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Vo l u m e x X I X , N o . 3 J u n e 2 015

The e-health roadmap A collaborative effort to improve care By Paul Kleeberg, MD


ealth care is changing and be coming more of a team effort. Part of that is being driven by the new payment methods on the horizon, intended to pay providers based on the quality, rather than merely the quantity of care we provide patients. To help facilitate this transition, the state is developing e-health roadmaps in order to advance high-quality, coordinated care. The roadmaps will focus on four providers from particular settings as they participate in the Minnesota Accountable Health Model. The model expands patient-centered, team-based care and integrates it with medical care. The four settings upon which the roadmaps will focus are: • Long-term and post-acute care • Local public health

The Minnesota Accountable Health Model Creating community partnerships By Rahul Koranne, MD, MBA, FACP


ou may not know it, but Minnesota is currently in the midst of testing a new model of health care, the Minnesota Accountable Health Model. At the heart of this model is the idea that authentic collaboration is key to solving Minnesota’s health challenges. Minnesota currently has one of the best medical care systems in the U.S. and the world. But we are still a ways from having a

“health” system—meaning an effective coordinated system for promoting and achieving health and wellness—for all Minnesotans. Practicing physicians know that the health and wellness of our patients is often dependent on social and economic factors outside of our direct The Minnesota Accountable Health Model to page 16

• Behavioral health • Social services These roadmaps will help Minnesota understand what’s needed to engage in accountable care models. The U.S. Department of Health & Human Services (HHS) has set rigorous goals for using alternative payment models and valThe e-health roadmap to page 18

rehabilitation services from P ost-acute the Good Samaritan Society. Post-acute care is designed to heal and assist patients with care and support following a hospitalization from serious illness, injury or elective surgical procedure. Multiple in-patient and out-patient post-acute locations are located throughout the Twin Cities metro area and state of Minnesota. To learn more about our post-acute services, call us at 866-GSSCARE or visit

The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, gender, disability, familial status, national origin or other protected statuses according to applicable federal, state or local laws. Some services may be provided by a third party. All faiths or beliefs are welcome. Š 2015 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 15-G0066

An approach to consider for type 2 diabetes therapy starts here

Trulicity™ is a glucagon-like peptide-1 receptor agonist (GLP-1 RA) that is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitations of Use: Not recommended as first-line therapy for patients inadequately controlled on diet and exercise. Has not been studied in patients with a history of pancreatitis; consider another antidiabetic therapy. Not for the treatment of type 1 diabetes mellitus or diabetic ketoacidosis. Not a substitute for insulin. Has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis. Not for patients with pre-existing severe gastrointestinal disease. Has not been studied in combination with basal insulin.

Select Important Safety Information WARNING: RISK OF THYROID C-CELL TUMORS In male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance could not be determined from clinical or nonclinical studies. Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Routine serum calcitonin or thyroid ultrasound monitoring is of uncertain value in patients treated with Trulicity. Counsel regarding the risk factors and symptoms of thyroid tumors.

Please see Important Safety Information for Trulicity, including Boxed Warning about possible thyroid tumors including thyroid cancer, and Brief Summary of Prescribing Information on following pages. Please see Instructions for Use included with the pen. June 2015 Minnesota Physician


Trulicity offers proven A1C reduction* and once-weekly dosing in the Trulicity pen ™


*In clinical trials, the range of A1C reduction from baseline was 0.7% to 1.6% for the 0.75 mg dose and 0.8% to 1.6% for the 1.5 mg dose.1

Trulicity may be a good option for adult patients with type 2 diabetes who need more control than oral medications are providing.1 To learn more about Trulicity and the savings card for patients, talk to your Lilly sales representative or visit

Trulicity is a glucagon-like peptide-1 receptor agonist (GLP-1 RA) that is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitations of Use: Not recommended as first-line therapy for patients inadequately controlled on diet and exercise. Has not been studied in patients with a history of pancreatitis; consider another antidiabetic therapy. Not for the treatment of type 1 diabetes mellitus or diabetic ketoacidosis. Not a substitute for insulin. Has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis. Not for patients with pre-existing severe gastrointestinal disease. Has not been studied in combination with basal insulin.

