2011 January/February

You wouldn’t give a 2-year-old a drink, so why would you give one to an unborn child?

As a physician, it’s your responsibility to let her know: the U.S. Surgeon General Advisory says no amount of alcohol is safe during pregnancy.

Share 049: Zero Alcohol For Nine Months.

www.mofas.org

Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

January/February Index to Advertisers TCMS OfďŹ cers

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President Thomas D. Siefferman, M.D. President-elect Peter J. Dehnel, M.D.

Physician Co-editor Lee H. Beecher, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Thomas B. Dunkel, M.D. Physician Co-editor Gregory A. Plotnikoff, M.D. Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Katie R. Snow TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reect the ofďŹ cial position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.

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Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Katie Snow at (612) 362-3704.

Secretary Anthony C. Orecchia, M.D. Treasurer Melody A. Mendiola, M.D. Past President Edward P. Ehlinger, M.D. TCMS Executive Staff

Sue A. Schettle, Chief Executive OfďŹ cer (612) 362-3799 sschettle@metrodoctors.com Jennifer J. Anderson, Project Director (612) 362-3752 janderson@metrodoctors.com Nancy K. Bauer, Assistant Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Kathy R. Dittmer, Executive Assistant (612) 623-2885 kdittmer@metrodoctors.com Katie R. Snow, Administrative Coordinator (612) 362-3704 ksnow@metrodoctors.com For a complete list of TCMS Board of Directors go to www.metrodoctors.com.

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January/February 2011

MetroDoctors

The Journal of the Twin Cities Medical Society

CONTENTS VOLUME 13, NO. 1

2

Index to Advertisers

4

PRESIDENT’S MESSAGE

JANUARY/FEBRUARY 2011

Who’s Grabbing Your Wallet?

By Thomas Siefferman, M.D.

5

TCMS IN ACTION

By Sue Schettle, CEO

6

With Shoe on the Other Foot, Budget Still Looms Large

By Nathaniel Mussell, J.D.

Page 9

8

2010 Charles Bolles Bolles-Rogers Award Recipients

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COLLEAGUE INTERVIEW

Edward Ratner, M.D. HOSPICE & PALLIATIVE CARE

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s Advance Care Planning: A Legal Perspective

By Kristine E. Mullmann, J.D.

15

s Honoring Choices Minnesota: It’s About the Conversation...

By Sue Schettle

Page 26

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s Delivering Palliative Care Elements Across the Care Continuum

By Cally Vinz, RN

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s Hospice of the Twin Cities: Offering Comfort and Care at the End of Life

By Pam Schaid

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SPC Helps Bridge the Medicare Gap

By Jean Fusco

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New Health Care CEO: Andrew S. Cochrane, CEO, Maple Grove Hospital

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Medical Student Lunch ’n Learn/ Thomas P. Cook Scholarship Recipient

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New Members/Caring Hearts Supply Drive

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West Metro Senior Physicians Association

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East Metro Senior Physicians Association/In Memoriam/ Career Opportunities

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LUMINARY OF TWIN CITIES MEDICINE

Page 32

Alvin L. Schultz, M.D. Page 8 MetroDoctors

The Journal of the Twin Cities Medical Society

On the cover: Palliative and hospice care wishes are honored through advance care planning. Articles begin on page 12.

January/February 2011

3

President’s Message

Who’s Grabbing your Wallet?

THOMAS SIEFFERMAN, M.D.

A

s I start my term as President of the Twin Cities Medical Society, I get the pleasure of expressing my perspective on the future and present practice of medicine in my adopted state of Minnesota. As usual, there is always some event that upsets our world whether in private life or professional world.

After a wonderful day at our new Target Field, watching our beloved Twins pull off a win at the bottom of the ninth inning, I was truly enjoying life with my wife and two of our four children. Life was going as predicted and expected. On the light rail after the game, two less than savory characters forced their way onto our overcrowded rail car. No sooner had I taken my hand off my wallet to brace myself did I realize that our new passengers had stolen it, and as quickly as I could announce it to my wife, these rats were scuttling off the train to spend over two thousand dollars before I could even get all the cards canceled — all within 20 minutes at a local big name store. My drivers license and other important documents all lost and never to be seen again. Robbed of irreplaceable photos of our engagement and photos of our children. I was forced to find a way to get a new driver’s license, block all the credit cards that I had the misfortune of carrying that day, obtain new or temporary cards. Putting credit freezes on and writing up affidavits of events was my new life. After two weeks, the investigator called and confirmed my fears that though they have excellent cameras on the platforms, the crooks know where they are and how to avoid them. The police also confirmed that a certain bulls-eye retailer does not care that there were four of me on different check-outs all at the same time using different credit cards, and if one credit card was denied, they let them substitute another.

Instead of timely action, delays occur. Instead of reasonable precautions, all caution was thrown to the wind. Instead of what I expected, I received what I feared. Not physically assaulted, yet my predictable world was turned on its ear.

Many physicians feel the same with our changing world. Having to re-identify ourselves either by becoming corporately employed or struggling to find our place in the new world of Accountable Care Organizations (ACOs) and Clinically Integrated Networks (CINs). We find ourselves missing irreplaceable aspects of caring for our patients in the midst of all this chaos. We struggle to complete the “right forms,” the “right way,” to get paid; only to find “they” are withholding some of our “promised” incentives because some of our patients did not do their part and complete their prescribed treatments. It seems that every time we turn around, someone else is attacking our profession. Attacks under the guise of cost control or containment. Many of our friends had been lulled into a sense of a promising future of single payer. Instead, this has been replaced with a confusing plethora of acronyms and incomplete schemes for quality assurance and cost control. The federal and state governments are being presented with rocketing costs and spiraling tax returns, resulting in creative accounting and cost shifts and using “low hanging fruit” like our beloved MinnesotaCare Tax and the Tobacco Settlement funds in ways they were never intended.

Your Twin Cities Medical Society (TCMS) has been tasked by its members to help physicians through this morass of governmental regulations and tsunami of acronyms. We hope to have lively discussions at our TCMS Forums which will unfold in 2011 as well as discussions on the online forum (http://forum.metrodoctors.com) and can agree with a plan of action to correct problems. The TCMS Policy Committee has received a charge to produce a white paper (guide) on ACOs. TCMS will continue to monitor and confer your interests with legislators and insurance companies and hospital organizations to the best of our ability. The key to having your voice heard is to communicate with your leadership at TCMS. Hopefully, we have provided enough avenues to let your ideas and concerns be heard. If you ever run into me or any of the TCMS leaders, let us know how we are doing and what we can do better.

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January/February 2011

MetroDoctors

The Journal of the Twin Cities Medical Society

TCMS IN ACTION SUE A. SCHETTLE, CEO

MetroDoctors News Award The Minnesota Magazine & Publishing Association recently acknowledged MetroDoctors with a Bronze Award for Best Single Cover for the May/June 2010 issue, a graphic design featuring medical students connecting with the community.

West Metro Medical Foundation The West Metro Medical Foundation is losing five members this year due to term limits. A special thanks goes to Richard Simmons, M.D., outgoing chair of the Foundation, in addition to Paul Bowlin, M.D., Virginia Lupo, M.D., Edward Spenny, M.D., Wade Swenson, 4th year medical student; and Trish Vaurio, West Metro Medical Society Alliance Representative.

East Metro Medical Society Foundation Board of Directors The East Metro Medical Society Foundation Board of Directors wishes to thank Michael Hummel, M.D., Saint Paul Radiology, for his two-year term on the EMMS Foundation Board. We’d also like to thank Carol Nimlos for serving for six years on the EMMS Foundation Board. Carol volunteered with the Caring Hearts program each year and was active in the Alliance prior to the EMMS Foundation Board.

MetroDoctors Editorial Board Adds New member Dr. Gregory Plotnikoff, Institute for Health and Healing at Abbott Northwestern Hospital, has agreed to serve as a member of the MetroDoctors editorial board. He will join his colleagues, Peter Dehnel, M.D., Charles Terzian, M.D., Lee Beecher, M.D., Tom Dunkel, M.D. and Marvin Segal, M.D. as co-editors.

Thanks to Outgoing Board Members Twin Cities Medical Society The Twin Cities Medical Society Board of Directors wishes to thank the following physicians for their service on the Board of Directors. Peter Boosalis, M.D., Valley Anesthesiology Consultants; Clint Hawthorne, M.D., resident; Candy Simerson, MMGMA representative; Wade Swenson, 4th year medical student; Jessica Voight, 4th year medical student; and Marie Witte, M.D., Stillwater Medical Group.

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East Metro Council on Professionalism and Ethics The TCMS wishes to thank Bob Geist, M.D. for his chairmanship of the former East Metro Medical Society Council on Professionalism and Ethics over the past decade or so. His great work has led to the formation of the new TCMS Forum which will carry on much of the spirit that Dr. Geist has brought to the Council on Professionalism and Ethics.

Other TCMS News TCMS Forum The Twin Cities Medical Society Forum Steering Committee met recently to discuss the role that TCMS can play in providing educational opportunities for physicians on a variety of topics including accountable care organizations in Minnesota, the erosion of the independent medical practice in the metro, mental health parity, what to do with the GMAC population, and universal coverage. In 2011 and 2012 there will be a series of opportunities for our members to become engaged in these discussions.

The Journal of the Twin Cities Medical Society

Honoring Choices Minnesota We are continuing to raise funds for a three-year public engagement campaign to launch in 2011.

The project includes a partnership with the Citizens League and Twin Cities Public Television.

The funding for this effort will come from multiple sources including the health care community and community-based foundations. We feel very optimistic about receiving the funding that we are looking for to sustain this multi-year project. To learn more about Honoring Choices Minnesota visit our website www.metrodoctors.com.

Healthy Eating Minnesota The Healthy Eating Minnesota (HEM) project of the Twin Cities Medical Society has moved into the implementation phase with its first coalition meeting on November 18. This meeting signifies that the grassroots work of building community support for the passage of an obesity prevention resolution in Bloomington has begun. There was a high level of excitement around the table from the newly formed coalition, which will meet again in January 2011 to finalize a coalition name and future steps.

For more information about the Healthy Eating Minnesota work, please contact Project Coordinator Jennifer Anderson at (612) 3623752 or janderson@metrodoctors.com.

History Theatre Discount Tickets TCMS is pleased to offer its members, and your staff, the opportunity to purchase discount tickets to the History Theatre in downtown St. Paul.

Discounts are $5.00 off adult and senior single tickets and $7.00 off for groups of 12 or more.

This offer is good on the five plays being offered now through May 22, 2011.

Ticket information and a synopsis of the plays can be viewed here: http://www.metrodoctors.com/images/stories/History_Theatre_Proposal-TCMS_Members.pdf. See page 14 for more information.

