself lasts about an hour and requires an over-night hospital stay. Post-procedure follow-up will take place in the Hypertension Clinic at TriStarCentennial Heart and Vascular. The multidisciplinary team at TriStar Centennial Heart and Vascular is proud to help create innovations in patient care that improve their quality of life and lower their risks for more serious cardiovascular complications. For more information about the Spyral HTN trial and to refer a patient for enrollment consideration, call 615-329-7641.

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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 investigators at institutions across the country who Dr. Anne Fitzpatrick 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.

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The Biggest Threats to Public Health, continued from page 1 The Opioid Crisis

“The crisis regarding opioid use and abuse … that’s got to be right at the top of the list,” stated Schaffner. Opioid addiction and misuse have been well documented across all socioeconomic levels, ethnicities, religious beliefs and ages. While some areas of the country have been hit harder, no community has escaped the crisis. Statistics from the National Institute on Drug Abuse show just under 17,000 deaths from drug overdose in 1999. By 2017, that number had jumped to 70,237 with 47,600 of those overdose deaths involving opioids in some form. In addition to the immediate human toll caused by misuse, Schaffner said there are far-reaching consequences that are only beginning to be understood. Opiate addiction, he continued, has a wide range of downstream implications from family disruption to increasing a user’s risk for an array of infectious diseases. The latter, he noted, has caused ethical dilemmas for providers and payers. 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.”

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

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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. “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.”

Blog Log The Nashville Medical News Blog features additional insights and information from a cross-section of industry leaders. The blog can be accessed directly through NashvilleMedicalNews.Blog or from the homepage of the main website. NEW IN APRIL: Christine Hart, manager of the Healthy Air Campaign in Tennessee with the American Lung Association, discusses the public health impact of the EPA’s proposed weakening of the Mercury and Air Toxics Standards. Danny Jeter, president and founder of Jeter IT Solutions, looks at the end of an era as the Microsoft support deadline approaches and what that might mean for medical practices. Amy Wilson, chief nursing officer for Ascension Saint Thomas, outlines an innovative structure for transformative nurse leadership.

ONLINE BONUS EDITORIAL Go online to NashvilleMedicalNews.com for breaking news and additional editorial in April including: • The American Medical Association’s letter to technology giants asking for help in combatting vaccine misinformation. • Vanderbilt University Medical Center joins effort to stop the spread of two deadly viruses through the development of vaccines and other treatments. • Information on the upcoming Social Determinants of Health Symposium, scheduled for June 6 in Cleveland, Ohio. • Dr. Morgan McDonald has been named Deputy Commissioner for Population Health for Tennessee.

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Public Health Happens in the Community … Not Just the Clinic Public health is the bedrock on which the healthcare system we have today has been built. The purpose of public health is to protect and improve the health of people and their communities. From Dr. John Snow ceasing the deadly cholera outbreak in 1854, to the ongoing development of vaccines to eliminate childhood disease to By KATINA R. creating safe com- BEARD, MSPH munities for walking and biking, public health has served the greater community for the greater good. We continue to look to the field of public health to lead the way to eliminating health disparities; the differences in health outcomes, access to health care and the presence of disease between population groups. Health disparities are typically driven by an individual’s social determinants of health – where they are born, live, work, worship and play. Through our public health lens, we already have one key to the issues of health disparities and social determinants of health – poverty. According to the newly released data from the Metro Social Services (MSS) Community Needs Evaluation (CNE), 14.5 percent of Nashville residents are living in poverty compared to 15 percent of the state and 13.4 percent of the nation. Although the poverty rate is similar to that in 2010, the population boom to Nashville has increased the number of individuals and households living in poverty. The number of households increased from 12.8 percent in 2016 to 13.5 percent in 2017.

Poverty and poor health are closely linked. Living in a home infested with pests, not having access to nutritious foods because of a lack of reputable grocery stores and inferior educational outcomes are very real issues for people living in poverty. The health issues attributed to living in poverty are what keep people in poverty. Most people living in poverty are hourly wage earners, and poor health will keep them from working, which keeps them from getting paid. Poverty is a multi-faceted social disease that is growing every day. In addition to our environment, public health must also look at biology, genetics and human behavior to have an impact on health disparities. We cannot begin to understand how to reduce the gaps in health outcomes until we implement methods to equalize the community. Therefore, addressing poverty as a public health issue is as central to our community as is addressing communicable diseases. This is not the sole responsibility of the local health department, nor can a bank simply infuse money into a community. Addressing health disparities will require innovative public-private partnerships. We must consider how health is intertwined with housing, viable employment and education. It’s not enough to have a doctor on every corner if we don’t look at the totality of health as it is defined by the World Health Organization: “Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.” Together, evidence-based and culturally tailored interventions should be developed that will be sustainable to move individuals, communities and generations out of poverty. Matthew Walker Comprehensive Health Center believes in the totality of health of an individual and our community.

Since our founding in 1968 by Dr. Matthew Walker, Sr., our model has included services that are designed to prevent and eliminate disease and infirmity, but it is also so much more. Our service model includes primary medical care, comprehensive oral health services, radiology and laboratory services and behavioral health programs for counseling and treatment. What makes us unique are the services that address the social wellbeing of our patients and our community. Our staff assist individuals with accessing insurance, housing and employment opportunities. The various collaborations with our local schools provide care to students, families and staff. Our programs for seniors like SALT (Seasoned Adults Living Triumphantly) and our Annual Red and White Affair build the social supports that keep our community safe and strong. We also play an important role in landmark research studies including the Southern Community Cohort Study that helped to identify evidence-based interventions to identify cancer risk factors in African Americans and REACH 2010 that helped set policy that changed eating habits and stopped illegal tobacco sales in the minority community. Today we are moving ahead with personalized medicine by serving as the community voice on the Precision Medicine and Health Disparities Collaborative Advisory Board

and continuing to support the work of the Nashville Health Disparities Coalition. Matthew Walker Comprehensive Health Center is not alone in this work. The Safety Net Consortium of Middle Tennessee is made up of 20 member organizations representing federally qualified health centers, faith-based organizations, free and charitable clinics, as well as public entities and hospitals. The Safety Net Consortium is an effective collaboration that brings together leaders to problem-solve, plan and implement shared strategies toward a larger community-wide goal: a more coordinated and integrated system of care that leaves no Nashvillian behind. Together the Safety Net Consortium cares for 132,053 patients of which over 51,000 are uninsured. This is an example of what public-private partnerships can do for the greater community for the greater good. Addressing poverty through the public health model is the path to eliminating health disparities in our community. Katina Beard serves as CEO of Matthew Walker Comprehensive Health Center. Beginning her work with the federally qualified health center in 1996, she took on increasing leadership roles during her tenure before being tapped to lead the organization. She holds an undergraduate degree in healthcare administration from TSU and a master’s in public health from Meharry. For more info, go to mwchc.org.