Important Safety Information WARNING: RISK OF THYROID C-CELL TUMORS In male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance could not be determined from clinical or nonclinical studies. Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Routine serum calcitonin or thyroid ultrasound monitoring is of uncertain value in patients treated with Trulicity. Counsel regarding the risk factors and symptoms of thyroid tumors.




ŠLilly USA, LLC 2015. All rights reserved.

Minnesota Physician June 2015

Trulicity is contraindicated in patients with a prior serious hypersensitivity reaction to dulaglutide or any of the product components. Risk of Thyroid C-cell Tumors: Counsel patients regarding the risk of medullary thyroid carcinoma and the symptoms of thyroid tumors (eg, a mass in the neck, dysphagia, dyspnea, persistent hoarseness). Patients with elevated serum calcitonin (if measured) and patients with thyroid nodules noted on physical examination or neck imaging should be referred to an endocrinologist for further evaluation. Pancreatitis: Has been reported in clinical trials. Observe patients for signs and symptoms including persistent severe abdominal pain. If pancreatitis is suspected discontinue Trulicity promptly. Do not restart if pancreatitis is confirmed. Consider other antidiabetic therapy in patients with a history of pancreatitis. Please see Important Safety Information continued on following page.

Important Safety Information, continued

Once-weekly Trulicity 1.5 mg showed significant A1C reduction1

Hypoglycemia: The risk of hypoglycemia is increased when Trulicity is used in combination with insulin secretagogues (eg, sulfonylureas) or insulin. Patients may require a lower dose of the sulfonylurea or insulin to reduce the risk of hypoglycemia.

Recommended starting dose is 0.75 mg. Dose can be increased to 1.5 mg for additional glycemic 1-3 control.

A1C reduction from baseline

A1C reduction from baseline


Hypersensitivity Reactions: Systemic reactions were observed in clinical trials in patients receiving Trulicity. Instruct patients who experience symptoms to discontinue Trulicity and promptly seek medical advice.

Severe Gastrointestinal Disease: Use of Trulicity may be associated with gastrointestinal adverse reactions, sometimes severe. Trulicity has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis, and is therefore not recommended in these patients.


Gastric emptying is slowed by Trulicity, which may impact absorption of concomitantly administered oral medications. Use caution when oral medications are used with Trulicity. Drug levels of oral medications with a narrow therapeutic index should be adequately monitored when concomitantly administered with Trulicity. In clinical pharmacology studies, Trulicity did not affect the absorption of the tested, orally administered medications to a clinically relevant degree. Pregnancy: There are no adequate and well-controlled studies of Trulicity in pregnant women. Use only if potential benefit outweighs potential risk to fetus. Nursing Mothers: It is not known whether Trulicity is excreted in human milk. A decision should be made whether to discontinue nursing or to discontinue Trulicity taking into account the importance of the drug to the mother. Pediatric Use: Safety and effectiveness of Trulicity have not been established and use is not recommended in patients less than 18 years of age. Please see Brief Summary of Prescribing Information, including Boxed Warning about possible thyroid tumors including thyroid cancer, on following pages. Please see Instructions for Use included with the pen. DG HCP ISI 12NOV2014 Trulicity™ is a trademark of Eli Lilly and Company and is available by prescription only. Other product/company names mentioned herein are the trademarks of their respective owners.

Byetta® (10 mcg BID) (n=276; Baseline A1C: 8

7.8 7.6



Trulicity™ (0.75 mg) (n=280; Baseline A1C: 8

7.2 7.0



-1.3* † -1.5*

6.6 6.4

93% fewer injections3

Trulicity™ (1.5 mg) (n=279; Baseline A1C: 8

6.2 Baseline

Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Trulicity or any other antidiabetic drug. The most common adverse reactions reported in ≥5% of Trulicity-treated patients in placebo-controlled trials (placebo, Trulicity 0.75 mg, and Trulicity 1.5 mg) were nausea (5.3%, 12.4%, 21.1%), diarrhea (6.7%, 8.9%, 12.6%), vomiting (2.3%, 6.0%, 12.7%), abdominal pain (4.9%, 6.5%, 9.4%), decreased appetite (1.6%, 4.9%, 8.6%), dyspepsia (2.3%, 4.1%, 5.8%), and fatigue (2.6%, 4.2%, 5.6%).