January/February 2011

5

With Shoe on the Other Foot, Budget Still Looms Large

O

n January 4, 2011 two new realities arrive. The legislature has a new majority. The governor’s office has a new occupant. But with so much different, the end result might be more of the same. With a 6.2 billion dollar deficit hole to fill and another statewide election looming in two years, legislators and the governor’s office might be preparing for another long spring and possibly long summer. Heading into the 2011 legislative session, Republicans now find the shoe on the other foot, but this time they are charged with making the difficult decisions to balance a significant budget gap. Can the Republicans find an agreeable solution that relies entirely on cuts or will the governor’s promise of new revenue win out in the end? All of these decisions will play out in the discussions about the future of health care delivery in Minnesota and the overall state budget during the 2011 legislative session.

November Elections Change Balance of Power

Midterm elections often bring change, but no one could have predicted the change this past November’s election brought in Minnesota.

Not only did the state elect a DFL governor in Mark Dayton for the first time in over 20 years, but the state elected 60 new legislators to the Minnesota House and Senate, a sweeping change that brought new Republican majorities to both legislative bodies. The changing of the guard in the legislature is particularly eye opening in the Senate which hasn’t had a Republican majority for almost 40 years. The only thing clear after the November elections

By Nathaniel Mussell, J.D.

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January/February 2011

is that the legislature and governor will take vastly different approaches in attempting to balance the budget.

The new legislative majorities will have a steep learning curve with 60 new legislators and a Senate majority that has never held power. Republican’s chose new legislative leaders shortly after their November victories. In the House, Rep. Kurt Zellers (Maple Grove) was elected Speaker of the House while Rep. Matt Dean (Dellwood) was elected House Majority Leader.

Rep. Dean comes to his leadership post with a significant health care background having been the ranking member of the House Health and Human Services Budget Division. In the Senate, Sen. Michelle Fischbach (Paynesville) was elected President of the Senate. Senate Republicans also elected Sen. Amy Koch (Buffalo) to serve as the new Senate Majority Leader. Rep. Jim Abeler (Anoka) and Rep. Steve Gottwalt (St. Cloud) will chair the Health and Human Services Committees in the House while Sen. David Haan (Eden Prairie) will chair the Health and Human Services Committee in the Senate. Democrats also elected new minority leaders in Rep. Thissen (Richfield) in the House

and Sen. Bakk (Cook) in the Senate. The new leadership in both bodies are now charged with coming up with a myriad of fixes that address the budget deficit.

The governor will put forward his budget recommendations in early March. Although most of these recommendations are unlikely to pass the legislature, given the new Republican majorities, they will likely serve as the starting points for an ultimate budget compromise at the end of session. The one area of Governor Dayton’s budget that offers some predictability is the question of new revenue. Dayton made it clear during his gubernatorial campaign that he was intent on raising taxes on the wealthy to help balance the state’s budget shortfall. However, this proposal will garner little support even among DFL members. Many in the health care industry have expressed their desire to see new revenue in an increase in the price of tobacco.

Again though, an increase in the tobacco tax is likely a non starter for Governor Dayton given its regressive nature and likely doesn’t generate enough support among Republican legislators. It also appears, at least for the time being, that an increase in the provider tax has little support this legislative session. The more likely discussion is what the future holds for the provider tax.

Equally as important as the governor’s budget recommendations, is the shape that both the Department of Health and Department of Human Services take under Governor Dayton. Both departments will play a critical part next year in shaping the health care delivery system in Minnesota. There is considerable work to be done in implementing provisions of the Accountable Care Act in addition to the continued implementation of the state’s 2008 health reform legislation.

MetroDoctors

The Journal of the Twin Cities Medical Society

What to do About the Budget Deficit

Right out of the gates, the new governor, not the legislature will have the option to take a significant chunk out of the budget deficit with the decision to accept an expansion of the state’s Medical Assistance (Medicaid) program. Going back to the end of the 2010 legislative session, an expanded Medicaid program proved to be politically contentious as Republicans tried to distance themselves from “ObamaCare.”

Although the state paid for the expanded program as part of the 2010 budget agreement, only the new governor was given the ultimate decision to accept the 1.4 billion federal dollars to expand the Medical Assistance program. The governor’s decision to take the federal dollars for the expanded MA program not only has an impact on the state’s budget but comes as a welcome alternative to the coordinated care delivery system legislation that was passed during the 2010 session to provide health care coverage for this population.

The projected 6.2 billion dollar budget deficit will largely shape the health care discussion during the 2011 legislative session.

However, unlike in previous years where the legislature held large Democratic majorities, the new Republican legislature creates a number of uncertainties, particularly as to the potential cuts in the health and human services budget.

With the governor opting to expand the state’s Medical Assistance program, expect both House and Senate Republicans to focus on potential reforms or cuts to the MinnesotaCare program. In recent years, both House Republicans and former Governor Tim Pawlenty had proposed a reduction in eligibility under MinnesotaCare for single adults as a means to generate savings in the health care budget. This proposal could again return during the 2011 legislative session with legislators hamstrung by maintenance of efforts requirements in the Medical Assistance program and a growing deficit in the Health Care Access Fund. If Republicans in either body move in the direction of eligibility cuts or significant reforms in MinnesotaCare, the likelihood of a drawn out budget stalemate with the governor’s office becomes even more apparent.

Even with a change in the legislative majorities, physician reimbursement continues to remain on the table as a possible budget

MetroDoctors

solution. After being cut almost 15 percent over the past two legislative sessions, many physicians are beginning to question their continued participation in the state’s public health care programs. The recent reimbursement cuts at the state level coupled with the impending crisis in Medicare reimbursement at the federal level has left many out-state physician practices on the brink of closing their doors. A bevy of new freshman legislators in 2011 provides an ample opportunity for physicians and clinics around the state to turn the tide on reimbursement and educate legislators on the long-term effects of continuing down the current path.

What Other Health Care Issues will be on the Table?

Aside from the efforts to fix the budget deficit, there will likely be increased attention in the 2011 session on certain initiatives passed as part of the Accountable Care Act. Legislators continue to wait for federal guidance on two key initiatives, accountable care organizations and health insurance exchanges, both of which will have a direct impact on the future of Minnesota’s health care delivery system. Over the summer and fall months legislators met in working groups to begin addressing a number of proposed payment reform initiatives and the question of how and if the state will lay the groundwork for a health insurance exchange by 2014. How the legislature and administration choose to proceed in the next two years with accountable care organizations and other payment reform mechanisms in both the public and private health care marketplace stands to have a significant impact on the future of health care delivery in Minnesota.

The other areas that could see considerable reform during the 2011 legislative session are the no fault auto system and the workers compensation system. The property and casualty insurers will likely take advantage of a friendly legislative environment to launch an assault on the state’s no fault auto system to the no fault system by instituting a fee schedule.

Further cuts to both provider reimbursement and employee benefits could surface in the state’s workers compensation system. These are just two of a bevy of potential issues that physicians and clinics need to watch in the upcoming legislative session as legislators struggle to govern in a deficit year.

The Journal of the Twin Cities Medical Society

Ultimately, health care will continue to dominate the discussion at the Capitol throughout the 2011 legislative session. The only uncertainty this year from previous years will be how a new legislative majority and new governor address the difficult health care decisions that so often plagued those that came before them.

Nathaniel Mussell is an attorney and lobbyist with the Lockridge Grindal Nauen’s (LGN) government relations with a focus primarily on health care clients.

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2010 Charles Bolles Bolles-Rogers Award Recipients The Charles Bolles Bolles-Rogers Award, an engraved sterling silver Revere Bowl, is given to a physician who, in the opinion of the members of the selection committee, by reason of his/ her professional contribution on the basis of medical research, achievement or leadership, has become the outstanding physician in this and other years. The late Mr. Charles Bolles Bolles-Rogers established this award, originally called the St. Barnabas Bowl, in 1951. Two members of the west metro medical community, nominated by their medical staff colleagues, were selected to receive the 2010 award.

Joseph M. Cardamone, M.D. Joseph M. Cardamone, M.D. received his medical degree from the University of Pennsylvania School of Medicine; completed an internal medicine residency at the University of Pennsylvania; and a fellowship in hematology and oncology at the University of Utah and University of Minnesota. He earned a reputation early in his career as an excellent teacher and a unique person, and was recognized for his teaching activities and clinical research as associate professor at the University of Minnesota and director of the Division of Hematology at Hennepin County Medical Center. Dr. Cardamone became an integral part of the Eastern Cooperative Oncology Group as the practice of oncology spread throughout the metro area. In addition, he has served as medical director, cancer liaison and past vice

Dennis O'Hare, M.D., vice president for medical affairs (L) and Joseph Goswitz, M.D., chief of staff, Mercy Hospital, pose with Joseph Cardamone, M.D., Charles Bolles Bolles-Rogers Award winner.

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January/February 2011

president for medical affairs at Mercy Hospital.

He initiated community awareness and support groups for people with cancer offering a truly unique perspective in dealing with this difficult diagnosis and remains a phenomenal resource to fellow physicians, patients and cancer support groups throughout the metro area.

Dr. Cardamone has provided leadership to the Minnesota Society of Clinical Oncology, serving as its vice president and president.

He values physician’s abilities to “change the system” within hospital walls, complex systems (like Allina) and relating to clinical competence.

Joseph Cardamone, M.D. is looked to as a role model and teacher. His clinical competence, state of the art knowledge and maturity as well as his emotional and spiritual gifts make him an ideal recipient of the Charles Bolles BollesRogers Award.

The award was presented to Dr. Cardamone at the Mercy and Unity Hospitals Physician Recognition Dinner and Awards Ceremony on November 13, 2010.

Richard A. Carlson, M.D. Richard A. Carlson, M.D. graduated from the University of Minnesota Medical School receiving his medical degree in 1972. He completed an internship and residency in radiology at Mayo Clinic, Rochester, MN. Dr. Carlson has already served a lifetime of an incredible career — an excellent, conscientious physician who specializes in breast imaging. He has worked tirelessly throughout his career creating an optimized

Richard Carlson, M.D. (L) receives the Charles Bolles Bolles-Rogers Award from Richard Simmons, M.D., Chair, West Metro Medical Foundation.

system of breast imaging in the Twin Cities.

He is recognized locally, nationally, and internationally for his excellence in the “triangle of care” providing: 1) education and teaching; 2) research and leadership; and 3) treatment of breast disease. His work changed the landscape for breast imaging.

Dr. Carlson is active at the local, state and national levels within radiology organizations to further the breast imaging needs of Minnesotans and has served in leadership roles at the Minnesota Radiologic Society. He is a fellow of the American College of Radiology.

Dr. Carlson’s service efforts extend beyond medicine into the community providing philanthropic and volunteer leadership to the Minnesota Medical Foundation, Mount Olivet Lutheran Church, Gustavus Adolphus College, the American Swedish Institute and throughout the community.

Richard Carlson, M.D. is a very gentle physician; truly a humble personality. He is a patient favorite and is passionate for helping others. The award was presented to Dr. Carlson at a meeting of the Fairview Southdale Medical Staff held on November 30, 2010.

MetroDoctors

The Journal of the Twin Cities Medical Society

COLLEAGUE INTERVIEW

A Conversation With

Edward Ratner, M.D.