HEALTHCARE HELPINGS SERIES

Music City SCALE

Aesthetic Medicine Meeting Set for May 9-11 By CINDY SANDERS

The 14th Annual Music City SCALE meeting featuring up to 22 hours of CME for medical practitioners is set for May 9-11 at the Music City Center. Designed for physicians and other clinicians interested in aesthetic medicine, the 2019 Symposium for Cosmetic Advances & Laser Education (SCALE) will cover a variety of topics including special tracks on cosmetic, medical and industry topics. Specific plenary lectures and panel discussions include symposiums on acne, hair, atopic dermatitis and psoriasis, in addition to sessions on energy-based devices, full field vs. fractional lasers, cosmeceuticals, new and emerging treatments of keloids and excessive scarring, anatomic region rejuvenation and practice management. There are also a number of live demonstrations including injection demos by Brian S. Biesman, MD, and laser demos nashvillemedicalnews

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by Michael Gold, MD, co-founders of the SCALE event. A product theatre, exhibit hall and networking opportunities with colleagues from across the United States round out the 2019 meeting schedule. In addition, the Cadaver Head Dissection Workshop will be held on Thursday, May 9 from 9:30 am-12:30 pm at the Cambria Hotel. There is an additional fee, and pre-registration is required for this unique full face surgical anatomy and injection course. Participants will gain hands-on experience during the last 90 minutes of the workshop. There is also a two-part course, Lasers 101, offered at the Hilton Hotel on Thursday morning and Friday afternoon at no additional cost, but pre-registration is required. Music City SCALE is presented by the Tennessee Society for Laser Medicine and Surgery. To review the agenda or register for the upcoming conference, go online to ScaleMusicCity.com.

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A New Vision for Safety Net Care

Indigent Care Stakeholders Look to Leave No One Behind By CINDY SANDERS

Last month, the Indigent Care Stakeholder Work Team, formed by Meharry Medical College President and CEO James E.K. Hildreth, PhD, MD, unveiled their vision for a revamped safety net healthcare system that leaves no one behind. Members of the work team included representatives of Nashville General HosDr. James Hildreth pital, private hospital systems, area health clinics, city government and local churches. The recommendations in the report (available online at NashvilleMedicalNews.com) were the culmination of 14 months of studying indigent care models in other cities and conferring with area providers who serve the underserved. “Unfortunately, although we’ve made a lot of progress in healthcare and medicine, the progress has not benefitted all populations equally,” Hildreth said of the impetus to form the team. “Social determinants of health have a lot to do with that,” he continued, adding many researchers and public health officials now recognize a person’s zip code matters as much or more than their genetic code.

In Nashville, as across the nation, there are zip codes with a shortage of primary care physicians, affordable housing, effective transportation, safe recreational areas and nutritious food … all of which combine to make it difficult to achieve and maintain health. “Like many, I’ve adopted the mantra that health is more than the absence of disease,” said Hildreth. “What we really want is to keep people from getting sick or being unhealthy in the first place. That starts with social determinants and delivering care in the appropriate setting.” He continued, “When points of service are not aligned appropriately, it ends up costing much more. What distinguishes the populations are when, where and how conditions are brought to the attention of healthcare providers. When people turn up in the emergency department, it’s often very late in an episode.” The work group formed shortly after former Mayor Megan Barry announced the intention to end inpatient care at Nashville General Hospital and turned their focus to the patient at the center of the system. While the decision to end inpatient care at Nashville General was rescinded, the broader focus of care delivered in the right place at the right time remained central to the vision. “The hospital is a key component of taking care of the vulnerable in the city, but it’s just one component,” noted Hildreth. In

addition to Nashville General, Hildreth was quick to praise the work of Ascension Saint Thomas, HCA and Vanderbilt in caring for the uninsured and underinsured, as well. To move the needle, however, Hildreth said care had to be conveniently accessible in the community. “We have to deploy and utilize advanced practice providers including nurse practitioners and PAs,” he said of delivering lower acuity care. Physicians would still play a critical role in oversight, Hildreth said, but more manpower is required on the primary care front. Utilizing a collaborative network to deliver integrated, patient-centered care, the plan calls for the development of an indigent care management program called BetterHealth Nashville®, which will coordinate care for patients to ensure services are adequately funded, treatment is tracked and integrated across care settings, and social needs are addressed. Meharry Medical College will manage the program and assign care coordinators to help eligible patients navigate the broader healthcare system. “When you look at Nashville as a city, I would venture to guess there aren’t many cities with the kinds of healthcare resources as we have. The beauty of the proposal is it leverages the strengths we already have in the city,” he said, adding the disparate voices and viewpoints at the Indigent Care Stakeholder Work Team table allowed

them to come up with a plan that utilizes all those resources. Churches, faith-based clinics, federally qualified health centers, Metro Public Health, city planners, Nashville General, and the three large hospital systems all have a role to play in addressing social determinants and delivering care to vulnerable populations at the most efficient point of contact, said Hildreth. “We’re not asking the hospitals to do any more charity care than they’re already doing … because they do a lot … and maybe we transfer some of the lower acuity patients to Nashville General Hospital, which would free up their beds,” Hildreth added of utilizing the three big hospital systems for specialty services that couldn’t easily be accessed in other settings. “We have to do this in a way that is cost conscious,” Hildreth stressed. “If we do this right, the cost of indigent care should go down. The next step,” he continued, “is to create an organization to operationalize this plan.” By next month, he hopes to begin that process. While setting up the infrastructure will take time, he has no doubt stakeholders across the continuum will come together to create a system that leaves no one behind. “There are a lot of people in the city who want the same thing – to help those who are vulnerable or without access to care,” Hildreth concluded.

