Methow Valley Health & Wellness 2014

Methow Valley

Health&Wellness

Affordable Care Act revisited

2014 – 15

Coping with disaster-related stress

Emergency care in the Methow

Dean Quigley, M.D. General Surgeon

Andy Swartzel, PA

regular Hours

Mon. - Thurs. 7:30 a.m. - 5:30 p.m.

Fri. 7:30 a.m. - 4:30 p.m.

Walk in clinic Hours

Mon. - Thurs. 4:30 p.m. - 5:30 p.m. sat. 8 a.m. - 12 p.m.

Your Friends For liFe! - www.mvhealth.org

2 HEALTH & WELLNESS 2014 – 15

Methow Valley

Emergency medicine: providing care when the hospital is far away 4

Health & Wellness

Help when you need it

Don Nelson, publisher/editor Darla Hussey, design Sheila Ward & Tyson Kellie, advertising associates Dana Sphar, ad design & production Rebecca Walker, office manager

One of the primary reasons we publish the annual Health & Wellness supplement is so it can be kept year ‘round as a handy reference for your health care needs. Our advertisers reflect the reassuring variety of practitioners and service providers in the Methow Valley and beyond in Okanogan County. Doctors, hospitals, specialists (for ears, eyes and other parts), clinics, spas, social service providers, therapists, counselors, masseuses, herbalists, chiropractors, dentists, ophthalmologists, nurse practitioners, mental health care providers, pharmacists, insurers — it’s an impressive array of options for a rural area.

For all that, emergency care can be a challenge given the distances that first responders may have to travel in a county that’s larger than some states.

The stress of events such as those endured in the Methow Valley this past summer can take a toll.

The Affordable Care Act is about to enter year two, with more options but, possibly, more complications for those who have taken advantage of it.

The need for medical care professionals of all types persists.

Each of those topics is covered in the 2014 – 15 Health & Wellness publication. We hope you’ll find it informative and useful until we produce another one next year.

Don Nelson Publisher/editor

2014 – 15

CONTRIBUTORS Ann McCreary Laurelle Walsh Marcy Stamper Theresa Taylor A publication of the Methow Valley News P.O. Box 97, Twisp, WA 98856 509.997.7011 • 509.997.3277 fax editor@methowvalleynews.com www.methowvalleynews.com Find us on Facebook Cover photo of Northwest Medstar heliCopter by l aurelle walsh

Your well-being — it’s physical and mental 8 Fast-track nursing assistant training program comes to the Methow Valley 11 Affordable Care Act makes more choices available in Washington 12

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Emergency medicine: providing care when the hospital is far away

By Laurelle Walsh

E

medical care in the Methow Valley is the primary responsibility of Aero Methow Rescue Service, a nonprofit emergency medical service (EMS) headquartered in Twisp.

Aero Methow’s service area corresponds to the Methow Valley School District boundaries, which run from the Canadian border to Gold Creek, (roughly between the towns of Carlton and Methow), and from Rainy Pass to the Loup Loup summit. The lower Methow Valley — downstream of Gold Creek — is served by Douglas Okanogan Fire District 15 EMS, based in Brewster.

Unlike the populous west side of the Cascades, where EMS is based at neighborhood fire stations scattered throughout the region, Aero Methow alone must respond to emergency medical calls in a 2,000-squaremile area — much of that in rugged wilderness.

So Aero Methow doesn’t just run a fleet of four ambulances staffed by highly trained EMTs and paramedics, it must also be ready at all times to assist the Okanogan County Sheriff’s Department in search and rescue missions, in all seasons and in any terrain.

Cindy Button, director of services for Aero Methow Rescue Service, with one of the two ambulances that Aero Methow stations at its Twisp office. Photo by Don nelson

Equipped All Aero Methow ambulances — two stationed in Twisp, and one each in Winthrop and Mazama — are equipped to provide advanced cardiac life support. They also carry IV pumps, airway management supplies, multi-casualty incident supplies, pediatric and obstetric emergency kits, and burn and trauma care supplies, among other sophisticated equipment.

Five four-wheel-drive rapidresponse vehicles, assigned to the paramedics on call, are equipped

with the same supplies as the ambulances, enabling the first responder at the scene to begin emergency care immediately.