E

dward Ratner, M.D. has many roles in our health care community, including being an educator and researcher at the University of Minnesota, a primary care geriatrician, and a medical director for home health agencies. He is a graduate of Carleton College and the University of Chicago Pritzker School of Medicine. Trained in internal medicine, he completed a fellowship in geriatrics at the University of Minnesota. He is a past president and current board member of the Minnesota Medical Directors Association and the American Academy of Home Care Physicians. He also serves on the Minnesota Leadership Council on Aging and the Minnesota Medical Association Ethics Committee.

What circumstances stimulated your interest in geriatrics and end-of-life care?

When I was first exposed to geriatrics as a medical resident, the field in the United States was in its infancy. A former chief resident who was one of the first fellowship-trained U.S. geriatricians visited our program.

I organized an elective rotation with him the summer of my third year of residency, in part to learn more about this field and in part to avoid breaking in the new interns. I quickly found I loved the strong connections possible between geriatricians and their patients, the highly varied nature of the work, and the intellectual challenges associated with patients who have multiple, complex medical and psychosocial challenges.

Although end of life is an important subject in general geriatrics, my focus in this area began after my wife and I experienced hospice care for our daughter, Ilana. My role as medical director for Allina’s home care agency at that time enabled me to build a team to promote advance care planning (ACP) and grief support. I then led a state-wide initiative to improve end-of-life care. When I joined the University of Minnesota faculty, I continued my efforts to study how best to promote and organize ACP programs.

Please describe your research in end-of-life care.

In the 1990s, while at Allina, we developed and formally evaluated a process of ACP for seriously ill home health patients. Follow-up a year later found that half of the targeted patients had died, almost all of them in their preferred setting, at home. For the past eight years at the MetroDoctors

The Journal of the Twin Cities Medical Society

University of Minnesota, I have been fortunate to work with several colleagues in the Center for Bioethics on end-of-life issues among the homeless. Results of focus groups and surveys suggested that ACP was both needed and desired in this population. Our team, including Drs. John Song and Dianne Bartels has just completed a three year, NIHfunded randomized trial that offered ACP and health care directives to over 300 homeless individuals. The purpose was to establish the best way to deliver this service to a vulnerable population and to assess its impact on the homeless and their health care. We have published our primary findings. When offered 1:1 assistance with ACP, 38 percent would complete a valid health care directive. (Song et al, Annals of Int. Med, 153(2): 76-84, 2010). Additional publications related to factors that influenced willingness to do ACP, role of family among homeless who complete ACP, and failure to use available health care directives in an emergency room are forthcoming.

Homeless people are typically much younger than the elderly you serve in practice. Aren’t they too young to bother with end-of-life issues?

Although the typical age of the chronically homeless is 30s-40s, the median age of death in this group is below 50 years old. Many deaths among the homeless are unexpected, due to trauma, violence, overdose of drugs, or exposure to elements. We found that a majority of individuals who are homeless worry about end-of-life issues at least monthly.

(Continued on page 10)

January/February 2011

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Colleague Interview (Continued from page 9)

What is POLST? Why should doctors know about POLST?

For individuals who are homeless, who may communicate with family infrequently and lack a primary care physician, ACP offers a way to inform others of preferences for care in event of serious illness. It can also be used to describe often strongly stated preferences for care after death, such as rituals desired or location of burial.

For the general population, what is the optimal time for health care providers to start the conversation with the patient and/or his/her family about ACP? All adults should have a health care directive, if only to name a surrogate decision-maker. For example, without a health care directive, a parent of a student in college who is seriously injured technically does not have the legal right to even be informed of medical information, let alone make health care decisions. Thus, discussions about preferences for end-of-life care, such as which life sustaining measures would be desired in event of a reversible or irreversible loss of function or cognition, are appropriate between patients and their surrogate decision maker even among the young and healthy. Medical providers should become involved in this process when age or illness makes a life-threatening situation more than a remote possibility. For example, the Twin Cities Medical Society program to promote ACP, Honoring Choices, includes pilots focussing on those with chronic illnesses and those over retirement age.

A health care directive, also known as a living will, is a legal document that communicates preferences from a patient to health care providers and/or surrogate decision makers. There is a recognized need for those preferences to be documented in medical records. One approach is to put the health care directive into the chart, but the physician must still communicate the plan of care, consistent with stated preferences, to other clinicians. The Provider Order for Life Sustaining Treatment (POLST) addresses this need.

A Minnesota POLST form, adopted statewide in 2009, organizes the key preferences onto one page, including desire (or lack thereof) for CPR, hospitalization, intubation, antibiotics and medical nutrition and hydration. Many metro health care organizations, such as the large health systems and nursing homes, are implementing the POLST for their seriously ill patients, as a POLST is most appropriate when life expectancy is less than one-two years. Like the process for ACP, a patient or family may be assisted in discussions of issues on a POLST by a nurse, social worker, or chaplain. The POLST would be completed by that health professional and sent to a physician for signature. In addition, nurse practitioners or physician assistants are considered authorized to sign a POLST. I have been privileged to chair the Minnesota POLST Task Force since its inception several years ago. More information about POLST can be found at http://www.polstmn.org.

What are the main barriers to and issues about matching patient, family, and physician expectations?

Minnesota Epilepsy Group is the largest and most comprehensive epilepsy program in the Midwest. As a regional referral facility, we are the recognized leader in treating epilepsy and other seizure-related conditions in patients of all ages, from infants to the elderly. We also offer comprehensive neuropsychological assessment for a broad range of acquired or developmental neurological conditions in both adult and pediatric patients.

Adult Epileptologists Deanna L. Dickens, MD Julie Hanna, MD Patricia E. Penovich, MD James R. White, MD (Now seeing patients in Hudson, WI) Pediatric Epileptologists Jason S. Doescher, MD Michael D. Frost, MD Frank J. Ritter, MD

Appointments (651) 241-5290 225 Smith Avenue N St. Paul, MN 55102 www.mnepilepsy.org

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January/February 2011

Functional Neuro-Imaging Wenbo Zhang, MD, PhD Neuropsychologists Elizabeth Adams, PhD Robert Doss, PsyD Ann Hempel, PhD Donna Minter, PhD Gail Risse, PhD

There are many barriers to achieving concordance between patient, family and physician expectations about care, especially near the end of life. The ďŹ rst is recognizing when end of life may be near. Physicians are known to often greatly overestimate life-expectancy, thereby denying patients and families the opportunity to prepare. Second, physicians are trained and have incentives (e.g. ďŹ nancial, pride, and quality comparisons) to focus on prolonging survival of patients. For those at very advanced age or those with severely disabling illness, patients and families may prefer a focus on enjoying remaining life or simply being comfortable.

Geriatrics and palliative medicine are recognized subspecialties, but all physicians need the capacity to address patient goals other than living as long as possible. A third often unmet expectation of patients and families relates to teamwork. The elderly and dying almost always require a team of multiple physicians, nurses, therapists, social workers, etc. Outside of highly organized teams, such as found in some transitional care units of nursing homes or hospice, communication about and coordination of care MetroDoctors

The Journal of the Twin Cities Medical Society

between providers rarely meets expectations. Patients and families resent re-explaining histories. Serious errors in medication orders or delays in implementing care plans too frequently occur, especially at transitions between hospital and other settings.

How have you integrated these principles of care into your practice of medicine?

more time be devoted to geriatrics and palliative care than the modest amount currently required in courses for pre-clinical (Years 1-2) medical students. One approach I have taken is to offer a non-clinical elective in geriatrics service learning for students in Years 3 or 4. Three of the students enrolled in this year-long, 80-hour course have opted to live in a senior high rise to simultaneously learn from and serve the elderly. In addition, a few students each year take a clinical elective in hospice and palliative medicine. For residents interested in these fields, the University and Fairview offer a fellowship in Hospice and Palliative Medicine. A geriatrics fellowship is offered only by Hennepin County Medical Center, as the University has discontinued its geriatrics program.

Although I have practiced in all typical settings of care, including hospital, nursing home, and clinic, I have gravitated toward practicing home-based care as the setting most suitable for having discussions about end-oflife care and honoring preferences. Surveys have found that over 80 percent of patients want to be at home at the end of life, yet less than ¼ of Suburban Radiologic Consultants, Ltd. congratulates Minnesotans die at home. I currently maintain a small practice of elderly patients, most who rarely, if ever, leave home. Working collaboratively with home care or hospice staff and health plan or county case managers, we organize comon the honor of being named recipient of the prehensive plans of care consistent with patient and family choices. For many, family members 2010 Charles Bolles Bolles-Rogers Award prefer to provide the bulk of day-to-day care. In & this model, we are even able to manage patients 2010 Fairview Southdale Hospital requiring a ventilator or those with moderate to Physician of the Year Award severe dementia and no family in their homes.

Avoiding transitions avoids the complications of changing settings and providers.

Richard A. Carlson, M.D., FACR

What role will/can medical home visits play in future care models?

Dr. Carlson has dedicated his professional career to advancing breast imaging in his professional practice, for our hospital system and for our community. His professional life goal is to reduce mortality from breast cancer and enhance the quality of breast care in the population whom we serve.

As the numbers of elderly and severely mobility impaired grow, we need new models of health care delivery. Home medicine is a model that has shown great promise. The Veterans Administration has expanded its Home Based Primary Care to almost all of its hospitals, based on evidence of increased patient satisfaction and lower overall cost. The recent federal health care reform legislation included a national demonstration project, called Independence at Home (IAH), to formally test this model in populations enrolled in the Medicare fee-for-service program. Starting in 2012, IAH programs will share savings achieved with Medicare, allowing innovation impossible under traditional Medicare reimbursement models. For more information on IAH, see www. iahnow.com.

Dr. Carlson is a dedicated leader in radiology and mammography standards on state and national levels.

He is also a committed volunteer for the University of Minnesota Medical School.

How is the University of Minnesota Medical School teaching principles of geriatrics and palliative care to our future doctors?

{ Career Highlights } Partner, Suburban Radiologic Consultants, Ltd. Founding Medical Director, Fairview Southdale Breast Center Chair of Radiology, Fairview Southdale Hospital Founding Chair of Radiology, Fairview Ridges Hospital Clinical Assistant Professor of Radiology, University of Minnesota Medical School President, Minnesota Radiological Society Mammography Accreditation Committee, American College of Radiology Councilor from Minnesota, American College of Radiology President, University of Minnesota Medical School Alumni Society Dean’s Board of Visitors, University of Minnesota Medical School Board of Trustees, Minnesota Medical Foundation Barbara Forster Volunteer Leadership Award, Minnesota Medical Foundation President’s Gold Medal (Glenn Hartmann Award), Minnesota Radiological Society

[ www.subrad.com ]

The growth in the aging population suggests that MetroDoctors

The Journal of the Twin Cities Medical Society

January/February 2011

11

Palliative & Hospice Care

Advance Care Planning A Legal Perspective Over the past 60 years, life expectancy of the average American has surged from 68 to 78 years.

However, as life expectancy has increased, so too have the multiple complications associated with chronic illnesses. Due to this phenomenon it is vitally important for advance care planning to become part of every patient’s health care experience.

Advance care planning is about having conversations between patients and their health care agents and loved ones about their desires and values related to health care. One result of advance care planning is the completion of a health care directive.