In the Community: Recent News of Note April is National Minority Health Month

The U.S. Department of Health & Human Services Office of Minority Health has announced the theme for 2019 is ‘Active & Healthy.’ OMH and minority health advocates throughout the nation look to emphasize the health benefits of incorporating even small amounts of moderateto-vigorous physical activity into weekly schedules. Follow OMH on Twitter or Facebook @MinorityHealth or @OMH_ Espanol for updates on April activities.

Nashville MSA Fares Relatively Well in County Health Rankings

On March 19, the Robert Woods Johnson Foundation in collaboration with the University of Wisconsin Population Health Institute released the annual County Health Rankings for 2019. All eight counties in the Nashville MSA ranked in the top quartile of the state’s 95 counties for health outcomes, measuring how long people live and how healthy they feel. Of the eight MSA counties, all but Davidson also ranked in the top quartile for health factors – behaviors, clinical care, socioeconomics, and physical environment – with Davidson ranking at the top of the second quartile. Williamson County ranked number one for both health outcomes and health factors with Wilson County ranking second in both. Davidson ranked 11th in outcomes and 26th in factors. However, as usual, there is much more work to be done as Middle Tennes6

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see and the state lag behind the nation in a number of key metrics. Race and ethnicity also play a major role in how specific populations fared. For example, in the healthiest Tennessee county, low birthweight was a problem for 6 percent of the population. In the least healthy county, low birthweight registered at 10 percent. Racial disparities come into play when looking at specific populations statewide, with low birthweight disproportionately impacting American Indian (9 percent) and Black (14 percent) residents. Those disparities are not unique to Tennessee. The County Health Rankings report noted, “Across the U.S., values for measures of length and quality of life for Native American, Black, and Hispanic residents are regularly worse than for Whites and Asians. For example, even in the healthiest counties in the U.S., Black and American Indian premature death rates are about 1.4 times higher than White rates. Not only are these differences unjust and avoidable, they will also negatively impact our changing nation’s future prosperity.” Nashville’s size and diversity of activities helped Davidson County when it came to access to exercise opportunities and healthy food, along with access to providers. When it came to socioeconomic factors, however, Davidson County ranked 36th out of the 95 counties, faring worse than state averages in several areas including percentage of children living in poverty, children in single-parent households, violent crime, and number of high school graduates (although simultaneously surpassing the state in per-

centage of population with at least some college). Housing also presented challenges to Davidson County in terms of shortages and cost. However, at press time, Mayor David Briley had just announced “Under One Roof 2019” – a $500 million initiative to create 10,000 new affordable housing units in the city over the next decade. He also called on the private sector to commit an additional $250 million to fund additional affordable housing solutions over the next 10 years. The annual rankings provide a snapshot of communities but were also designed to provide a starting point for change. To drill down on the data for counties throughout Tennessee and to explore actions to improve outcomes, go online to countyhealthrankings.org. You can also go online to register for the April 23 webinar – County Health Rankings & Roadmaps 101 – to use the 2019 data to move toward action in the community.

Clinic to Aid Uninsured Women with Substance Abuse Disorders

Vanderbilt’s Department of Obstetrics and Gynecology (OB-GYN) was recently awarded a $200,000 grant by the Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS) to provide increased access to medicationassisted treatment for uninsured women with substance use disorders. Between now and June 30, Vanderbilt will have the capacity to care for new uninsured patients through its Drug

Dependency Clinic, which provides antepartum and postpartum care, well-woman care, psychiatry services, social work and group therapy for women with substance use disorders. The clinic currently has two locations — One Hundred Oaks in Nashville and at NorthCrest Medical Center in Springfield. Funds from the grant will cover the cost of visits, medications, group counseling and lab testing, among other services. The clinic hopes to assist women who are pregnant, postpartum, parenting or who may plan to become pregnant soon. According to Jessica Young, MD, MPH, associate professor of OB-GYN, women in this population are often uninsured until they become pregnant, leaving them without care leading up to or in between pregnancies. For women who present to the clinic and are already pregnant, the goal is to help them have the healthiest pregnancy possible. “The opioid epidemic in Tennessee continues to grow and impact the health of all people, but particularly women of reproductive age,” said Young, who has led the Drug Dependency Clinic since it opened at Vanderbilt Health One Hundred Oaks in 2011. “Increasing access to care for opioid use disorder has an effect on a woman’s overall health. By getting these patients into medication treatment, we’ll be able to decrease the complications associated with opioid use disorder, such as infections.” Patients can be referred to the program through the TDMHSAS or by other referring physicians, including through the Emergency Department. nashvillemedicalnews

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PHYSICIAN SPOTLIGHT

Tackling Health Equity VUMC’s Wilkins Leads Efforts for Tennesseans By MELANIE KILGORE-HILL

For Consuelo Wilkins, MD, MSCI, vice president of Health Equity at Vanderbilt University Medical Center and associate dean for Health Equity for Vanderbilt University School of Medicine, the road to medicine was paved early in life.

Finding her Passion

Growing up in the Mississippi Delta, Wilkins often accompanied her mother – a math teacher – to the homes of elderly residents where her mother would assist with taxes, accounting and medical forms. “I always loved going with her and spending time with older adults, who were so wise and encouraging,” Wilkins said. “That exposed me to the health needs of older people, and I knew from the time I was very young that not only did I want to be a physician, but a geriatrician.”

Starting Out

After leaving Hollandale, Miss., Wilkins attended Howard University in Washington, D.C., where she received both her bachelor’s degree and her medical degree. She then completed a residency in internal medicine at Duke University Medical Center before earning a Master of Science in Clinical Investigation at BarnesJewish Hospital at Washington University in St. Louis, where she also completed a fellowship in geriatric medicine. Her two-year fellowship turned into a 12-year faculty appointment with Wilkins serving as associate professor of Internal Medicine, Geriatrics, Surgery and Psychiatry. She also served as director of the Center for Community Health and Partnerships and the Institute for Public Health, and as co-director of the Center for CommunityEngaged Research Institute of Clinical and Translational Sciences (CTSA). The busy physician-scientist also acted as director of “Our Community, Our Health,” a collaboration between Washington University and Saint Louis University.