Aero Methow went out on 550 calls in 2013, responding to car accidents, emergencies at local clinics, broken hips on the ski trails, cardiac arrests and strokes. The EMS provider also gets its share of cancellations and false alarms, said director of services Cindy Button.

“At least five times a year a driver pulls over on the highway to take a nap and somebody passing by calls it

mErgEncy

4 HEALTH & WELLNESS 2014 – 15

in. By the time we get up there, [the napping driver] has driven away,” Button said.

Ambulances stand by at special events like football games and rodeos, and also on fire calls, where the firefighters’ heart rates, blood pressures and blood oxygen saturation are monitored, Button said.

When called to assist the sheriff’s department with rescue operations — 10 times so far in 2014 — Aero Methow brings its own search and rescue trailer equipped with gear for winter, high-angle and

swiftwater rescues, as well as supplies for transporting and treating injured people in the back country.

Getting there Aero Methow’s emergency response time is “drive time plus 5 minutes,” Button said. This, of course, is limited to road conditions and hazards and “where people decide to build their houses,” she added.

On-call paramedics take home a rapid response vehicle and are required to live within 5 to 10 minutes of the base in Twisp. Therefore,

residents of Lost River, for example, should expect a 25-minute response time for a middle-of-the-night emergency, Button said. From there it is 70 road miles to the nearest hospital.

Patients go to Mid-Valley Hospital in Omak, about 35 highway miles from Twisp via Loup Loup Pass, or to Three Rivers Hospital, a public, nonprofit hospital operated by Okanogan/Douglas Hospital District 1 in Brewster, about 45 highway miles from Twisp.

Around 10 times per year Aero Methow is asked to transport patients to Central Washington Hospital in Wenatchee, as directed by a local physician or when a local hospital is not equipped to handle a patient’s condition, Button said.

Sometimes an air ambulance is called to transport patients to trauma centers in Seattle or Spokane. Last May, Northwest MedStar opened its sixth full-time air medical base in Brewster, a 10-minute helicopter flight from the Twisp airport.

Airlift Northwest, with its nearest base in Arlington, may also respond to calls here, and was on alert last

summer when wildfires placed temporary flight restrictions over the Methow, Button said.

Prepared for the worst “The message of the last few months is to be really prepared,” said Button, referring to the massive Carlton Complex wildfires that left the Methow Valley without power for eight days, cut off telephone communications, closed two of three highways in and out of the valley, and restricted air traffic.

Local physicians divvied up on-call shifts throughout the emergency, but the valley was suddenly cut off from the nearest hospitals. In response, Aero Methow — in cooperation with Three Rivers Hospital and local clinics — set up and operated a satellite emergency room (ER) at its facility in Twisp. Over three days the MASH-style ER treated 14 patients.

The satellite ER was re-opened over Labor Day weekend when highways 20 and 153 were closed again due to mudslides.

The satellite ER has been so successful that Three Rivers Hospital

This map shows Aero Methow’s service area. Graphic courtesy aero Methow

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and Aero Methow have committed to operating it again next year during Memorial Day, Rhythm and Blues, and Labor Day weekends, offsetting increased call volumes during the valley’s busiest weekends, Button said.

On an individual level, “People should be able to handle an emergency until help can get to them safely,” Button urged. “You need to be up on CPR and first aid and know how to use the AEDs [automated electronic defibrillators] stationed around the valley.”

At last count there were 40 AEDs at public places like the Mazama Store, Winthrop Barn, the Methow Valley Senior Center and the Carlton Store.

Community CPR/AED and first aid classes are regularly offered at Aero Methow’s training room. Check www. aeromethow.org for schedules and more information.

911 services The Okanogan County Communications Center, based in the city of Okanogan, fields 911 calls 24 hours a day, seven days a week. Serving all of

Okanogan County, the communications center normally receives around 1,800 calls to 911 per month, rising to about 2,200 during the busy summer season.

The communications center was put to the test last summer during the Carlton Complex Fire, when total calls to dispatch jumped from 446 on July 14 — the day lightning strikes started four separate fires — to more than 1,000 calls on both July 17 and 18 as the firestorm swept through the valley.

When phone and fiber optic lines were burned, the 911 system in the Methow Valley went silent, even though several redundant systems are in place in case one line of communications fails, according to Sheriff Frank Rogers. Fire, law enforcement and EMS were able to communicate via radio, but for around eight hours citizens were unable to make emergency calls.