A health care directive has two primary functions: 1. Appointment of a health care agent with authority to act on the patient’s behalf when the patient is unable to do so; and 2. Provide health care instructions to both the health care agent and the patient’s health care providers on a full range of health care issues.

A Minnesota health care directive does not have to utilize any particular form. To be valid, it must only meet the following six minimum requirements: 1. in writing; 2. dated; 3. state the principal’s name; 4. be executed by a principal with capacity to do so; 5. verified by a notary or two witnesses; and 6. include either health care instructions or a health care power of attorney1.

History Minnesota first passed a living will statute in 1989,2 considerably later than many other

By Kristine E. Mullmann, J.D.

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January/February 2011

states. A living will in Minnesota did not permit the appointment of a health care agent, required the use of a prescribed form that many found daunting, and was limited to providing instructions for a terminal illness.

In 1993, without repealing the living will statute, a durable power of attorney statute was passed, permitting patients to designate an agent for decision making, but only provided for health care instructions when the patient was terminally ill.

In 1998 Minnesota law underwent a fundamental change. The living will statute was made inoperative for any documents executed after August 1, 1998. The durable power of attorney statute was replaced with the health care directive statute with broad scope. All aspects of advance care planning could be addressed in one health care directive, which had no legally prescribed form. These changes created the health care directive that we continue to use today.

Health Care Agent Through the health care power of attorney provisions, individuals may name a health care agent to act on their behalf when unable to make or communicate decisions.3 This is viewed by most health care providers as the most important aspect of the health care

directive because it designates a substitute decision maker with whom physicians can discuss care options and from whom they can receive authorization for care delivery. When making decisions a health care agent has a duty to act in good faith, but this obligation does not constitute a legal duty to act.4 A health care agent acting pursuant to a health care directive has the same right as the principal to receive, review, and obtain copies of medical records of the principal, and to consent to the disclosure of medical records of the principal.5 Even though the legislature gave this power to the health care agent, it is often recommended that specific language authorizing the agent to obtain medical records be used to overcome the misapplied barriers of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Health Care Instructions The health care directive also provides an opportunity to state specific health care instructions.6 Unlike the living will, health care instructions can address any health care issue, not just those that arise when the patient is in a terminal condition. Patients are free to address their “values, preferences, guidelines, and directions regarding health care”7 now or in the future.

Capacity A health care directive can be executed or revoked by anyone “with the capacity to do so.”8 The drafters of the statute gave considerable thought to this definition after studying many other definitions of capacity, and concluded that this definition provided for the maximum exercise of decision making autonomy while providing sufficient safeguards against inappropriate actions.9 The principal is presumed

MetroDoctors

The Journal of the Twin Cities Medical Society

to have the capacity to execute a health care directive and to revoke a health care directive, absent clear and convincing evidence to the contrary.10 A health care directive becomes effective when a principal lacks “decision-making capacityâ€? to make a health care decision.11 Decisionmaking capacity is deďŹ ned as the “ability to understand the signiďŹ cant beneďŹ ts, risks, and alternatives to proposed health care and to make and communicate a health care decision.â€?12 A health care directive is not effective for any decision for which the principal, in the determination of the attending physician of the principal, has decision-making capacity.

Optional Provisions Other advance planning designations can also be included in a health care directive. For example, the health care agent is automatically nominated as the guardian of the person.13 A health care directive can also include: s ! DECLARATION REGARDING INTRUSIVE MENtal health treatment or a statement that the agent is authorized to give consent to voluntary treatment or admissions to a treatment facility;14 s !NATOMICAL GIFT 15 and s &UNERAL AND BURIAL INSTRUCTIONS 16 Presumptions The health care directive statutes include certain presumptions to make execution and implementation of the health care directive document easier. Absent a showing of clear and convincing evidence to the contrary, a health care directive is presumed to be properly executed and remain in effect until the principal modiďŹ es or revokes it.17 A copy of a health care directive is presumed to be a true and accurate copy of the executed original and must be given the same effect as an original.18 A health care provider acting pursuant to the direction of a health care agent is presumed to be acting in good faith.19 There is also a presumption that addresses the rare situation in which health care decisions need to be made for pregnant women unable to express their own wishes. The presumption is that an incapacitated pregnant woman would have authorized health care to sustain her life, and the life of the fetus, if reasonable medical judgment indicates a real possibility of her fetus surviving to the point of live birth.20 MetroDoctors

Immunities A health care provider is not subject to criminal prosecution, civil liability, or professional disciplinary action if the health care provider relies on a health care decision made by the health care agent and the following requirements are satisďŹ ed: 1. The health care provider believes in good faith that the decision was made by a health care agent appointed to make the decision and has no actual knowledge that the health care directive has been revoked; and 2. The health care provider believes in good faith that the health care agent is acting in good faith.21 A health care provider who administers health care necessary to keep the principal alive, despite a health care decision of the health care agent to withhold or withdraw that treatment, is not subject to criminal prosecution, civil liability, or professional disciplinary action if that health care provider promptly took all reasonable steps to: 1. Notify the health care agent of the health care provider’s unwillingness to comply; 2. Document the notiďŹ cation in the principal’s medical record; and 3. Permit the health care agent to arrange to transfer care of the principal to another health care provider willing to comply with the decision of the health care agent.22 National Healthcare Decisions Day For the past four years, April 16th has ofďŹ cially been designated as National Healthcare Decisions Day (NHDD)23 by Congress. On April 16th of every year, hundreds of NHDD events are held around the country. The NHDD Initiative is a collaborative effort of national, state and community organizations committed to ensuring that all adults with decision-making capacity have the information and opportunity to communicate and document their health care decisions. Attendees of Minnesota NHDD24 events will have their next opportunity to learn about and complete a Minnesota Health Care Directive on April 16, 2011.

In 2010 approximately 3,000 people attended 41 events held around the State of

The Journal of the Twin Cities Medical Society

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To schedule a consultation, please contact Eric Garten, HealthStyle Services Consultant, at 612-362-0353 or email at eric.garten@ameripride.com

(Continued on page 14)

January/February 2011

13

Palliative & Hospice Care Advance Care Planning (Continued from page 13)

Minnesota and over 1,500 health care directives were signed. Publicity for NHDD was circulated to over 100,000 people in Minnesota. These events were sponsored by hospitals, hospices, law ďŹ rms, senior centers, churches, community centers, insurers, and law schools.

Professionals in the legal, medical and social work ďŹ elds all donated their time to the initiative as volunteers. Governor Tim Pawlenty, Minneapolis Mayor R.T. Ryback, and St. Paul Mayor Christopher B. Coleman all declared April 16, 2010 to be National Healthcare Decisions Day. Honoring Choices Minnesota Honoring Choices Minnesota is a collaborative, community-wide public health initiative led by the Twin Cities Medical Society.25 The goal of Honoring Choices Minnesota (HCM) is to promote discussions about end of life choices and to assist health care organizations with the installation of a comprehensive advance care planning program. Honoring Choices Minnesota has been widely accepted throughout

the health care community and recently has discovered an exciting opportunity to engage the broader Minnesota community through a unique partnership with Twin Cities Public Television (TPT) and the Citizens League.26 Conclusion Advance care planning can be addressed every day with every patient in the manner appropriate for that patient. The execution of a health care directive can provide a signiďŹ cant amount of comfort and certainty for all concerned — patients, providers and family.

Please join the National Healthcare Decisions Day initiative on April 16, 2011 or work with Honoring Choices Minnesota to help patients have the important discussions about advance care planning and encourage them to memorialize their instructions and designate an agent in a Minnesota health care directive.

Kristine E. Mullmann, J.D. has been practicing in the areas of estate planning and elder law since graduating from William Mitchell College of Law. She was elected to the Elder Law Governing Council of the Minnesota State Bar Association in 2008, served as Secretary of the Council in

2009 and is the current Chair of the Pro Bono Committee. Since 2009 Kristine has served as Chair of National Healthcare Decisions Day– Minnesota, working to ensure that all adults with decision-making capacity have the information and opportunity to communicate and document their health care decisions.

Footnotes 1 Minn. Stat. §145C.03 2 Laws of Minnesota 1989 CHAPTER 3-S.F.No. 28 3 Minn. Stat. §145C.02 4 Minn. Stat. §145C.07 Subd. 3 5 Minn. Stat. §145C.08 6 Minn. Stat. §145C.02 7 Minn. Stat. $145C.01, subd. 7a 8 Minn. Stat. §145C.02 9 Interview with Barbara J. Blumer, Barb Blumer Law, P.A, November 5, 2011 10 Minn. Stat. §145C.10 11 Minn. Stat. §145C.06(2) 12 Minn. Stat. §145C.10 Subd. 1b 13 Minn. Stat. §145C.07 Subd. 2 14 Minn. Stat. §145C.05 Subd. 2(6) 15 Minn. Stat. §145C.05 Subd. 2(5) 16 Minn. Stat. §145C.05 Subd. 2(7) 17 Minn. Stat. §145C.10 18 Id. 19 Id. 20 Id. 21 Minn. Stat. §145C.11 Subd. 2(b) 22 Minn. Stat. §145C.11 Subd. 2(c) 23 www.nhdd.org 24 www.mnhealthcaredecisions.info 25 www.metrodoctors.com 26 Id.

History Theatre Discount Tickets

Education t Experience Excellence ...with a smile! t 0QFOJOHT JO 2 UP 8FFLT t 4BNF %BZ 6SHFOU 3FGFSSBMT

The Twin Cities Medical Society is pleased to offer its members, and your staff, the opportunity to purchase discount tickets to the History Theatre in downtown St. Paul.

Discounts are $5.00 off adult and senior single tickets and $7.00 off for groups of 12 or more. This offer is good on plays offered now through May 22, 2011.

When ordering tickets, all you need to say is that you are a part of the Twin Cities Medical Society.

Adrift on the Mississippi— February 10–27, 2011 A Tale of Twin Cities— March 12–April 3, 2011 American as Curry Pie— March 17–April 10, 2011 Buddy-The Buddy Holly Story— April 30–May 22, 2011

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Healthy Skin, it’s a Beautiful Thing!

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January/February 2011

Ticket information and a synopsis of the plays can be accessed through the TCMS website at www.metrodoctors.com.

MetroDoctors

The Journal of the Twin Cities Medical Society

It’s About the Conversation...

D

eath panels. Those two words received a lot of attention over the past year.

The death panel rhetoric started gaining steam after a few high profile people, including former Alaska Governor Sarah Palin commented on the national health care reform bill known as the Patient Protection and Affordable Care Act. In August 2009, Palin posted on her Facebook page the following: “…who will suffer the most when they ration care? The sick, the elderly, and the disabled, of course. The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s ‘death panel’ so his bureaucrats can decide, based on a subjective judgment of their ‘level of productivity in society,’ whether they are worthy of health care. Such a system is downright evil.” Palin’s comments were in reference to Section 1233 of the proposed legislation, labeled Advance Care Planning Consultation, which would have allowed Medicare to reimburse physician consultations with patients about end-of-life planning including discussions about a living will or health care directive.