The Move to Tennessee

In 2012, Wilkins left St. Louis for Nashville, where she began serving as executive director of the Meharry-Vanderbilt Alliance. Her primary responsibilities included developing and supporting collaborative initiatives and programs in biomedical research, community engagement and interprofessional learning. “I was doing a lot of research at Washington University focused on community health and engagement, and specifically how we bring the voices of patients and the community into research so that it’s more relevant and person-centered,” Wilkins explained. “What was most attractive to me about Vanderbilt was the opportunity to collaborate and the willingness of other facnashvillemedicalnews

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ulty to support new ideas and innovation,” she continued. “I really liked that focus on leadership, and the culture of striving for excellence in everything through support and collaboration.”

Addressing Health Equity

Wilkins took on a new role in Jan. 2019 when she was named vice president for Health Equity at VUMC and associate dean for Health Equity with the Vanderbilt University School of Medicine. In this role overseeing the newly established Office of Health Equity, Wilkins is connecting existing community health and health equity initiatives from across the organization while scaling system-wide efforts to identify and address disparities in health. The model for the new office of Health Equity stems from an initiative of the Association of American Medical Colleges in which VUMC was one of eight institutions selected to understand how academic medical centers can influence and improve population and community health by making healthcare safer and more equitable. “There’s a lot of buy-in for a program like this to work at the institutional level somewhere as large as Vanderbilt, and it takes a lot of commitment from leadership,” Wilkins said. She believes need for the initiative stems from a number of factors, including the evolution of healthcare reimbursement from fee-for-service to outcomes based – a shift making organizations nationwide more responsible for overall

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health of the community. “The internal culture at Vanderbilt is growing and focusing on making sure we’re delivering the best care for patients, which translates into healthier communities,” Wilkins said. That community includes Vanderbilt’s 23,000 employees from varied backgrounds, income levels and zip codes. “We need to make sure the people who are keeping others healthy have opportunities to thrive, because they and their families depend on Vanderbilt,” she said. The office also will focus on research and creating opportunities to educate medical students about social determinants of health in various populations, including challenges of rural communities that might lack access to healthy foods and places to exercise. She also wants students to understand challenges of those with limited health literacy and English proficiency. Wilkins said progress requires a shift in mindset from traditional physician roles to serving communities by connecting them to resources. To that end, Wilkins is developing a new health equity certification course to be rolled out fall 2019. “This is an early win for the new office

and adds a level of distinction with additional research opportunities for medical students,” she said. Wilkins also is working with other non-profits to conduct community health needs assessments every three years. Partners currently include Saint Thomas Health and the Metro Public Health Department. “Non-profits are working together to understand community needs and stop collecting data in silos, so we can generate it together and think about useful ways we can actually use the data,” she said. “It’s a very powerful collaboration.” It’s just the beginning of what Wilkins hopes will be a concerted effort to embrace health equity across VUMC. In fact, more than 180 health equity initiatives have already been identified system-wide, and the office is working to fill the disconnect in resources and infrastructure. “We want to think collectively about how to enhance and think about outcomes for the populations we’re hoping to reach,” Wilkins said. “We’re really understanding how academic medical centers can influence and improve population and community health by making healthcare safer and more equitable.”

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HEALTHCARE ENTERPRISE

Ticket to Ride

Senior Ride Nashville Prevents Isolation, Connects Riders & Drivers By MELANIE KILGORE-HILL

Social isolation is an increasingly common challenge for seniors nationwide. Getting to doctor’s appointments, accessing nutritious foods and simply engaging with others is particularly difficult for those who no longer drive or who do not have easy access to transportation. In Nashville, there are 30,000 residents who are 75 years or older. In fact, it’s projected that 22 percent of Tennesseans will be 65 or older by 2020, creating a need for greater social support statewide. That’s exactly what Senior Ride Nashville is doing. The 501(c)3 was created in 2017 by the Council on Aging of Middle Tennessee and the Senior Transportation Leadership Coalition with strong support from the local community. The organization has given seniors more than 4,500 trips since its November 2017 launch.

and dignity while improving quality of life.” According to Brumfield, older adults typically live six to 10 years after they stop driving, and reduced mobility puts seniors at higher risk for illness, isolation, loneliness, food scarcity and depression. “This is the reason a group of leaders stepped up to find solutions to support all of us as we age,” she said. “It’s something we will all face, and we need to work together to create solutions.”

Making Connections

Executive director Carrie Brumfield said the organization’s objective is to connect older adults who no longer drive with volunteers who do. “Transportation has been one of the biggest unmet needs for seniors in Davidson County for decades,” Brumfield said. “The Coalition spent two years researching other models around the country and created a plan to help older adults maintain their independence

Filling a Need

Today, Senior Ride Nashville has 95 drivers who transport adults over age 60 to doctors’ appointments, grocery stores and community centers – or anywhere else they need to go. Seniors pay a yearly $25 membership fee and $6 per round trip. Outings can last up to three hours and are scheduled a week or more in advance. To be considered for eligibility, riders receive an in-home assessment from a partnering home health agency to ensure

they can transfer in and out of a vehicle with limited assistance. Brumfield said that the first year of the program exceeded expectations and that interest from potential riders remains high. In fact, the organization is looking for more volunteers to help drive the increasing number of riders. “Our drivers are also people looking to stay connected in the community and to give back,” she said. “We’re relying on the community to support this, because expansion depends on the willingness of volunteer drivers to come forward and participate. It’s a wonCarrie Brumfield derful and easy way to give back.” Senior Ride Nashville currently serves riders in Hermitage, Donelson, Old Hickory, Madison, West Nashville and East Nashville, with gradual expansion planned to meet the entire county’s needs. For more information on becoming a volunteer or to refer a senior, go online to SeniorRideNashville.org.