Placebo (n=141; Baseline A1C: 8


LS mean A1C LS mean A1C(%) (%)

Renal Impairment: In patients treated with GLP-1 RAs there have been postmarketing reports of acute renal failure and worsening of chronic renal failure, sometimes requiring hemodialysis. A majority of reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. In patients with renal impairment, use caution when initiating or escalating doses of Trulicity and monitor renal function in patients experiencing severe adverse gastrointestinal reactions.


Week 13

Week 26

Placebo (n=141; Baseline A1C: 8.1%) Byetta® (10 mcg BID) (n=276; Baseline A1C: 8.1%) Trulicity™ (0.75 mg) (n=280; Baseline A1C: 8.1%) Trulicity™ (1.5 mg) (n=279; Baseline A1C: 8.1%) Data represent least-squares mean ± standard error. * Multiplicity-adjusted 1-sided P value <.025 for superiority of Trulicity vs Byetta for A1C. † Multiplicity-adjusted 1-sided P value <.001 for superiority of Trulicity vs placebo for A1C. Mixed model repeated measures analysis. After 26 weeks, placebo-treated patients were switched in a blinded fashion to Trulicity 1.5 mg or Trulicity 0.75 mg. ‡ American Diabetes Association recommended target goal. Treatment should be individualized.4 •

Data represent least-squares mean ± standard error.

52-week, randomized, placebo-controlled phase 3 study

*(open-label assignment to Byetta or blinded assignment to

Multiplicity-adjusted 1-sided P value <.025 for superiority of Trulicity vs Byetta for A1C.

Trulicity or placebo) of adult patients with type 2 diabetes Multiplicity-adjusted 1-sided P value <.001 for(≥1500 superiority of Trulicity vs placebo for A1C. treated with maximally tolerated metformin mg/day) and Actos® to 45 mg/day) Mixed model(up repeated measures analysis. • Primary objective was to demonstrate superiority of Trulicity After 26vsweeks, placebo-treated were switched in a blinded fashion to Trulicity 1.5 mg or Trulicity 0.75 mg. 1.5 mg placebo on change inpatients A1C from baseline at 26 ‡weeks (-1.5% vs -0.5%, respectively; difference of -1.1%; 95% American Diabetes Association recommended target goal. Treatment should be individualized.4 CI [-1.2, -0.9]; multiplicity-adjusted 1-sided P value <.001; analysis of covariance using last observation carried •forward); primary objective met †

52-week, randomized, placebo-controlled phase 3 study (open-label assignment to Trulicity or placebo) of adult patients with type 2 diabetes treated 1. Trulicity [Prescribing Information]. tolerated metformin (≥1500 mg/day) and Actos (up to 45 mg/day) Indianapolis, IN: Lilly USA, LLC; 2014. References assignment

2. Data on file, Lilly USA, LLC. TRU20140910A. • Data Primary objective was to demonstrate superiority of Trulicity 1.5 mg vs placebo o 3. on file, Lilly USA, LLC. TRU20140919C. 4. American Diabetes Association. Standards from baseline at 26 weeks (-1.5% vs -0.5%, respectively; difference of -1.1%; 95% CI [ of medical care in diabetes—2014. Diabetes Care. 2014;37(Suppl 1):S14-S80. adjusted 1-sided P value <.001; analysis of covariance using last observation carr

objective met

References 1. Trulicity [Prescribing Information]. Indianapolis, IN: Lilly USA, LLC; 2014. 2. Data on file, Lilly USA, LLC. TRU20140910A. 3. Data on file, Lilly USA, LLC. TRU20140919C. 4. American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(Suppl 1):S14-S80.