As proposed, this provision would have allowed Medicare to reimburse physicians once every five years to provide this service.

When the discussion about death panels hit the airwaves initially there was some trepidation from some of us who were working closely with the Honoring Choices Minnesota project. We had no idea where this discussion would lead and how it might impact Honoring Choices Minnesota. We soon realized, however, that the dialogue about end-of-life issues was increasing across the country which resulted in higher level discussion and understanding of the importance of advance care planning.

By Sue Schettle

MetroDoctors

The chart below shows clearly the results of Respecting Choices integration in La Crosse compared to national information.

What this data helps to highlight is how the Respecting Choices program has moved the needle on how patient’s preferences are documented and addressed when it comes to end-of-life care.

Honoring Choices Minnesota

In fact, the foundation of Honoring Choices Minnesota’s work — Respecting Choices based in La Crosse, WI — was touted by the national news media and others as groundbreaking work with proven results.

Respecting Choices

The Respecting Choices program started in the late 1990s under the leadership of Dr. Bud Hammes who was serving as an ethicist at the Gundersen Lutheran Health System.

Dr. Hammes was often called in to consult on dialysis patients and their families confronted with making decisions relating to life-threatening issues for their loved ones. It occurred to him after doing a couple of these consults that the discussion about what kind of care the patient would have wanted at the end of life should have occurred much earlier in the process. So he, along with others, began this journey to develop an integrated system strategy to address end-of-life care that includes training staff to help facilitate discussions. They partnered with Franciscan Skemp Healthcare to develop a community standard that involved training and education, community outreach and quality improvement. Their program has grown nationally and internationally.

The Journal of the Twin Cities Medical Society

The mission of Honoring Choices Minnesota is to promote the benefits and implement processes and methods of advance care planning to the community at large. One of the ways that we are accomplishing this is by utilizing the approach and proven methodology of the Respecting Choices program. Their program offers experience, training and education. They have assisted us in creating the firm structure from which to build the Honoring Choices Minnesota program. Using Respecting Choices (Continued on page 16)

La Crosse Nationally 100 90 80 70 60 50 40 30 20 10 0 Patients had advance directive

Document found in chart

Care consistent with directive

National information: Research in Action, AHRQ, Issue #12, March 2003 La Crosse Information: Hammes BJ, Rooney B. “Death and End-of-Life Planning in One Midwestern Community.” Archives of Internal Medicine. 1998; 158-383-390.

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Palliative & Hospice Care Honoring Choices Minnesota (Continued from page 15)

as the foundation we have constructed the program to include Minnesota governance, Minnesota-specific forms and quality measurements, and are developing patient education materials. We are also about to embark on a three-year community engagement campaign with some key partners.

Honoring Choices Minnesota Model

Community Engagement Quality Measurement and Form Development

Local Governance Respecting Choices Methodology and Training Programs

Methodology and Training

We utilize Respecting Choices’ proven training programs and supplemental educational materials to train individuals as Facilitators and Instructors. Facilitators are those individuals who would have the direct contact with patients and their families, such as nurses, physicians, clergy, hospice workers, social workers and community volunteers. Facilitators are required to take an online six-module training course in addition to attending a one day in-person course. Once the training day is completed, Facilitators receive a certification and supplemental materials for their use. Instructors complete this training as well as a higher level course and are able to train others as Facilitators once they have been certified. Instructors must conduct a minimum of one training session per year in order to maintain their Instructor certification status.

To date Honoring Choices Minnesota has trained 10 Instructors and nearly 75 Facilitators. Some of the Instructors have actually taught a Facilitator training course recently which was what our goal was as we began this initiative — building a sustainable community-based platform for educating the broader community.

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Local Governance

Honoring Choices Minnesota has a locallybased advisory committee directing much of the work of the initiative. The advisory committee is comprised of representatives from organizations such as the Minnesota Network of Hospice and Palliative Care, Institute of Clinical Systems Improvement (ICSI), Stratis, and nearly all of the health care institutions including metro area hospitals and local health plans. The work of the advisory committee reports to the Twin Cities Medical Society through its Foundation. th The advisory committee assists in the rrecruitment of pilot sites and has recruited hhospitals, clinics and long-term care facilities aand nursing homes.

Q Quality Measures and Form Development a

T advisory committee has developed two The qquality measurements for those organizations th that are piloting the Honoring Choices Minnnesota program within their institutions. These qquality measures were developed so that all pilot ssites would be able to collect similar data. The tw two measurements are: 1. Percentage of patients who had an advance care directive at the time of death.

2. Percentage of time the advance care directive document was found in the chart.

Each pilot site has been encouraged to add more quality measures to their work.

The advisory committee has also developed a health care directive document that is used by all pilot sites and others. It is free and available on our website at www.metrodoctors. com. A subset of the advisory committee is also working on developing patient education materials that health care and community organizations can purchase at or near cost from Honoring Choices Minnesota. We were pleased that many of the health care organizations in the metro area have indicated a willingness to collaborate on the development of the patient education materials and to potentially use them within their organizations. This would be a win-win for all involved as the cost savings could be substantial.

Interestingly, all of the hospital systems in the metro area have agreed to pilot the program in one form or another within their institutions.

By agreeing to pilot organizations have:

s s s s

COMMITMENT FROM SENIOR LEADERSHIP DEDICATED STAFF TO SERVE AS THE 0ILOT 4EAM AGREED TO EDUCATE &ACILITATORS CREATED A PROCESS mOW DIAGRAM OF HOW THE pilot will function s AGREED ON COLLECTING AT LEAST TWO QUALITY measures The first pilot sites wrapped up in July 2010. The second round of pilot sites will begin in January 2011 and work through July 2011.

Community Engagement

The health care community has been very welcoming of a community collaborative such as Honoring Choices Minnesota. It has truly been remarkable how so many otherwise competing organizations have come together to work in such a collaborative manner.

Our next phase is community engagement. Fundraising is currently underway to support a three-year project which includes a comprehensive community engagement strategy with key partners including Twin Cities Public Television and the Citizens League.

It’s About the Conversation…

At its core, Honoring Choices Minnesota is about having the conversation resulting in comfort that comes from knowing the values, wishes and beliefs of the patient. It’s about allowing families the opportunity to discuss what they would want to have happen to them if they could not speak for themselves.

Sue Schettle, project director, Honoring Choices Minnesota, chief executive officer, Twin Cities Medical Society.

Sources: Statement on the Current Health Care Debate; by Sarah Palin on Friday, August 7, 2009 at 3:53 p.m.—Facebook page. Retrieved November 3, 2010 from http://www. facebook.com/note.php?note_id=113851103434.

Search for Twin Cities Medical Society on Facebook

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The Journal of the Twin Cities Medical Society

Delivering Palliative Care Elements Across the Care Continuum

A

pproximately 90 million people in the U.S. have at least one chronic illness, and seven out of 10 die from chronic disease. Palliative care has emerged as a specialty to address pain and symptom management, care coordination, and patient-family communication for these patients with life-limiting or debilitating diseases.

The Institute for Clinical Systems Improvement (ICSI) launched a strategic initiative on palliative care in the fall of 2009 that focuses on developing a model to integrate the elements of palliative care into routine care delivery starting at the diagnosis of a patient’s life-limiting or debilitating illness.

The foundation for the initiative is ICSI’s palliative care guideline, which outlines key considerations for creating a “plan of care” to meet patient, family and other caregivers’ needs and preferences throughout the patient’s care continuum. These considerations include: s 0LANNING SHOULD BEGIN EARLY IN THE PAtient’s journey through a progressive, debilitating illness. s 0RIMARY AND NON PALLIATIVE SPECIALTY CARE providers, in partnership with their patients, should begin palliative care planning early. When the patient’s needs can no longer be managed by their primary care provider alone, the patient should be referred to palliative care specialty. s (EALTH CARE PROVIDERS SHOULD INITIATE COLlaborative conversations with their patients and document the patients’ goals for care and advance directives. s 2ECOGNITION ASSESSMENT AND MANAGEMENT of comfort and non-physical issues depend on the quality of communication between the provider and the patient and family. Setting realistic goals of care to live

By Cally Vinz, RN

MetroDoctors

Actions to Date

effectively with a life-limiting disease is essential. s )N THE DELIVERY OF PALLIATIVE CARE AGGRESSIVE

life-prolonging interventions may be used, along with an ongoing focus on symptom management. s 5NLIKE HOSPICE PALLIATIVE CARE IS NOT limited by life expectancy. Elements of palliative care should be initiated at the diagnosis of a life-limiting condition (such as COPD, CHF, cancer, and kidney disease) and be continued through the end of life. This care can be provided for many years.

The model intends to outline processes to identify patients who will benefit from receiving elements of palliative care, when such elements can be introduced along the care continuum, and how to reliably integrate and sustain these functions within primary and specialty care (referring to palliative care specialty when the patient care needs indicate).

A key goal is to create a partnership between patients, families and care providers to address the patient’s physical, psychological, social, spiritual and existential needs.

The Journal of the Twin Cities Medical Society

With evidence pointing to the benefits of introducing elements of palliative care earlier in the care continuum, ICSI formed a steering committee comprised of providers, health plans, hospice and home care representatives, Minnesota Department of Health, an Honoring Choices Minnesota representative, and patients.

The steering committee cataloged the palliative care programs and projects underway in Minnesota and the Upper Midwest. A survey of ICSI members indicated that the biggest obstacles to offering palliative care programs are cost (such as reimbursement), staffing and program design. This information was used to explore potential barriers for delivery of palliative care in primary and non-palliative specialty care.

The steering committee mapped the current “typical” path through the health care system for the patient with a life-limiting or debilitating illness. This was done from the patient’s perspective to identify deficiencies in current care delivery systems. The exercise revealed how uncoordinated care is for patients and their families, and how it results in a high sense of hopelessness, disappointment, fear and panic for them. The steering committee created an “ideal” care delivery flow that provided a coordinated care experience meant to provide patient’s families with a sense of control, and allow for more open communication and shared decision-making with the provider.

ICSI is currently working to advance this initiative toward implementation. Four subcommittees are working to: s $ESIGN A CARE DELIVERY MODEL TO INCORPOrate elements of palliative care across the care continuum.

(Continued on page 18)

January/February 2011

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Palliative & Hospice Care

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Delivering Palliative Care Elements (Continued from page 17)

s

%XPLORE lNANCIAL SUSTAINABILITY OF DELIVering such elements across the care continuum by examining multiple payment models (i.e., accountable care organizations, health care home, bundles of care, fee-for-service and government payers). s 2AISE AWARENESS AMONG PROVIDER GROUPS and the general populace in Minnesota of the value of introducing palliative care as a usual component of primary and specialty care for patients with life-limiting illnesses. s )DENTIFY PRACTICE DATA THAT DEMONSTRATES quality, patient-family experience and affordability (Triple Aim) used to make decisions that improve effectiveness of the delivery of palliative care elements in primary and non-palliative specialty care.

The steering committee completed a parametric analysis to deďŹ ne essential elements of palliative care. This was a critical step so providers could understand what was required if they adopt the ICSI-created model.