NMGMATen Minute Takeaway Relationship Marketing through a Strong Brand By CINDY SANDERS

The second Tuesday of each month, practice managers and industry service providers gather for an educational Nashville Medical Group Management Association (NMGMA) meeting at Saint Thomas West Hospital. In March, David Coppock, regional vice president with Professional Office Services (POS), discussed building patient relationships through a strong practice brand. While practices need an effective brand to set them apart, he specified a brand is not simply a logo, font or color. Today, the focus David Coppock is on relationship marketing, Coppock said, noting the brand is actually the last piece of the process. “Relationship marketing is not a campaign … it’s a strategy,” he continued. It’s not enough to simply complete a service transaction. Instead, Coppock said relationship marketing is the brand’s ability to create an emotional connection. “Healthcare is personal, and it’s emotional,” he pointed out. When a practice creates twoway communication and puts the patient’s needs at the center, then that relationship 8

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fosters loyalty, long-term engagement, a channel to proactively manage care, and a strong referral source. Coppock referenced information from Salesforce that showed over 50 percent of an experience is based on emotions. “Without that personal, emotional experience, the customer will go to a competitor,” he stated. While patient engagement, experience and satisfaction seem similar, they are actually different. Engagement, explained Coppock, is proactive in nature and taken with the patient. Satisfaction is all about the outcome. Patient experience is a cumulative measure. Using the Beryl Institute definition, Coppock said patient experience is “the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care.” The patient experience, Coppock added, is the brand battlefield. “In the world we live in today, we’re all one post away from a negative review and losing a patient,” he said. “For every negative experience,” he continued, “10-15 people are going to be told about it or see it.” He added, “Your online reputation lives anywhere a patient can leave a rating.” And, he noted, those ratings matter: • 82 percent of patients use online reviews to view or post comments and ratings of physicians, • 75 percent of patients use online

reviews as a first step in choosing a provider, and • 50 percent of patients would go out of network to see a physician with positive reviews. “A brand is perception,” he said. “It’s that emotional connection. It’s what patients say about your practice, how they feel about it, how you and the staff feel about it.” Coppock suggested six steps to establishing or improving practice branding: • Discover your brand: Coppock said the brand starts from the top down and suggested practice leaders walk through the door as if they were a new patient to check out signage, patient forms, and interactions. Do signs and forms look alike? Do they make sense? • Research the marketplace: Where does your practice fit in the space? Do a bit of light research on the competition. What’s similar or different to you, and what do you do that’s different? • Position your brand: What is your point of distinction? Are you the market leader in an area? Be specific – ‘all of our providers are board certified’ rather than ‘we have the best providers.’ • Develop your brand story: “The personality of your brand is determined in large measure by the words you use and the sentences you write,” explained Coppock.

What are three words that describe your brand or practice? Then use those words consistently to tell your story in a variety of places, including the website, You Tube, blogs, texts and collateral materials. Know your audience and how they like to receive information. Generational differences require varied communications. • Create your brand identity: This is the part where you think about font, color, taglines and a visual identity guide – and then use it consistently. “If you’re going to go to the trouble of creating a brand, use it on everything,” Coppock said. • Activate your brand: “It’s not a ‘one and done’ approach,” Coppock said of marketing. “How many times do you have to tell someone before a message gets through? Seven. Seven times before your message sinks in,” he stressed. Be committed to your brand and make sure everyone on the team ‘walks the talk.’ Finally, Coppock encouraged practices to do a brand audit every three years. He suggested laying all materials out on a conference table to look for anything that doesn’t adhere to your visual guide. He also said the audit should include taking a fresh look at the practice from the customer viewpoint and surveying patients to find out about their experiences. The most important step is to take that information, make a plan and put it into action. nashvillemedicalnews

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ACHEMT: Healthcare Today & the Future of Surgery The American College of Healthcare Executives Middle Tennessee (ACHEMT) gathered at LifePoint Health on Feb. 28 for an informative program on healthcare today and the future of surgery.

improve the quality of care. His presentation covered four key topics.

By DAVID WEIL

Healthcare Today

Victor E. Giovanetti, FACHE, executive vice president of Hospital Operations at LifePoint Health and a co-founder of our ACHEMT chapter, offered welcoming remarks and shared the perspective of a healthcare executive who started his career as a clinician. Giovanetti began the event with several bold and challenging statements: 1. What you do matters every day. 2. When we make a mistake, somebody – the patient and also the family – pays the price. 3. If you are not committed to continuously improving the quality of care, then you should leave the business and do something else. Noting we have all been consumers of healthcare, Giovanetti said those experiences have informed his own responsibilities, and those for whom he has responsibility. He shared his personal story about the diagnosis of his brother, Tony, at the age of 48, with Type A Leukemia. The treatment required a stem cell transplantation from their sister. Unfortunately, graft versus host disease followed. Giovanetti said he felt at a deep loss as to how to tell his brother that he was going to die and how to tell their father, who had recently lost his wife, that he would lose his son, too. Giovanetti enlisted an oncology nurse to help communicate the news. He said we have a tremendous opportunity to show that we really care about the people we serve, the patients and also their families. Patients assume, but also deserve, to get more than good quality care. Having been on both sides, Giovanetti said what really matters is that patients and families feel cared about and cared for and that, as providers and system executives, we listen and respond. He drew attention to four key elements of leadership – formal training, experience, talent and lifelong learning. Building on that foundation, Giovanetti called on those gathered to find something worth learning in every situation.

OR of the Future

The event’s second speaker was Alexander Langerman, MD, SM, FACS, associate professor of Otolaryngology and director of Surgical Analytics Lab for Vanderbilt University Medical Center, who is the founder of ExplORer Surgical Corporation. With a mix of confidence and humility, Langerman captivated the audience with his passion and commitment to nashvillemedicalnews