June 2015 Minnesota Physician



(dulaglutide) Brief Summary: Consult the package insert for complete prescribing information. WARNING: RISK OF THYROID C-CELL TUMORS • In male and female rats, dulaglutide causes a dose-related and treatment-durationdependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance could not be determined from clinical or nonclinical studies. • Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Routine serum calcitonin or thyroid ultrasound monitoring is of uncertain value in patients treated with Trulicity. Counsel regarding the risk factors and symptoms of thyroid tumors. INDICATIONS AND USAGE Trulicity™ is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitations of Use: Not recommended as a first-line therapy for patients who have inadequate glycemic control on diet and exercise. Has not been studied in patients with a history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis. Should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. It is not a substitute for insulin. Has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis. Not recommended in patients with pre-existing severe gastrointestinal disease. The concurrent use of Trulicity and basal insulin has not been studied. CONTRAINDICATIONS Do not use in patients with a personal or family history of MTC or in patients with MEN 2. Do not use in patients with a prior serious hypersensitivity reaction to dulaglutide or to any of the product components. WARNINGS AND PRECAUTIONS Risk of Thyroid C-cell Tumors: In male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. Glucagon-like peptide (GLP-1) receptor agonists have induced thyroid C-cell adenomas and carcinomas in mice and rats at clinically relevant exposures. It is unknown whether Trulicity will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of this signal could not be determined from the clinical or nonclinical studies. One case of MTC was reported in a patient treated with Trulicity. This patient had pretreatment calcitonin levels approximately 8 times the upper limit of normal (ULN). Trulicity is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2. Counsel patients regarding the risk for MTC with the use of Trulicity and inform them of symptoms of thyroid tumors (eg, a mass in the neck, dysphagia, dyspnea, persistent hoarseness). The role of serum calcitonin monitoring or thyroid ultrasound monitoring for the purpose of early detection of MTC in patients treated with Trulicity is unknown. Such monitoring may increase the risk of unnecessary procedures, due to the low specificity of serum calcitonin as a screening test for MTC and a high background incidence of thyroid disease. Very elevated serum calcitonin value may indicate MTC and patients with MTC usually have calcitonin values >50 ng/L. If serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Patients with thyroid nodules noted on physical examination or neck imaging should also be referred to an endocrinologist for further evaluation. Pancreatitis: In Phase 2 and Phase 3 clinical studies, 12 (3.4 cases per 1000 patient years) pancreatitisrelated adverse reactions were reported in patients exposed to Trulicity versus 3 in non-incretin comparators (2.7 cases per 1000 patient years). An analysis of adjudicated events revealed 5 cases of confirmed pancreatitis in patients exposed to Trulicity (1.4 cases per 1000 patient years) versus 1 case in non-incretin comparators (0.88 cases per 1000 patient years). After initiation of Trulicity, observe patients carefully for signs and symptoms of pancreatitis, including persistent severe abdominal pain. If pancreatitis is suspected, promptly discontinue Trulicity. If pancreatitis is confirmed, Trulicity should not be restarted. Trulicity has not been evaluated in patients with a prior history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis. Hypoglycemia with Concomitant Use of Insulin Secretagogues or Insulin: The risk of hypoglycemia is increased when Trulicity is used in combination with insulin secretagogues (eg, sulfonylureas) or insulin. Patients may require a lower dose of sulfonylurea or insulin to reduce the risk of hypoglycemia. Hypersensitivity Reactions: Systemic hypersensitivity reactions were observed in patients receiving Trulicity in clinical trials. If a hypersensitivity reaction occurs, the patient should discontinue Trulicity and promptly seek medical advice. Renal Impairment: In patients treated with GLP-1 receptor agonists, there have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis. Some of these events were reported in patients without known underlying renal disease. A majority of reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. Because these reactions may worsen renal failure, use caution when initiating or escalating doses of Trulicity in patients with renal impairment. Monitor renal function in patients with renal impairment reporting severe adverse gastrointestinal reactions. Severe Gastrointestinal Disease: Use of Trulicity may be associated with gastrointestinal adverse reactions, sometimes severe. Trulicity has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis, and is therefore not recommended in these patients. TrulicityTM (dulaglutide) DG HCP BS 12NOV2014


Trulicity DG HCP BS 12NOV2014 Brief Summary 7 x 9.75 Minnesota Physician June 2015

Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Trulicity or any other antidiabetic drug. ADVERSE REACTIONS Clinical Studies Experience: Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice. Pool of Placebo-controlled Trials: These data reflect exposure of 1670 patients to Trulicity and a mean duration of exposure to Trulicity of 23.8 weeks. Across the treatment arms, the mean age of patients was 56 years, 1% were 75 years or older and 53% were male. The population in these studies was 69% White, 7% Black or African American, 13% Asian; 30% were of Hispanic or Latino ethnicity. At baseline, the population had diabetes for an average of 8.0 years and had a mean HbA1c of 8.0%. At baseline, 2.5% of the population reported retinopathy. Baseline estimated renal function was normal or mildly impaired (eGFR ≥60mL/min/1.73 m2) in 96.0% of the pooled study populations. Adverse Reactions in Placebo-Controlled Trials Reported in ≥5% of Trulicity-Treated Patients: Placebo (N=568), Trulicity 0.75mg (N=836), Trulicity 1.5 mg (N=834) (listed as placebo, 0.75 mg, 1.5 mg) nausea (5.3%, 12.4%, 21.1%), diarrheaa (6.7%, 8.9%, 12.6%), vomitingb (2.3%, 6.0%, 12.7%), abdominal painc (4.9%, 6.5%, 9.4%), decreased appetite (1.6%, 4.9%, 8.6%), dyspepsia (2.3%, 4.1%, 5.8%), fatigued (2.6%, 4.2%, 5.6%). (a Includes diarrhea, fecal volume increased, frequent bowel movements. b Includes retching, vomiting, vomiting projectile. c Includes abdominal discomfort, abdominal pain, abdominal pain lower, abdominal pain upper, abdominal tenderness, gastrointestinal pain. d Includes fatigue, asthenia, malaise.) Note: Percentages reflect the number of patients that reported at least 1 treatment-emergent occurrence of the adverse reaction. Gastrointestinal Adverse Reactions : In the pool of placebo-controlled trials, gastrointestinal adverse reactions occurred more frequently among patients receiving Trulicity than placebo (placebo 21.3%, 0.75 mg 31.6%, 1.5 mg 41.0%). More patients receiving Trulicity 0.75 mg (1.3%) and Trulicity 1.5 mg (3.5%) discontinued treatment due to gastrointestinal adverse reactions than patients receiving placebo (0.2%). Investigators graded the severity of gastrointestinal adverse reactions occurring on 0.75 mg and 1.5 mg of Trulicity as “mild” in 58% and 48% of cases, respectively, “moderate” in 35% and 43% of cases, respectively, or “severe” in 7% and 11% of cases, respectively. In addition to the adverse reactions  ≥5% listed above, the following adverse reactions were reported more frequently in Trulicity-treated patients than placebo (frequencies listed, respectively, as: placebo; 0.75 mg; 1.5 mg): constipation (0.7%; 3.9%; 3.7%), flatulence (1.4%; 1.4%; 3.4%), abdominal distension (0.7%; 2.9%; 2.3%), gastroesophageal reflux disease (0.5%; 1.7%; 2.0%), and eructation (0.2%; 0.6%; 1.6%). Pool of Placebo- and Active-Controlled Trials: The occurrence of adverse reactions was also evaluated in a larger pool of patients with type 2 diabetes participating in 6 placebo- and active-controlled trials evaluating the use of Trulicity as monotherapy and add-on therapy to oral medications or insulin. In this pool, a total of 3342 patients with type 2 diabetes were treated with Trulicity for a mean duration 52 