“When [911] went down we were at the mercy of the phone company to get it repaired as fast as they could,” Rogers said.

While solutions to preventing

future outages are out there, a countywide unified communications system would cost around $20 million, an amount the county can’t shoulder on its own, Rogers said. “It all hinges on getting all the players on board.”

Unlike the populous west side of the Cascades, where EMS is based at neighborhood fire stations scattered throughout the region, Aero Methow alone

The future of emergency care EMS providers will be called on to provide more clinical and in-home care in the future, Button predicts. Called “community paramedicine,” this new paradigm for mobile health care addresses specific community needs: managing patients who need frequent care, helping hospitals reduce readmission rates, and offering options for patients who don’t require an emergency room visit.

must respond to emergency

medical calls in a 2,000-squaremile area — much of that in rugged wilderness.

With no after-hours facilities in the valley, Aero Methow is exploring community paramedicine as a way to bridge the gap between primary care and hospital care, Button said.

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Your well-being — it’s physical and mental

By Marcy Stamper

“P

Child and family therapist Valerie Potts uses toys and art supplies to teach families positive, successful interactions.

Photo by Marcy StaMPer

eoPle go to physical therapy when they pull a muscle, but those same people often discount stress, their mood or anxiety,” said Lisa Spitzmiller, a licensed mental health counselor in Winthrop.

This tendency comes from society’s overall approach to mental health, but it can be heightened in rural areas like the Methow Valley because people are resourceful and anonymity is hard to come by, said Spitzmiller.

“Ongoing stress harms our physical health in so many ways,” said Sharon Cohen, who teaches

mindfulness-based stress reduction in the Methow Valley. Stress elevates our heart rate, causes shallow breathing, and interferes with digestion.

“The brain doesn’t know the difference between an emotional and a physical threat—it’s the same fightor-flight response,” she said.

Spitzmiller agrees. “There is a very biological and physical component to the way that we feel—people don’t always understand that.”

Depending on whether we are under stress or having positive interactions, the brain releases different chemicals. For example, when we are under stress or need to react quickly to escape a threat, the brain releases

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hormones such as adrenaline, which increases the heart rate and elevates blood pressure, said Spitzmiller.

Chemicals that contribute to a sense of well-being, such as endorphins, are released during positive interactions and physical activity.

Valerie Potts, a licensed mental health counselor in Winthrop who specializes in child and family therapy, also emphasizes the link between physical and mental health. Simply moving around can be particularly helpful when people are stressed or upset, she said.

“I always talk to people about moving, which can be very healing,” said Potts. She talks about “moving” rather than “exercise,” since everyone moves but not everyone can handle an exercise program.

“It could be a walk around the block, or playing catch with their child. We talk about what it feels like when they move and how that can make them feel better,” said Potts.

Past and present Current research in neuroscience

has shown how behaviors and responses learned in childhood create a structure in the brain — and that we can alter those structures by practicing new behaviors, said Spitzmiller.

So while the formation of the brain is influenced by our earliest experiences, that does not mean that those experiences will always drive us.

Recognizing the origins of these patterns is often the first step in making changes, said Spitzmiller.

Positive interactions with a therapist or others can actually produce new connections in the brain, she said. The way we think and feel emotionally is influenced by the way we feel physically.

Therapists and individuals find different approaches useful to deal with stress and other emotional issues, and many combine various techniques.

Potts focuses more on the present than the past. “The past is not ignored — it’s part of the solution — but the focus is on what’s in this moment to help people move forward in a way that’s healthy and

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powerful,” she said.

Cohen teaches people how to use mindfulness to develop an awareness of how stress is manifested in their life and what triggers it. In mindfulness, the emphasis is on what arises in the present moment, as opposed to the past, she said.

Mindfulness techniques are often integrated into more traditional “talk” therapy to help people recognize their habits and create new behaviors, said Cohen. “Mindfulness is a practice, not a philosophy,” she said.

In her practice, Potts uses what’s called the Nurtured Heart Approach, which is tailored to each family and helps parents and their children build the type of relationship they want. It emphasizes what a child is doing right and involves setting clear boundaries and expectations. Potts works with the entire family so they can all learn new ways of relating.

“When I bring parents and children together, I’m very intentional,” she said. “The family members have to feel they’ve moved forward and that

something positive has happened.”

The benefits of stress?