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Versatility versus Specificity: Langerman said one of the main challenges facing surgical environments today is balancing versatility with specificity. Structural equipment needs change with each clinical task with some tasks requiring significant infrastructure and complex devices. Yet, too much specificity, he noted, could adversely limit the extensibility of the space needed. The long-standing way of organizing, noted Langerman, is to use a preference card. However, there is significant inefficiency with the lack of certainty as to preferences. Staff fear being reprimanded if the layout isn’t correct, patient harm is possible if the wrong instrument or material is inadvertently selected, and delays occur when needed instruments are not present. Conversely, overprovisioning also causes problems including waste from open-butunused instruments that some estimate to be a multibillion-dollar annual loss healthcare, as well as cognitive overload from the overwhelming number of unnecessary supplies arranged on the surgical table. Langerman shared his own results from an institution-wide tray reduction effort where seven trays with more than 400 instruments were reduced to two trays – one universal and the other contingency tray with 60 specialized instruments. He noted the challenge in improving efficiency and quality by reducing variability relies on collecting better data. The first hard data on redesigning operating rooms for efficiency came out of a study performed at the Clemson School of Architecture’s Center for Health Facilities Design & Testing (RIPCHD.OR). While healthcare facility design has moved toward the use of lots of booms, Langerman said what is not taken into consideration are logistics, such as whether or not a surgeon can see the clock on the operating room wall, poorly thought out trash flow or poor placement of a vital monitor. Langerman showed how these impediments could be identified with real-time simulation using full-sized, mocked-up operating room spaces. An early example was Frank and Lillian Gilbreth’s Surgical Motion Studies if the early 1900s, which has evolved into the “OR Black Box” project at the University of Toronto where everything happening in the operating room is recorded and analyzed. Langerman said the next horizon will be automated analysis using artificial intelligence techniques. Enhanced Teamwork Support: To increase efficiency and quality in surgery, Langerman said we need to create technological and environmental supports for enhanced teamwork. Most surgical care incudes fractured teams as a result of breaks, handoffs and cross-coverage. When the operating room staff is 100 people, there are millions of potential combinations, which means many teams lack situational awareness and a consistent “game plan” for the surgical intervention.

ACHEMT College Night • April 24 Students interested in a corporate healthcare career are encouraged to attend the upcoming college event at the Tennessee Hospital Association on April 24 from 6-7 pm. To register for the free event, go online to achemt.org.

Human Interoperability: While medical interoperability is an important trend in healthcare information technology, Langerman said the focus also needs to be on “human interoperability.” How does information get into and out of information technology systems via the human participants? Considerations include tailored information for decision support, cognitive hierarchy and inclusiveness to the patient to meet the ultimate goal of making spaces better for patients. Transparency: One of the critical incoming trends in healthcare is transparency. Consumerism, increased liquidity of data and the erosion of trust in professions, including medicine, alongside the growing publicity of conflicts of interest and “bad behavior,” combine to create an expectation that hospital pro-

cesses be transparent. Langerman noted the modern-day operating room is one of the most secluded of environments in the hospital despite being critical to patient care and quality improvement. Recently, there has been a push for more transparency. Langerman said while there is still much opposition, the “pulling away of the curtain” in surgery is gaining public support. However, he said there is a delicate balance between offering patients and physicians access to a procedural video and a video of the surgical team, which could lead to burnout and a need to ‘perform’ for the camera. This concern was underscored by a study examining the response of TSA employees to “coercive surveillance,” causing depersonalization and adverse behaviors as a result of cameras at work. Ultimately, Langerman said the future of surgery will entail a balance of technology, creative space design and environmental supports to provide an enhanced operating room that advances human teamwork and medical interoperability and transparency with the goal to not only continuously improve the quality of surgical care, but also to improve patient experience. David Weil, Esq., MBA, serves as vice president of Legal Services for QUORUM Health and as chair of the Membership Growth Subcommittee for ACHEMT. For more information on the organization, go online to achemt.org.

Rohan Installed as ACHE Chairman

TriStar Division President Leads National Organization HCA TriStar Division President Heather J. Rohan, FACHE, has assumed the office of chairman of the American College of Healthcare Executives (ACHE). Rohan was installed at the Council of Regents Meeting preceding ACHE’s 62nd Congress on Healthcare Leadership on March 2. ACHE is an Heather J. Rohan international professional society of 40,000 healthcare executives who lead hospitals, healthcare systems and other healthcare organizations with a mission of advancing its members and healthcare management excellence. As chairman, Rohan is serving the second part of a three-year term preceded by serving as chairman-elect and followed by serving as immediate past chair. Board certified in healthcare management as an ACHE Fellow, Rohan has served on the ACHE Board of Governors since 2015. She also served as the ACHE Regent for Florida - Eastern from 2011 to 2012. Rohan has more than 30 years of extensive healthcare experience,

serving in a variety of leadership roles in both administration and clinical care positions with HCA Healthcare. As president of the HCA TriStar Division, which includes HCA facilities in Tennessee, Southern Kentucky and Northwest Georgia, Rohan oversees a total of 19 hospitals and related care settings that are supported by approximately 2,800 physicians and over 15,000 employees – including over 5,800 nurses. “Early in my career as a bedside nurse, I immediately recognized the unique opportunity I had been given to make a difference and to create a personal connection with the patients under my care,” said Rohan. “Throughout my career and service in various healthcare leadership roles within HCA Healthcare, I’ve always carried that same passion for a patient-first culture and will commit to furthering that mission in my new role as ACHE Chairman.” In addition to her service to the HCA TriStar Division and ACHE, Rohan serves as a board member for the United Way of Middle Tennessee, American Heart Association of Greater Nashville and the HCA Foundation.  She also serves on the board of trustees for Barry University, her alma mater.  APRIL 2019

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Covering Kids, continued from page 1 coverage to parents who didn’t have options before. “We know when parents have health coverage, kids are more likely to, as well,” she explained when the Georgetown report was released. In Tennessee, Young cited TennCare enrollment numbers for those ages 0-18 and said the program has experienced a drop of more than 125,000 children between February 2017 and February 2019. “This is alarming to us for several reason,” said Kinika Young Young. “Most children should remain eligible even if parents have an increase in income, because there are other pathways to coverage,” she explained. Programs like TennCare Standard and CoverKids are designed to insure families with incomes up to 250 percent above the poverty level. Young also noted the lower enrollment numbers coincide with TennCare’s recent reexamination of the recertification process. She said enrollees received a 95-page packet (printed in both Spanish and English) to help determine if eligibility requirements were still being met. Young said many families didn’t receive the packet, didn’t understand its purpose, or never received confirmation of recertification after mailing it back. “Children are being disenrolled because their packets weren’t received, so the state may not be correctly screening children for other categories with

higher income cutoffs,” she said. “We’re really trying to figure out what’s happening with the process, why it’s occurring, and getting the public and providers to ask legislators and TennCare why we’re losing ground with covering children.”