The group also identiďŹ ed gaps in care and barriers to delivering palliative care elements as

â&#x2122;Ś Insurance/Patient Billing and Collection â&#x2122;Ś Accounts Receivable Management â&#x2122;Ś Accounts Payable/General Ledger â&#x2122;Ś Payroll/Fringe Benefit Management â&#x2122;Ś Experienced in over 30 Medical Specialties â&#x2122;Ś Qualified and Experienced Staff â&#x2122;Ś Owned and Managed by Experienced Healthcare Practice Management Professionals +HDOWKFDUH %LOOLQJ 5HVRXUFHV ,QF +LJKZD\ 6XLWH (DJDQ 01

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January/February 2011

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usual care. The care model design subcommittee is developing pilots with provider groups to see how to overcome these barriers. Pilots may include: system supports to have collaborative conversations, do shared decision-making and complete advanced care planning; system design to identify patients and coordinate palliative care elements within usual care work ďŹ&#x201A;ows; how to collect data to measure the success of earlier delivery of palliative care elements, and how best to network with community services in care delivery.

Grant from RWJF

ICSIâ&#x20AC;&#x2122;s palliative care work will delve deeply into shared decision-making (SDM) between the care provider and the patient-family through a three-year grant from the Robert Wood Johnson Foundation. The grantâ&#x20AC;&#x2122;s focus is to use SDM to arrive at care choices consistent with the patient-family values and preferences. It will capitalize on the shared decision-making work being done within the state, such as in the Honoring Choices Minnesota collaborative where patients and providers are using collaborative conversations to deďŹ ne patients preferences in an advance care plan.

Work to date includes a thorough evidence review, and collaborative work with payers, providers and patients. A key ďŹ nding has been that in situations involving high-stake decisions like those involving a life-limiting illness, the conversations required for SDM often do not get initiated. Consequently, ICSI and the committees developed a SDM model that identiďŹ es opportunities for care team members to initiate collaborative conversations and inďŹ&#x201A;uence patients and families to actively participate in the process. This model and the use of collaborative conversations are being piloted in the metro area, and additional pilots are planned. Findings from the pilots will be used to reďŹ ne and improve the SDM process for palliative care decisions and will, in turn, be put into practice.

Cally Vinz, RN, is vice president, Clinical Products and Strategic Initiatives, ICSI. She leads ICSIâ&#x20AC;&#x2122;s palliative care strategic initiative. Ms. Vinz has extensive experience in clinical, administrative and leadership roles in both large integrated systems (Mayo Clinic) and small rural settings (Olmsted Medical Center). Ms. Vinz holds a nursing degree from Rochester Community College in Minnesota.

MetroDoctors

The Journal of the Twin Cities Medical Society

Hospice of the Twin Cities: Offering Comfort and Care at the End of Life

H

ospice care is considered the model for quality compassionate care for people facing life-limiting illness, providing expert medical care, pain management, and emotional and spiritual support specific to the patient’s and family’s needs and goals of care. The unit of care in hospice extends beyond the patient. Support is also provided to the patient’s loved ones.

Hospice of the Twin Cities has been providing hospice care in Minneapolis, St. Paul and the surrounding communities since 1993. As a community-based, Medicare certified, nonprofit organization, Hospice of the Twin Cities has been able to expand and create unique services to meet the needs of the terminally ill in the metro area. The staff includes a strong interdisciplinary team comprised of physicians, registered nurses, licensed practical nurses, social workers, chaplains, music therapist, pet therapist, massage therapists, chaplains, bereavement counselors, and hospice aides, as well as a full complement of volunteers and support staff. Committed to excellence in end-of-life care, the hospice mission is to seek out and serve those in need of the expert, unique services hospice can offer, including those who have been historically underserved by hospice programs. Hospice of the Twin Cities is a wholly owned subsidiary of the Minnesota Visiting Nurse Agency.

By Pam Schaid, Executive Director

MetroDoctors

The decision to enroll in hospice can be difficult. Health care providers, particularly physicians, play a key role in helping patients explore available options for advanced illness care. Introducing hospice as an option before the family is in crisis can facilitate informed decision making. Difficult conversations about next steps with open and honest communication about the disease progression and assisting the patient in identifying their goals of care can be helpful in introducing hospice. Ultimately, the decision to enroll in hospice lies with the patient and the family.

Hospice care focuses on caring, not curing. In most cases, hospice care is provided in the patient’s home with the family serving as the primary caregiver. Hospice is there to support the family in their care giving role, offering education and support while also providing direct care and support to the patient. However, hospice care can be delivered wherever the patient calls home — a skilled nursing facility, residential hospice facility, assisted living facility, or, perhaps, there is no place to call home.

Hospice of the Twin Cities reaches out to all in need of care and support at the end of life wherever they live because hospice is not a place, but rather a philosophy and approach to care.

In the early days of hospice care, cancer patients made up the largest group receiving care by hospice. Today, cancer patients account for less than half the patients. Patients seeking hospice care are more likely to have advanced chronic illness such as heart disease, dementia, or lung disease or a combination of chronic illnesses leading to significant debility. Any of these situations lead to considerable caregiver burden. Hospice can have a dramatic effect in reducing that burden.

The Journal of the Twin Cities Medical Society

Services provided to a hospice patient and their family through Hospice of the Twin Cities include: s 3PECIALIZED CARE OF THE INTERDISCIPLINARY team to alleviate pain and other distressing symptoms and suffering. s !SSISTANCE WITH THE EMOTIONAL PSYCHOSOcial and spiritual aspects of dying. s .URSING CARE TO ASSIST WITH PERSONAL CARE for the patient. s $RUGS MEDICAL SUPPLIES AND EQUIPMENT needed to care for the patient. s %DUCATION AND INSTRUCTION FOR THE FAMILY on how to care for the patient. s !VAILABILITY OF CARE AND SUPPORT HOURS a day, seven days a week. s 3PECIAL SERVICES SUCH AS MUSIC THERAPY PET therapy and massage therapy and other complimentary therapies. s !CUTE INPATIENT CARE FOR PAIN OR SYMPTOM management.

(Continued on page 20)

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Palliative & Hospice Care Hospice of the Twin Cities (Continued from page 19)

s

2ESPITE CARE FOR THE CAREGIVER WHO NEEDS a break from caregiving. s "EREAVEMENT CARE AND COUNSELING TO SURviving family and friends. s 6OLUNTEER SERVICES LENDING ASSISTANCE TO both the patient and the family in a variety of ways.

The goal of Hospice of the Twin Cities is to meet the family where they are at the time of referral into hospice care and accompany them on their journey of caring for someone at the end of life. Upon admission, a comprehensive

W

been rewarding: a time of healing, loving and personal growth.

With end-of-life care, continuity is important to ensure adherence to the plan of care to maximize symptom control and support services. Typically, a patient is assigned to a team of hospice professionals. All care and services are delivered by this team. Good communication and coordination between team members provides the needed continuity in both staff and process.

Physician services include the involvement of the primary care physician or the specialist managing the terminal illness and the hospice medical director. The attending physicians are

“We, as a family, would like to thank everyone for their wonderful support during this time. We could not have done this without the entire Hospice team! We were able to have 2 ½ months of laughter, love and family pulling together.”

Family of a patient served by Hospice of the Twin Cities.

assessment is completed to determine the needs of the patient and family, their goals of care, and what is most important now. The hospice team helps the patient and family to reframe hope considering the terminal condition. The hope for cure is no longer realistic, but hope for quality family time or continued accomplishment can be realized. The assessment of the patient extends beyond the physical and medical needs, to include the spiritual and psychosocial aspects of the patient. The plan of care is customized to meet the individual needs of the patient and family. The scope of hospice care is not the same for every person, because each patient and family has different needs and goals. Hospice of the Twin Cities builds an individualized plan of care based on the patient’s goals and the Hospice’s core values of dignity, affirmation, advocacy and alleviation of suffering. If we can keep people from feeling abandoned and alleviate physical suffering, remarkable things can happen. It is possible for families who have walked this journey to feel that time spent with a dying loved one has

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encouraged to be an active part of the hospice team. It is important for hospice to be kept informed of discussions and visit outcomes so that recommendations by the attending physician may be incorporated into the hospice plan of care. Communication from the hospice team includes updates to the plan of care and reports of changes in the condition of the patient. The relationship between the patient and primary physician is very important and should be continued and fostered throughout end of life. The hospice medical director provides oversight of the hospice plan of care and serves as a resource to the hospice team, particularly regarding symptom management and medications. The hospice medical director provides ongoing assessment of the patient relative to continued appropriateness for hospice care. Hospice physicians also serve as liaisons to other physicians in the community.

Payment for hospice care is generally covered by a third party payer. Medicare is the most common reimbursement for hospice care. Medical Assistance and private insurance coverage

typically mirrors that of Medicare. Rarely is there a cost to the patient for hospice care.

For those living in alternative housing, such as skilled nursing facilities or assisted living, the payment for room and board falls outside the Medicare Hospice Benefit. The Medicare Hospice Benefit covers not only the services of the hospice team, but it also covers all supplies, medications and equipment which are part of the plan of care and needed to manage the patient’s terminal illness, as well as acute care for symptom management and respite care.

Hospice care does not end with the patient’s death. Bereavement support is available for surviving family members of hospice patients through mailings, follow-up phone calls, attendance at formal or informal grief support groups, memorial services and education. Bereavement support can help those who have suffered a significant loss to move forward in a healthy way.

The many volunteers of Hospice of the Twin Cities assist in providing care for our patients and families, adding living to their days. They provide companionship, friendship and support to both the patient and the family.

Volunteers provide opportunities for life review, legacy and finding meaning in this journey.

Through the donation of thousands of hours, Hospice of the Twin Cities’ volunteers add life to the days of Hospice patients. Hospice volunteers also provide clerical and administrative support, helping to keep costs low and expand the reach of Hospice of the Twin Cities.

With the help of hospice, patients and family member alike can focus on what really matters and live life to the fullest extent possible. With the supportive care of the hospice team guiding them along their final journey, those facing the end of life can die comfortably, with dignity, surrounded by those they love and cherish.

Pam Schaid is executive director of Hospice of the Twin Cities. Pam has worked in hospice for 20 years, both as a registered nurse and executive director. She has been active with Hospice Minnesota (Minnesota Network of Hospice and Palliative Care) serving as a committee member, board member and officer, including President in 2003. She is currently a Fiscal Intermediary representative for Minnesota.

MetroDoctors

The Journal of the Twin Cities Medical Society

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SPC Helps Bridge the Medicare Gap for Qualifying Individuals While Simplifying the Administrative Process for Providers

S

enior Partners Care (SPC) is a community service program of Volunteers of America-Minnesota, a nonprofit organization founded in 1896, which reaches over 27,000 community members annually through six program areas: children and family services; services for persons with special needs; corrections; housing; education; and senior services.

The mission of VOA-MN is to provide opportunities that will make a significant, lasting impact in the lives of program participants, and to elicit community support for program participants. The Senior Partners Care program, which currently serves 1,800 participants, is housed within the Senior Services division.