weeks. The mean age of patients was 56 years, 2% were 75 years or older and 51% were male. The population in these studies was 71% White, 7% Black or African American, 11% Asian; 32% were of Hispanic or Latino ethnicity. At baseline, the population had diabetes for an average of 8.2 years and had a mean HbA1c of 7.6-8.5%. At baseline, 5.2% of the population reported retinopathy. Baseline estimated renal function was normal or mildly impaired (eGFR ≥60 ml/min/1.73 m2) in 95.7% of the Trulicity population. In the pool of placebo- and activecontrolled trials, the types and frequency of common adverse reactions, excluding hypoglycemia, were similar to those listed as ≥5% above. Other Adverse Reactions: Hypoglycemia : Incidence (%) of Documented Symptomatic (≤70 mg/dL Glucose Threshold) and Severe Hypoglycemia in Placebo-Controlled Trials:  Add-on to Metformin at 26 weeks, Placebo (N=177), Trulicity 0.75 mg (N=302), Trulicity 1.5 mg (N=304), Documented symptomatic: Placebo: 1.1%, 0.75 mg: 2.6%, 1.5 mg: 5.6%; Severe: all 0. Add-on to Metformin + Pioglitazone at 26 weeks, Placebo (N=141), TRULICITY 0.75 mg (N=280), Trulicity 1.5 mg (N=279), Documented symptomatic: Placebo: 1.4%, 0.75 mg: 4.6%, 1.5 mg: 5.0%; Severe: all 0. Hypoglycemia was more frequent when Trulicity was used in combination with a sulfonylurea or insulin. Documented symptomatic hypoglycemia occurred in 39% and 40% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with a sulfonylurea. Severe hypoglycemia occurred in 0% and 0.7% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with a sulfonylurea. Documented symptomatic hypoglycemia occurred in 85% and 80% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with prandial insulin. Severe hypoglycemia occurred in 2.4% and 3.4% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with prandial insulin. Heart Rate Increase and Tachycardia Related Adverse Reactions : Trulicity 0.75 mg and 1.5 mg resulted in a mean increase in heart rate (HR) of 2-4 beats per minute (bpm). The long-term clinical effects of the increase in HR have not been established. Adverse reactions of sinus tachycardia were reported more frequently in patients exposed to Trulicity. Sinus tachycardia was reported in 3.0%, 2.8%, and 5.6% of patient treated with placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively. Persistence of sinus tachycardia (reported at more than 2 visits) was reported in 0.2%, 0.4% and 1.6% of patients treated with placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively. Episodes of sinus tachycardia, associated with a concomitant increase from baseline in heart rate of ≥15 beats per minute, were reported in 0.7%, 1.3% and 2.2% of patient treated with placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively. Immunogenicity : Across four Phase 2 and five Phase 3 clinical studies, 64 (1.6%) TRULICITY-treated patients developed anti-drug antibodies (ADAs) to the active ingredient in Trulicity (ie, dulaglutide). Of the 64 dulaglutide-treated patients that developed dulaglutide ADAs, 34 patients (0.9% of the overall population) had dulaglutideneutralizing antibodies, and 36 patients (0.9% of the overall population) developed antibodies TrulicityTM (dulaglutide) DG HCP BS 12NOV2014