Renewing Eligibility

TennCare spokesperson Sarah Tanksley said there has not been a policy change, and that lower enrollment numbers in recent years reflect the state becoming more current with its annual renewals. According to Tanksley, federal law requires states to renew eligibility of its members annuSarah Tanksley ally. However, CMS offered every state the option of pausing those renewal efforts during 2014 so states could focus on ACA-related implementations. Like virtually every other state, Tennessee requested and received this waiver. “The effect of us pausing renewals was that our enrollment ballooned (meaning, people continued to come onto the program every month, but no one came off the program through the renewal process),” Tanksley stated. “We restarted the renewal process again in 2015 through a combination of manual and other, slightly automated processes. Given the largely manual renewal processes that we were using, however, it wasn’t until 2016 and into 2017 that the impacts of the re-implemented renewal

Tennessee Coverage Numbers for Kids Enrollment numbers pulled from published enrollment data by the Division of TennCare available through tn.gov/tenncare/information-statistics and through tn.gov/ coverkids.html TennCare: Ages 0-18 Feb. 2019: 694,613 Feb. 2018: 790,694 Feb. 2017: 821,545 CoverKids: Ages 0-19 Feb. 2019: 40,669 Feb. 2018: 69,240

process really began to be noticeable in our membership numbers.” She said the impact continued to be seen through 2018 as the state became more current with renewing eligibility. “Historically, TennCare … prior to ACA and the 2014 renewal pause … was a program of about 1.2 million members,” she said. “Currently, we have approximately 1.3 million members. So, while there has been a drop in enrollment in recent years as we paused then resumed renewals, our current enrollment level is 100,000 members higher – or almost 10 percent higher – than our pre-ACA aver-

Briovation Signs Transatlantic Partnership Agreement MoU to Establish Presence in Northern England

At the end of March, this initiative. “We are excited Nashville-based investment and to partner with Briovation to strategic advisory firm Briovabroaden opportunity for local tion signed a Memorandum and regional healthcare busiof Understanding (MoU) with nesses that are looking both three key partners to establish a for strategic investment and presence in Greater Manchesthe ability to introduce their ter and Northern England, in offerings into the complex U.S. order to facilitate transatlantic healthcare market,” said Jackie investment and acceleration of Oldham, director of Strategic promising health and healthInitiatives, Oxford Road Corcare companies. ridor & Health Innovation Officials with Briovation Manchester. said the intention of the agreeThe U.K. partners will ment is to establish the joint facilitate access to and relaSigning of the Memorandum of Understanding by (L-R) Professor Ben Bridgewater, planning and co-development Health Innovation Manchester; Steve Tremitiere, Briovation; Professor Jackie Oldham, tionships with new and existof a comprehensive approach ing companies and potential Health Innovation Manchester and Manchester’s Oxford Road Corridor; Steven Cochrane, Manchester’s Oxford Road Corridor. to identifying, investing in and funding partners across the optimizing innovation in health region and will assist Briohealth and social care, and its dynamic and wellbeing to facilitate the extension of vation with the development of specific entrepreneurial environment creates an Greater Manchester/North of England entrepreneurial programs. Briovation ideal opportunity to implement our proven Partnership-based businesses to the U.S. intends to replicate its U.S. business model approach outside of the U.S.,” said Vic and vice versa. Briovation has identified – which includes Health:Further, its straGatto, Briovation’s CEO and co-founder. Greater Manchester and the North of Engtegic healthcare advisory group, seed fund The U.K. partners – which include land as an important worldwide center of Jumpstart Foundry, and the Jumpstart Health Innovation Manchester, Manhealthcare innovation and envisions this colCapital growth fund – in the U.K. The chester’s Oxford Road Corridor, and laborative partnering relationship as highly partnership is originally structured for TRUSTECH – are creating a dynamic complementary to its existing U.S. business. three years, and the partners have already Greater Manchester health innovation “The Greater Manchester region has begun the development of a comprehenecosystem and are continuing to develop developed a healthcare ecosystem that is sive implementation plan which will be partnerships to enhance the growth of recognized globally for its leadership in launched in the second half of 2019. 10

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age enrollment. And Tennessee is not an expansion state.” Tanksley also pointed to a state economy that continues to increase at what appears to be near-historic rates, which is positively impacting Tennesseans’ lives and, in some cases, decreasing their need to access health insurance through the state’s Medicaid and CHIP programs. 

Computer Upgrade

Young has noted the redeterminations occurred without TennCare having a “functioning” computer system. She isn’t the only one to point to an eligibility determination system that was far from flawless. The nearly $400 million system, which was supposed to be functioning by Oct. 2013, has drawn criticism both at a state and federal level over the ensuing five-and-a-half years. TEDS (Tennessee Eligibility Determination Systems) quietly made its debut last month alongside a web portal for online applications and a call center for phone applications. Together, the three parts are called TennCare Connect. However, the Tennessee Justice Center has already received complaints from the counties where the program has been piloted. Testing and tweaking continue to address glitches in the system.

Following Up

For her part, Young is reaching out to providers to examine individual cases of families who’ve been dropped from coverage. “If a parent comes in for a child’s appointment thinking they have insurance, but you verify they’re no longer enrolled and parents aren’t aware, they should immediately call TennCare Connect and ask if a redetermination packet has been sent to their house,” Young said. “If they’ve incurred an injury or illness in the meantime, they’re exposed to the medical bills, so they need to get their application in as soon as possible to backdate their coverage.” Young encouraged families to reapply in writing and keep track of the date the application was submitted. She also said families could appeal coverage denials through the Tennessee Justice Center, as children might still qualify under special categories. Tanksley said TennCare providers have access to an online lookup tool that allows them to verify eligibility for patients and noted those who have lost eligibility should fill out a new application. She said hospitals also could determine hospital presumptive eligibility to get people enrolled quickly while their full application is being reviewed. “Tennessee has one of the most robust appeals processes in all of the country, employing hundreds of people whose job it is to ensure that individuals who believe that they have been incorrectly determined ineligible for the program or who believe they were not given the correct advance notice before being terminated have every opportunity for a fair hearing so they have an opportunity to make their case before a judge,” Tanksley said. “We go to great lengths to ensure that our population is aware of this avenue to challenge a state’s decision or action concerning their TennCare coverage.” nashvillemedicalnews

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GRAND ROUNDS

Y O U R M I D D L E T N S O U R C E F O R P R O F E S S I O N A L H E A LT H C A R E N E W S

PUBLISHED BY: Graham | Sanders Publishing, LLC PUBLISHERS Susan Graham & Cindy Sanders SALES 615.397.2836 Cindy Sanders Maggie Bond Pam Harris Jennifer Trsinar

The Association of Clinical Research Professionals is holding their annual meeting in Nashville. Don’t miss out on this premier education and networking event for clinical research professionals featuring six educational tracks plus the Signature Series. Registration is available online through the NashvilleMedicalNews.com website or at 2019.acrpnet.org.