This division provides one of the most comprehensive arrays of community-based services for seniors in Minnesota including transportation, legal services, protective services, caregiver support, senior mental health and social services to Minneapolis public housing high rises. Additional services include volunteer opportunities, culturally specific programming, adult daycare, senior activities, assisted living, home delivered meals and congregate dining services.

The Senior Partners Care Program serves the unique group of seniors and individuals with disabilities who are at risk of forgoing regular medical care because they are not lowincome enough to qualify for Medical Assistance and cannot afford supplemental insurance or out-of-pocket co-payments. The program assists these individuals to access health care from participating providers that have agreed to consider a waiver of Medicare deductibles and co-payments. The program provides an opportunity for participants to stretch their limited dollars further and receive the care they need. The burden of increasing debt and the stress of illness can be distressing to any person,

By Jean Fusco

MetroDoctors

but even more so for the population served. Participants have shared that the program has helped to eliminate the financial burden of out-of-pocket expenses which allows them to focus on both preventative health care as well as healing when ill or injured.

The result is that participants are able to remain in their own homes, living independently. Many participants have expressed great appreciation for the reduction in anxiety over the financial weight, thus allowing them to live healthier, fuller lives.

To qualify for SPC, participants must be on Medicare Part A and Part B. They must also meet annual income and asset requirements, which are adjusted each year, based on 200 percent of the federal poverty guidelines. (At this time, that is an income of $1,805 per month or less for a single person or $2,428/month or less for a couple.) Total assets cannot exceed $43,785, excluding primary home and car. Finally, participants cannot be enrolled in any type of Medicare Advantage plan or Medical Assistance.

Most SPC participants are referred to the program by the business offices of participating hospitals and clinics when they are unable to pay their co-payment bills. Other referral sources include the Minnesota Senior Linkage Line, (a 1-800 number that connects seniors to community services) community action programs and through outreach activities at senior community/assisted living facilities.

Once a senior is referred to the program they are required to complete an application and provide supporting financial documentation.

All applications are reviewed and approved, or denied, by the program coordinator. Eligibility is reviewed and verified on an annual basis thereafter. The only cost to the participant is

The Journal of the Twin Cities Medical Society

a $29.50 application processing fee. This fee supports the cost of program administration.

There is no administrative cost to the provider to participate.

Currently the Volunteers of America-MN administers the Senior Partners Care program in conjunction with the Seven County Senior Federation, Central Minnesota Senior Federation, Minnesota Citizen’s FederationNortheast, and Northern Lights Association.

VOA-MN is responsible for the seven county metro area, as well as 67 counties out state which do not fall within the other organizations service areas. SPC’s network of participating providers includes most metro area hospitals and clinics, as well as hundreds of providers statewide. The program helps these providers give back to the community and simplify their administrative screening process for charity care.

If you have questions, or if your office, clinic, or hospital would like to become a Senior Partners Care participating provider, please call Jean Fusco at (952) 945-4180.

Jean Fusco is the Senior Partners Care Program coordinator at Volunteers of America of Minnesota.

January/February 2011

23

New Health Care CEO: Andrew S. Cochrane, CEO, Maple Grove Hospital Editor’s note: MetroDoctors continues to highlight newly named health care executives. Each CEO has been asked to outline his/her vision and challenges for their organization as well as offer some personal insights.

Andy Cochrane is chief executive officer of Maple Grove Hospital and has served in that capacity since November of 2008. Prior to relocating to Minnesota, Andy was administrator and chief executive officer of Methodist Willowbrook Hospital and senior vice president of The Methodist Hospital System in Houston, Texas.

Andy was born and raised in Lake Bluff, Illinois, a suburb 35 miles north of Chicago and has family roots in Wisconsin and locally in Edina. Andy earned a Bachelor of Arts Degree in Communications and Marketing as well as a Masters of Science Degree in Health Care Administration from Trinity University in San Antonio, Texas. He has served in various hospital leadership positions since 1989 in both Virginia and Texas.

What are the one or two most important principles for a hospital to be successful?

The traditional measures of success for hospitals are typically based on quality of care and financial performance such that the hospital can maintain its mission to the communities it serves. These measures are still important today but hospitals must add focus on culture and the importance of the experience that the patients, families, staff, physicians and the community have when interacting with us. It is important that we recognize the individual needs that people have and strive to meet or exceed those needs. Quality care and financial stability are expectations for us today — the experience is what will differentiate average hospitals and exceptional hospitals. A culture of accountability is key and is something we talk about the first day that folks arrive for orientation.

Culture begins at the top and leadership must share accountability for the expectations for behaviors and a culture of excellence in clinical quality and service. It’s a two-way street.

What challenges do you see in opening a new hospital in the Twin Cities market? How is its governance responsive to the owners? Who are they?

The challenges of opening this hospital were the same as those that any new hospital faces in the country. The economic condition of most 24

January/February 2011

families and individuals have caused the overall utilization of health care to decline. Reimbursement to hospitals and providers continues to decline. The rebound of the economy and the timing of such is uncertain at best. It is the responsibility of hospital leadership (governance and administration) to deliver services that meet the community need and do so in a financially responsible manner. This may indicate that we do some things on our own or that we do things within the framework of a partnership. Maple Grove Hospital is owned and governed by a partnership of North Memorial (75 percent) and Fairview Health Services (25 percent). As we grow and develop services, we do so by looking within the partnership to avoid duplication of services and seek existing expertise to build upon.

What part do physicians play in a hospital being successful?

Physicians are critical to our success — it is the physicians who trust the care of their patients to us as a hospital. The relationship between medical staff and the rest of the hospital must be one of partnership seeking not only involvement of the physicians but also a level of engagement that gives each physician a sense of ownership and pride. Many physicians in this community were involved in the design and development of this hospital including the care models, the level of services to provide, the use of information and technology and the governance model. Today, we continue to engage physicians in the planning for growth and new services. As health care becomes more integrated and payment mechanisms shift toward shared accountability for outcomes and performance, partnership and shared leadership with our physicians will be critical.

Our interactions each day provide opportunities to build relationships based on trust and mutual respect.

How is the medical staff constituted? Hospitalists are a feature of many hospitals — how do you (as a chief administrator) stay connected to the broader physician and medical community?

There are currently over 500 physicians on the Medical Staff at Maple Grove Hospital and more than 185 Allied Health Professionals. It is a voluntary medical staff and is governed by the Medical Executive Committee and ultimately the Board of Directors. Every interaction that I or a member of the hospital leadership team have with a member of the medical staff is an opportunity to connect and to share information. Other MetroDoctors

The Journal of the Twin Cities Medical Society

than more formal opportunities through department or committee meetings, daily rounding has been an effective way to help stay connected through informal hallway or lounge discussions. I also make it a point to occasionally visit physician groups at their monthly meetings just to touch base and share information.

What is your impression of Dave Durenbergerâ&#x20AC;&#x2122;s â&#x20AC;&#x153;Arms raceâ&#x20AC;? as it applies to your hospital and will it inďŹ&#x201A;uence your decision in the services that you offer to your patient population?

The â&#x20AC;&#x153;Arms Raceâ&#x20AC;? has proven time and again to be an expensive form of competition. One of the guiding principles at Maple Grove Hospital speaks to partnership. For us, this means something more than adding services simply to add services. It means that we evaluate existing services in the market and the potential to create and invest in partnerships which reduce ďŹ nancial risk and avoid unnecessary duplication of costly technology and services. The goal is always to deliver services that the market needs but it is clearly our accountability to do so in ďŹ nancially responsible ways. If we donâ&#x20AC;&#x2122;t evaluate ways to do things differently including through partnerships, weâ&#x20AC;&#x2122;re doing nothing but perpetuating the rising cost of health care.

How are decisions made about which services are to be provided and what are these?

The initial scope of services for the hospital was derived by looking at the market and asking the community to articulate their needs and desires through a series of focus groups. It was clear that a focus on a birth center and emergency services was a clear expectation and would be supported by the demographics of the market. A strong surgical program was also indicated with an initial focus on lower complexity cases related to general surgery, gynecology, orthopedics and urology. It was also a reasonable expectation that the hospital would offer state of the art diagnostic capabilities like CT scans, MRI, ultrasound, general radiology and non-invasive cardiology services.

As the hospital plans for additional growth, it is taking a similar path as it did in the initial facility planning. Market data has been updated and meetings have started with the Board of Directors, the medical staff and a number of executives within both North Memorial and Fairview.

A focus remains on easy access to all services, coordination with physicians and services at other sites and the overall experience that people are having when interacting with the hospital.

Special features of the newest hospital?

The opportunity to design and build a facility that incorporated the latest and greatest thinking in health care delivery was enormous. We had the opportunity to redesign processes and then design and build around those new ideas. Rather than changing work ďŹ&#x201A;ows to ďŹ t technology, we MetroDoctors

The Journal of the Twin Cities Medical Society

had the opportunity to install technology that supported our changed thinking. The hospital incorporates a number of special features: s 3TANDARDIZED hSAME HANDEDv ROOM DESIGN s 0ATIENT SERVERS IN EACH ROOM TO ACCOMMODATE THE MAJORITY OF SUPPLIES minimizing staff time spent looking for supplies and disruption of patient privacy. s "AR CODE ADMINISTRATION PROCESS FOR MEDICATIONS s 0ATIENT LIFTS INCORPORATED IN PATIENT ROOMS s h/N STAGE OFF STAGEv DESIGN TO AVOID TRANSPORT OF PATIENTS AND SUPplies in public areas of the hospital. s 3TATE OF THE ART INFANT PROTECTION SYSTEM s 4HE MAJORITY OF STAFF LOUNGES INCORPORATE WINDOWS SO THAT STAFF CAN maintain a connection to the outside during their shift. s .UMEROUS AND DIFFERENT hESCAPESv FOR FAMILY MEMBERS â&#x20AC;&#x201D; spaces for visitors to take a break from the hospital setting. s #LEAN $IRTY mOW DESIGN OF /PERATING 3UITES s %LECTRONIC -EDICAL 2ECORD FOR CONSISTENT AND RELIABLE DOCUMENTAtion of patient care.

How are you adapting your marketing/management strategy to the expected changes that will result from the recently passed health care reform?

The speciďŹ cs of â&#x20AC;&#x153;health care reformâ&#x20AC;? are in constant ďŹ&#x201A;ux. However, one direction is clear. There will be increasing accountability for physicians, hospitals and patients to work together to manage care in different and more efďŹ cient ways. We will be paid less and expected to provide better outcomes. I donâ&#x20AC;&#x2122;t think we should view the future as doing more with less â&#x20AC;&#x201D; that doesnâ&#x20AC;&#x2122;t work. Doing less in different, more efďŹ cient and collaborative ways is essential. We have great potential to ďŹ nd new ways to work together and change the way in which health care is delivered.

Not doing so is no longer an option.

January/February 2011

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Medical Student Lunch â&#x20AC;&#x2122;n Learn On November 11 eighty ďŹ rst and second year medical students gathered in room 2-620 Moos Tower on the University of Minnesota campus for a wrap-sandwich lunch and not-so-mucha-lecture, but rather an opportunity to learn about organized medicine.