We tend to think of stress in exclusively negative terms, but stress is a part of life, and it can be a healthy part, said Spitzmiller. We just need to learn to manage our response to it.

“It’s hard to use the word ‘stress’ in a positive way, but if you think of the opposite — an isolation chamber — there is a negative impact because there is no interaction with others,” said Spitzmiller. “We are social beings who need involvement with the world.”

Stimulating situations, such as work or social interactions, all include some degree of stress, said Spitzmiller. The key is how we handle these stresses — do they get in the way of normal functioning or prevent us from socializing or from being effective at work or at home?

“Stress is helpful when it challenges us to do our best,” said Cohen.

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Vitamins / Personal Care / Local, Organic Produce Natural Foods / Herbs / Unique Gifts Friendly, Knowledgeable Customer Service (509) 826-1445 • 1 North Main • PO Box 4217 • Omak, WA www.mainstreetmarketomak.com A variety of toys and art supplies — animals, a doll house, miniature cars and trucks, colored markers and materials for collage — help show how parents and children relate and provide an opportunity to acknowledge desirable interactions. Photo by Marcy StaMPer

(OBHC), in Omak, uses a managedcare model. “We understand the importance of treating the whole person,” said Skip Rosenthal, OBHC’s chief executive officer.

Part of this approach involves placing therapists in communities throughout the county. One of the first places where OBHC has set up decentralized services is the Methow Valley. Savannah Miller, a clinical social worker and mental health professional with OBHC, is available weekly at Room One, where she sees individual clients. Miller also spends time every week in the Methow Valley School District to provide counseling to students and families.

OBHC’s comprehensive approach includes prevention, early intervention, outpatient therapy and ongoing case management so that people can remain stable and productive, said Rosenthal.

The agency is also exploring opportunities to provide residential treatment

programs in the county.

A big change in mental health care is the recognition — in law — that mental health and substance abuse can be chronic conditions, just like physical health, said Rosenthal. The federal Affordable Care Act requires insurance plans to cover preventive services including depression screening for adults and behavioral assessments for children. Insurance companies also cannot place financial limits on mental health treatments, he said.

“We’ve improved access to care and destigmatized mental health care — it’s an important philosophical step,” said Rosenthal.

“People in the Methow Valley are strong and resourceful, but they need to be able to ask for help before something becomes a crisis,” he said. “There is no stigma about dealing with depression, anxiety or substance abuse.”

“Getting help is OK,” said Potts.

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Fast-track nursing assistant training program comes to the Methow Valley

By Theresa Taylor Wenatchee Valley College

I

recent weeks, as a result of the fires burning throughout the Methow Valley, residents and local businesses have shown how a community can come together to support one another during a time of need.

That kind of support was also demonstrated when, before and during the fires, the community collaborated with Wenatchee Valley College (WVC) to support a certified nursing assistant (CNA) training program.

North Central Washington — areas such as the Methow Valley, Okanogan, Tonasket, Chelan, Cashmere and Leavenworth in particular — needs nursing assistants. Recognizing that need, Carol Gaston, a board member at Jamie’s Place and Mountain View, Winthrop care centers for the elderly, asked Jenny Capelo, WVC Dean of Allied Health, whether a fast-track CNA program could be brought to the Methow Valley. The fast-track CNA program offered through WVC Continuing Education provides training in the provision of personal care skills and instructs students in the roles and responsibilities of a nursing assistant.

While the program is offered on the Wenatchee campus, it has never been taken off site before.

“The community in the Methow came together and said ‘we want this,’” said Michele Gedrose, program n

developer for WVC Continuing Education. “This was the perfect combination of people, facilities and timing.”

The process to start a new program takes nine to 12 months — the college must receive approval from the Department of Health Nursing Commission for the class location, clinical location and the instructor. Approval for a CNA fast-track course in the Methow Valley took only six months.

During that time Gaston had recruited students for the program and the Methow Valley School District provided a location for classes — Liberty Bell High School.

The class ran from July 8 through Aug. 20. Eight students, both traditional and nontraditional, enrolled in the course taught by Sheila Brandenburg, a nurse and director of Jamie’s Place. Judy Tonseth, treasurer for Methow Valley Senior Citizens, offered $2,000 to offset the $725 tuition that each student paid for the program. The donation was split among the eight students.