ACOG Annual Clinical & Scientific Meeting • May 3-6 Music City Center

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Mark Your Calendars ACRP 2019 • April 12-15 Music City Center

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The American College of Obstetrics and Gynecology is hosting their annual meeting in Music City. “Accessing the Spectrum of Quality Health Care” will feature sessions for every type of learner from formal lectures to hand-on workshops to informal discussions plus plenty of special events, networking and career opportunities and access to industry exhibitors. For more information or to register, go online to annualmeeting.acog.org.

CleanMed • May 7-9 Omni Nashville Hotel

The premier national conference for leaders in healthcare sustainability comes to Nashville in May. For more information on the 2019 programming or to register, go online to cleanmed.org.

CHS Sells Tennova Lebanon to VUMC

In late March, Community Health System and Vanderbilt University Medical Center announced a definitive agreement for CHS to sell the 245-bed Tennova Healthcare – Lebanon hospital and its associated assets to the academic medical center. The transaction is anticipated to close in the third quarter of this year. With this acquisition VUMC will have a substantial presence in four of Tennessee’s fastest growing counties: Davidson, Rutherford, Williamson and Wilson.

Enablr Therapy Launches Mobile Therapy Platform Serving

Enablr Therapy, Nashville’s first mobile therapy platform, launched last month after more than two years in development. The platform serves both children and adults in need of speech, physical, and occupational therapy as well as academic tutoring services. Founded by Project Play Therapy Co-founder and President Kyle Keene, Enablr Therapy was created to empower families and individuals with more choices when looking for a therapy provider. The platform allows users to browse local therapists that are available to meet when and where families need them most – saving time and allowing clients to meet with their pro-

viders in a natural environment. The platform allows users to find quality therapists and tutors in their area in a matter of minutes. Enablr also gives therapists more options, allowing professionals to set their own schedule, prices and coverage area.

Spero Health Announces New COO

Brentwood-based Spero Health, a CARF-accredited organization specializing in local, affordable, outpatient care for individuals suffering from substance use disorder, announced an executive leadership addition with the appointment of Edward Littlejohn as chief Ed Littlejohn operating officer. Littlejohn brings more than 20 years of leadership to his new role with Spero. Most recently, he was with Meridian Behavioral Health Systems where he was responsible for operations over nine facilities in six states. Prior to that, he served as COO of hospitals within Tenet Healthcare and Kaiser Permanente.

Area Healthcare Exes Launch ReVIDA Recovery

In other behavioral health news, Marty Rash and several other area healthcare executives have rolled out ReVIDA Recovery Centers. Lee Dilworth has been named CEO of ReVIDA, which launched with seven treatment facility locations in East Tennessee and Virginia. The addiction treatment company focuses on opioid use disorder and takes a ‘whole person’ approach to address addiction. “In order to make a positive and lasting impact on each patient’s life, our staff is dedicated to working with primary care providers, law enforcement, social services, non-profits, and other community members to help the entire community

overcome this epidemic,” said Dilworth. “Recovery saves lives, heals fractured families, reduces the costs of healthcare, social services, and in the criminal justice system.”

Let’s Give Them Something to Talk About! Awards, Honors, Achievements

The Leapfrog Group, a national patient safety watchdog that collects and transparently reports hospital performance data, has awarded TriStar Southern Hills Medical Center as one of the Top General Hospitals in the United States and as the only recipient in Tennessee for 2018. Tennova Rehab Center at McFarland in Lebanon has been recognized in the top 10 percent of inpatient rehabilitation facilities in the country. The latest rankings from the Uniform Data System for Medical Rehabilitation (UDSMR) placed the 26-bed inpatient center among high performers nationwide. Hadassah Nashville hosted their annual fundraiser, Best Strokes, last month putting the spotlight on breast cancer awareness. The evening also honored Ingrid Mayer, MD, MSCI, for her pioneering work in breast cancer research and treatment. Mayer is the clinical director of the Breast Cancer Research Program at the Vanderbilt-Ingram Cancer Center and a world-renowned leader in breast cancer research and treatment. Tami Stotts, practice manager

for Nashville Vascular & Vein Institute, recently earned her Certified Medical Practice Executive (CMPE) designation through the American College of Medical Practice Executives. WKRN’s Jared Plushnick has been named The American Lung Association in Tennessee 2019 LUNG FORCE Walk Chair. The 5K event, which raises awareness and funds for lung cancer and lung disease research, is set for May 18 and will start at 9 am at Public Square Park.

Saint Thomas Midtown Celebrates a Century

On March 20, Saint Thomas Midtown celebrated its 100th anniversary of healthcare service to the community. Formerly Baptist Hospital, the celebration reflected the legacy of care, quality, innovation and connection with the Middle Tennessee community. The hospital was originally founded in 1919 as Protestant Hospital. While the name has changed over the years, the devotion to the physical, emotional, and spiritual healing for all individuals has remained constant. “Celebrating a legacy of 100 years is much more than just an anniversary. For Nashville natives, there’s often a connection to Saint Thomas Midtown – whether it’s their birthplace, where they’ve held the hand of a loved one at a moment of vulnerability or have a relative who is an associate. Midtown is a part of Nashville’s identity,” said Fahad Tahir, president & CEO of Saint Thomas Midtown and West Hospitals. “Thank you to the physicians, associates and leadership at Ascension Saint Thomas Midtown hospital who live our mission each day, and congratulations on a century of service to individuals in need and helping our communities to lead healthier lives.”

Saint Thomas Midtown CEO Fahad Tahir (far right) leads a toast to the hospital’s century of service.

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