Laura Gorsuch, president of the medical student section, served as the moderator as presentations on the work and opportunities for involvement in the American Medical Association, Minnesota Medical Association and Twin Cities Medical Society were given.

Participants included: s "ENJAMIN 7HITTEN - $ !-! !LTERNATE Delegate and immediate past president of the MMA; s 3HAYLA 7ILSON TH YEAR MEDICAL STUDENT

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and representative to Minority and Cross-Cultural Affairs Committee; *ESSICA 6OIGHT TH YEAR MEDIcal student, member, TCMS Board of Directors and MMA spokesperson; past president Medical Staff Section U of M Twin Cities Chapter.

7ADE 3WENSON TH YEAR MEDIcal student, member TCMS Board of Directors and West Metro Medical Foundation Board of Directors. ,AURA 'ORSUCH ND YEAR MEDICAL STUDENT

current president, AMA Medical Staff Section U of M; Twin Cities Chapter, p MSS alternate alte al lte tern rnat rn atee ddelegate, at e eggat el atee, aand nd iinc incoming ncom omin inng m member, embbe em ber,, ber, TCMS TC T CMS Board B Boa oaardd of oard of Directors.

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Medical students gather for Lunch 'n Learn.

Thomas P. Cook Scholarship Recipient Shayla Wilson was selected as the 2010 recipient of the Thomas P. Cook Medical Student Scholarship, given to a medical student who has demonstrated outstanding leadership. This award, administered by the Minnesota Medical Foundation, is funded by the West Metro Medical Foundation.

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January/February 2011

Benjamin Whitten, M.D. describes how AMA, MMA and TCMS comprise the federation of medicine.

Laura Gorsuch sets the stage for â&#x20AC;&#x153;organized medicineâ&#x20AC;? Lunch 'n Learn.

Search for Twin Cities Medical Society on Facebook

MetroDoctors

The Journal of the Twin Cities Medical Society

New Members

Will Your Organization Share With Those Less Fortunate?

Neal D. Boeder, Jr., M.D. Stillwater Medical Group Internal Medicine John S. Berestka, M.D. Northwest Eye Clinic Ophthalmology Kathryn L. Eggleston, M.D. Planned Parenthood of Minnesota Family Medicine Anne M. Furuseth, M.D. Clinic Sofia OBGYN, P.A. Obstetrics & Gynecology Gloria M. Garcia, M.D., FAAFP Family HealthServices MN Family Medicine Cole D. Greves, M.D. Minnesota Perinatal Physicians Obstetrics & Gynecology/Maternal & Fetal Medicine

19th Annual Supply Drive February 2011 The Caring H Hearts for f Homeless H l PPeople l drive d i collects ll hhealth l h andd hhygiene i supplies and over-the-counter medications for homeless adults and children. Donated items will be sorted and distributed to the homeless through the following east metro programs: Health Care for the Homeless, Listening House of St. Paul, and SafeZone Resource Center.

Please consider putting out a collection box at your office and encouraging employees to donate. Many clinics and hospitals are involved in this drive year after year.

Paul F. Holten, D.O. HealthPartners Internal Medicine

Please call Katie Snow, EMMS Foundation, at (612) 362-3704 or e-mail her at KSnow@ metrodoctors.com if your organization would like to participate. You will receive posters and lists of suggested items to donate. The drive runs throughout the month of February and volunteers will pick up the items at your office in early March.

Evelyn F. Mai, M.D. Minnesota Lung Center Adult Psychiatry & Sleep Medicine

Sponsored by HealthEast Care System and East Metro Medical Society Foundation

Patricia A. Mills, M.D. Minnesota Perinatal Physicians Obstetrics & Gynecology/Maternal & Fetal Medicine Jeanne M. Nelson, M.D. Minnesota Lung Center Internal Medicine, Pulmonary Medicine Peter A. Pahapill, M.D., Ph.D. United Neurosurgery Associates Neurosurgery Matthew Ramsey, M.D. Northwest Eye Clinic Ophthalmology Neil A. Stein, M.D. Metro Urology Urology Jon Tomasson, M.D. Metropolitan Anesthesia Network, LLP Anesthesiology Jill M. Therien, M.D. Associates in Newborn Medicine, P.A. Pediatrics Dale R. Yingling, D.O. Minnesota Perinatal Physicians Obstetrics & Gynecology/Maternal & Fetal Medicine MetroDoctors

The Journal of the Twin Cities Medical Society

January/February 2011

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West Metro Senior Physicians Association THE WEST METRO SENIOR PHYSICIANS ASSOCIATION

met on September 21, 2010 where guest speaker, Brenda Paul, State Quality Measurement Program Development Project Manager enlightened us about the â&#x20AC;&#x153;Minnesota Community Measurement: New Measures and Updates.â&#x20AC;? Their mission is to accelerate the improvement of health by publicly reporting health care information.

This association also met on November 9, 2010. Guest speaker, Rebecca Schierman, Manager, Quality Improvement, Minnesota Medical Association presented: â&#x20AC;&#x153;Moving Healthcare Forward in an e-Health Environment â&#x20AC;&#x201D; New Doctors Donâ&#x20AC;&#x2122;t Know How to Use Paper.â&#x20AC;? Becky discussed the mandates that are coming in 2011 â&#x20AC;&#x201D; January 1, all providers, group purchasers, prescribers, and dispensers must establish and maintain an electronic Rx drug program. By January 1, 2015, all hospitals and health care providers must have in place an interoperable electronic health records system within their hospital system or clinical practice setting.

In January 2011, the West Metro and East Metro Senior Physicians Associations will merge. More information to come . . .

Richard Woellner, M.D., West Metro Sr. Physicians Association president, and guest speaker, Rebecca Schierman, MMA manager, Quality Improvement.

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January/February 2011

MetroDoctors

The Journal of the Twin Cities Medical Society

East Metro Senior Physicians Association THE EAST METRO SENIOR PHYSICIANS ASSOCIATION held a meeting at the end of October to hear from Claus Pierach, M.D., FACP. Dr. Pierach is a professor of medicine at the University of Minnesota Medical School and has done research in the areas of porphyria and the history of medicine.

Dr. Pierach presented a talk describing various illnesses that have befallen leaders in the past and the effects on the community — sometimes on the nation — when a leader is unable to serve for a time. He raised a number of thought-provoking points regarding the lack of backup plans or transfer of authority when a leader is ill. This is particularly alarming when the leader is the U.S. President or another influential political individual!

Beginning this year, the Senior Physicians Association will combine both east metro and west metro members to meet together as one larger group. This will provide new social and collegial opportunities, as well as reflect the current structure of the medical society.

In Memoriam JOHN N. GIEBENHAIN, M.D. died October 27, 2010 at the age of 91. He graduated from the University of Minnesota Medical School. Dr. Giebenhain practiced family medicine from 1945 to 1984 and established North Clinic in Robbinsdale. He served as chief of staff at North Memorial Hospital in 1957.

SUZANNE GRANT, M.D. passed away peacefully November 6, 2010 following a brief illness. She was 88. She graduated from the University of Minnesota Medical School.

Dr. Grant loved and practiced family medicine in Minneapolis for 43 years.

ALBERT GREENBERG, M.D., age 92, died peacefully at home Sept. 30, 2010. He graduated from the University of Minnesota Medical School. Dr. Greenberg practiced internal medicine for 56 years from his office at the Medical Arts Building in downtown Minneapolis from 1950-2006. He was known for making house calls with his black bag in hand until he retired at age 87. Dr. Greenberg was on staff at Abbott Northwestern Hospital and taught at the U of M Medical School.

MetroDoctors

The Journal of the Twin Cities Medical Society

Dr. Claus Pierach (left) chats with Dr. Dennis Callahan.

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Career Opportunities

CAREER OPPORTUNITIES

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The Journal of the Twin Cities Medical Society

January/February 2011

31

LUMINARY of Twin Cities Medicine

By Marvin S. Segal, M.D.

ALVIN L. SCHULTZ, M.D. This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, managing editor, nbauer@metrodoctors.com.

“Hi, I’m Al Schultz, c’mon in.”

That was the greeting heard many times by new visitors to the office of Alvin Schultz, M.D. Whether the visitor was new or an associate of long standing, that greeting was symbolic of his “open door policy” and 24/7 availability. Once comfortable in that office, the visitor was struck by his calm and reassuring voice and the warm and sincere look engendered by those wise brown eyes which nearly always gazed directly into yours.

Dr. Alvin Schultz began his life and his ascension to medical prominence in Minneapolis. He attended the University of Minnesota (U of M), obtaining his B.A., M.D. degrees — and later an M.S. in Medicine and Pathology. After an internship at Ohio State University Hospital and a post WW II California stint in the U.S. Army, he completed residency and fellowship training in internal medicine and endocrinology back at the U of M. He served the Minneapolis V.A. Hospital as the assistant chief of medicine before spending four years in the private practice of internal medicine/endocrinology as one of the earlier staff members of the St. Louis Park Medical Center. Dr. Arne Anderson, a founding physician of that institution, described Al as “brilliant, unselfish and a dedicated patient advocate.” Those important attributes plus his solid experiential foundation prepared him well for the outstanding leadership roles he was to play in local and national medicine.

Dr. Shultz’s six years as chairman of medicine and director of medical research at the U of M affiliated Mount Sinai Hospital served as a stepping stone to a remarkable 22 year tenure as chief of medicine at Hennepin County Medical Center (HCMC) and a professorship in the medical school of his alma mater.

He was administratively crisp and well organized, 32

January/February 2011

and was supportive and encouraging with his staff — exuding confidence in their creative initiatives as together they forged a nurturing environment for learning medicine while providing quality care for all patients — especially the underserved. His clinical skills were profound — whether it was calculating a cardiac output or chemotherapeutic dose, gently outlining (with pinky finger raised) a thyroid nodule or guiding a medical student in their first palpation of a spleen tip. Dr. Tom Stillman, a long-time associate, coined a metaphorical comment alluding to Dr. Schultz’s life-long love of sailing: “Everyone felt secure with him at the helm.” Under Al’s direction, over 350 residents completed their internal medicine training at HCMC. In addition to his devotion to his wife, Martha, and their accomplished four children, he shared his talents with the community achieving recognition in the American College of Physicians (ACP) as a Minnesota Governor, Chair of the Board of Governors, a Regent and a Master. He was president of the Council of Medical Specialty Societies and our own Hennepin Medical Society, and in later years led the Medical Affairs Division of Allina and its predecessor organizations.

The Laureate Award of the ACP and the Charles Bolles Bolles-Rogers and Shotwell Awards, along with national recognition for the highest standards of teaching excellence, are but a few of the numerous acknowledgements received by this Luminary of Twin Cities Medicine. However, if Al Schultz could now be asked what his most valued award had been, it is likely that he would respond that it was the pride felt by hundreds of his students and colleagues as we say, “Al Schultz — he was my teacher, he was my chief, he was my friend.”

MetroDoctors

The Journal of the Twin Cities Medical Society

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