“Despite the fact that there was a major wildfire in our valley, it worked,” Gaston said of the program.

As a statement to the resiliency of the program, only one class needed to be rescheduled.

The community of Omak also supported the program. Students commuted to Regency Omak Rehabilitation and Nursing Center, which agreed to provide a location for

clinicals. Students spent class time learning nursing theory and participated in a minimum of 35 hours of clinicals. Those who successfully complete the course may take the state licensure exam.

Gaston explained that she hopes the program will make it easier for people in the valley to get started in the health care field and that local students enrolled in the program will be able to work with elders in local care centers such as Jamie’s Place and Mountain View. Both Gaston and Brandenburg would like to see the program continue annually or semi-annually.

“It has been a great experience to instruct local people to advance their education and seek further opportunities for their future,” Brandenburg said.

“This is all about meeting the mission of the college,” Capelo said — to be responsive to community needs, and to celebrate the success of the students and community.

Students interested in future classes or who would like more information should contact Carol Gaston at gaston3950@gmail.com.

Theresa Taylor is a community relations staff writer at Wenatchee Valley College.

Certified nursing assistant students recently trained in the Methow Valley include, foreground: Brianna Sullivan and Kristen Austin; background: Angel Ochoa, Faurest Nelson Wicks and Lisa Doran. Photo by Jenny CaPelo, WenatChee Valley College

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Affordable Care Act makes more choices available in Washington

By Ann McCreary

B

Nov. 15, Washington residents will have the opportunity to purchase, renew or change health insurance coverage through Washington Healthplanfinder.

The open enrollment period for health insurance through the state’s online marketplace runs for three months, from Nov. 15 – Feb. 15, 2015.

Consumers will find additional choices this year when they shop for insurance plans on Healthplanfinder at www.healthplanfinder.org, the website created by the state to allow residents to select insurance under the federal Affordable Care Act (ACA).

The number of insurance companies approved to sell qualified health plans (that comply with ACA requirements) in Washington has increased from eight to 10, and the number of plans available throughout the state has almost doubled from 46 to 82.

“That’s really good news for customers who are looking for the best value for themselves and their family,” said Bethany Frey, communications specialist for the Health Benefit Exchange.

Not all plans are available in every county, however. Okanogan County consumers will be able to select from plans offered by five insurance eginning

Room One’s in-person assister, Lori Valentine, is one of two staff members trained to provide assistance to people signing up for health insurance through Washington’s online Health Benefit Exchange. Photo by Ann MccreAry

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The number of insurance companies approved to sell qualified health plans (that comply with ACA requirements) in Washington has increased from eight to 10, and the number of plans available throughout the state has almost doubled from 46 to 82. providers — two more than last year — based on information from the Health Benefit Exchange. They include Community Health Plan of Washington, LifeWise Health Plan of Washington, Moda Health Plan, Molina Healthcare of Washington and Premera Blue Cross.

To be approved as a provider on the Health Care Exchange, insurance companies must offer plans that provide coverage required under the ACA (sometimes called Obamacare).

This is comprised of 10 basic areas

of essential health coverage, including preventive screenings, maternity care, hospitalization and rehabilitation, and mental health care.

The ACA also prohibits insurance companies from denying coverage to people who are sick or who have chronic conditions, and from cutting off their insurance when they get sick.

People who purchase health insurance through the exchange may be eligible for assistance paying their premiums, depending on their

income. Subsidies for qualifying customers are provided through cost sharing, which helps offset out-ofpocket costs, or tax credits.

Less frustration The experience of purchasing insurance through the state’s online exchange is predicted to be less fraught with frustration for people trying to sign up for insurance during the second open enrollment period, Frey said.

The state has worked to fix the website glitches and the overwhelmed customer support systems that plagued the process last year, she said.

“There were error codes that consumers would get at certain points in the application and invoices that were not displaying correctly. Over time we have been working those out.

We are trying to eliminate some of the pain points” for customers, Frey said.

Last year the state had only about 100 – 150 trained telephone support staff to field a huge volume of calls

from confused and frustrated customers, many of whom could never get through to the call center.

On March 31, the final day of the open enrollment period, the call center was receiving 10,000 calls per hour, Frey said. The number of trained representatives will increase almost five-fold this year.

“The good news is now that we know what call volumes looked like last year, we can properly staff for the volumes expected,” Frey said.

“We will have about 500 customer support representatives at the start of open enrollment on Nov. 15.”

The overall application process has not changed drastically, but some features have been added to assist consumers trying to fill out the online application.

“We have added a screen-sharing feature so customer support representatives can share the screen with applicants. And we have added additional definitions or information along the way where people were getting stuck,” Frey said.

The home page will provide

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pathways for different customers to direct them to the appropriate application, such as Apple Health (Medicaid), new or renewing customers, and small businesses, Frey said.

Re-enrollment coming Many people who enrolled in an insurance plan last year will need to re-enroll. Some may be eligible to be automatically re-enrolled, Frey said, but only if they checked a box on their application allowing the Health Benefit Exchange to check their federal tax information for up to five years, and the plan they enrolled in for 2014 is still available in 2015.

“Only if the customer meets these requirements will we send them a letter that says they will be automatically re-enrolled in coverage through a 2015 qualified health plan with the maximum amount of any eligible tax credit applied,” Frey said.

Otherwise, customers will need to confirm their coverage renewal, or select a new plan and/or change their tax credit amount, or not renew coverage.

All customers who enrolled through Healthplanfinder will receive notification of the upcoming enrollment period from the Health Benefit Exchange and their insurance companies, Frey said.

Like last year, Methow Valley residents can receive free personal help from in-person assisters at Room One in Twisp. Two trained staff members at Room One are part of a network of assisters created to help people applying for insurance.

Lori Valentine, an in-person assister at Room One, said she expects to be just as busy during open enrollment this year as last year “because the penalties are higher.” She was referring to penalties imposed by the ACA on people who don’t have insurance as a way to encourage citizens to become insured.

For the first year the penalty for uninsured individuals was a fine of $95 or 1 percent of household income; this year it will increase to $325 or 2.5 percent of household income, Frey said. In 2016 the penalty increases to $695 or 2.5 percent of

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More support Valentine said in-person assisters “have more support this year” from regional program coordinators who are authorized to assist in problem solving and working with customer applications.

Mario Cantu, who coordinates the in-person assister program for a fivecounty area that includes Okanogan County, urged people to educate themselves about insurance plans.

“We help clients make good, educated choices … understand what a premium is, what a deductible is, and how that can affect them,” Cantu said.

A lower monthly premium may look like the best deal, but if there is a high deductible it may not be the best financial choice in the long run, he said.

While in-person assisters and customer support staff can provide information and assist with technical problems, they are not allowed

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to provide personal advice to individuals about insurance plans, Valentine said.

For people who want personal advice, Valentine said she encourages them to contact an insurance broker. A list of brokers is available on the Healthplanfinder website.

Jeff Lindstrom, a broker with Health Insurance Team in Seattle, has worked with many Room One clients, and helped conduct a seminar at Room One about insurance available through the exchange for small businesses.

Last year small business health insurance plans were offered in only two counties; this fall, plans will be available in all counties.

Lindstrom said he has worked with about 100 people in the Methow and Okanogan valleys as they sign up on the exchange, and most have qualified for subsidies.

He said he is encouraged by the increase in the number of plans

available this year, and by the improvements in the application process since the first enrollment period. “There’s been a real push to bring in new providers. That’s been really good. Competition holds down increases in premiums,� Lindstrom said. “I really have to give the Exchange a lot of credit. They have been working extremely hard to fix problems and it’s starting to show,� he said.

Although Washington’s Health Benefit Exchange was created to offer a consumer-friendly online marketplace for “one-stop shopping� where consumers could easily compare plans, the health insurance business is still complicated and difficult to understand for many people. “It’s gotten far more complex than it used to be, if you can believe that,�

Lindstrom said.

During the upcoming enrollment period, consumers need to enroll by Dec. 23 for coverage starting Jan. 1, 2015. If they sign up after Dec. 23, their coverage will start on Feb. 1.

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17 S. Western Ave. Tonasket, WA 98855

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Oroville Clinic

1617 Main St. Oroville, WA 98844

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Mon. - Fri. 8:30 a.m. - 5 p.m.

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509.476.3631 Family Medicine, Obstetrics, Anticoagulation, Women’s Health Care

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418 W. Main St. Brewster, WA 98812

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509.689.8900 Family Medicine, Preventative Medicine, CDL, Sports Physicals, Visiting Specialists, Well Child Checks & Immunizations