against native GLP-1. The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, the incidence of antibodies to dulaglutide cannot be directly compared with the incidence of antibodies of other products. Hypersensitivity: Systemic hypersensitivity adverse reactions sometimes severe (eg, severe urticaria, systemic rash, facial edema, lip swelling) occurred in 0.5% of patients on Trulicity in the four Phase 2 and Phase 3 studies. Injection-site Reactions : In the placebo-controlled studies, injection-site reactions (eg, injection-site rash, erythema) were reported in 0.5% of Trulicity-treated patients and in 0.0% of placebo-treated patients. PR Interval Prolongation and Adverse Reactions of First Degree Atrioventricular (AV) Block : A mean increase from baseline in PR interval of 2-3 milliseconds was observed in Trulicity-treated patients in contrast to a mean decrease of 0.9 millisecond in placebo-treated patients. The adverse reaction of first degree AV block occurred more frequently in patients treated with Trulicity than placebo (0.9%, 1.7% and 2.3% for placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively). On electrocardiograms, a PR interval increase to at least 220 milliseconds was observed in 0.7%, 2.5% and 3.2% of patients treated with placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively. Amylase and Lipase Increase:  Patients exposed to Trulicity had mean increases from baseline in lipase and/or pancreatic amylase of 14% to 20%, while placebo-treated patients had mean increases of up to 3%. DRUG INTERACTIONS Trulicity slows gastric emptying and thus has the potential to reduce the rate of absorption of concomitantly administered oral medications. Caution should be exercised when oral medications are concomitantly administered with Trulicity. Drug levels of oral medications with a narrow therapeutic index should be adequately monitored when concomitantly administered with Trulicity. In clinical pharmacology studies, Trulicity did not affect the absorption of the tested, orally administered medications to any clinically relevant degree. USE IN SPECIFIC POPULATIONS Pregnancy - Pregnancy Category C: There are no adequate and well-controlled studies of Trulicity in pregnant women. The risk of birth defects, loss, or other adverse outcomes is increased in pregnancies complicated by hyperglycemia and may be decreased with good metabolic control. It is essential for patients with diabetes to maintain good metabolic control before conception and throughout pregnancy. Trulicity should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. In rats and rabbits, dulaglutide administered during the major period of organogenesis produced fetal growth reductions and/or skeletal anomalies and ossification deficits in association with decreased maternal weight and food consumption attributed to the pharmacology of dulaglutide. Nursing Mothers: It is not known whether Trulicity is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for clinical adverse reactions from Trulicity in nursing infants, a decision should be made whether to discontinue nursing or to discontinue Trulicity, taking into account the importance of the drug to the mother. Pediatric Use: Safety and effectiveness of Trulicity have not been established in pediatric patients. Trulicity is not recommended for use in pediatric patients younger than 18 years. Geriatric Use: In the pool of placebo- and active-controlled trials, 620 (18.6%) Trulicity-treated patients were 65 years of age and over and 65 Trulicity-treated patients (1.9%) were 75 years of age and over. No overall differences in safety or efficacy were detected between these patients and younger patients, but greater sensitivity of some older individuals cannot be ruled out. Hepatic Impairment: There is limited clinical experience in patients with mild, moderate, or severe hepatic impairment. Therefore, Trulicity should be used with caution in these patient populations. In a clinical pharmacology study in subjects with varying degrees of hepatic impairment, no clinically relevant change in dulaglutide pharmacokinetics (PK) was observed. Renal Impairment: In the four Phase 2 and five Phase 3 randomized clinical studies, at baseline, 50 (1.2%) Trulicity-treated patients had mild renal impairment (eGFR ≥60 but <90 mL/min/1.73 m2), 171 (4.3%) Trulicity-treated patients had moderate renal impairment (eGFR ≥30 but <60 mL/min/1.73 m2) and no Trulicity-treated patients had severe renal impairment (eGFR <30 mL/min/1.73 m2). No overall differences in safety or effectiveness were observed relative to patients with normal renal function, though conclusions are limited due to small numbers. In a clinical pharmacology study in subjects with renal impairment including end-stage renal disease (ESRD), no clinically relevant change in dulaglutide PK was observed. There is limited clinical experience in patients with severe renal impairment or ESRD. Trulicity should be used with caution, and if these patients experience adverse gastrointestinal side effects, renal function should be closely monitored. Gastroparesis: Dulaglutide slows gastric emptying. Trulicity has not been studied in patients with pre-existing gastroparesis. OVERDOSAGE Overdoses have been reported in clinical studies. Effects associated with these overdoses were primarily mild or moderate gastrointestinal events (eg, nausea, vomiting) and non-severe hypoglycemia. In the event of overdose, appropriate supportive care (including frequent plasma glucose monitoring) should be initiated according to the patient’s clinical signs and symptoms. PATIENT COUNSELING INFORMATION See FDA-approved Medication Guide • Inform patients that Trulicity causes benign and malignant thyroid C-cell tumors in rats and that the human relevance of this finding is unknown. Counsel patients to report symptoms of thyroid tumors (eg, a lump in the neck, persistent hoarseness, dysphagia, or dyspnea) to their physician. • Inform patients that persistent severe abdominal pain, that may radiate to the back and which may (or may not) be accompanied by vomiting, is the hallmark symptom of acute pancreatitis. Instruct patients to discontinue Trulicity promptly, and to contact their physician, if persistent severe abdominal pain occurs. • The risk of hypoglycemia may be increased when Trulicity is TrulicityTM (dulaglutide) DG HCP BS 12NOV2014

Trulicity DG HCP BS 12NOV2014 Brief Summary 7 x 9.75

used in combination with a medicine that can cause hypoglycemia, such as a sulfonylurea or insulin. Review and reinforce instructions for hypoglycemia management when initiating Trulicity therapy, particularly when concomitantly administered with a sulfonylurea or insulin. • Patients treated with Trulicity should be advised of the potential risk of dehydration due to gastrointestinal adverse reactions and take precautions to avoid fluid depletion. Inform patients treated with Trulicity of the potential risk for worsening renal function and explain the associated signs and symptoms of renal impairment, as well as the possibility of dialysis as a medical intervention if renal failure occurs. • Inform patients that serious hypersensitivity reactions have been reported during postmarketing use of GLP-1 receptor agonists. If symptoms of hypersensitivity reactions occur, patients must stop taking Trulicity and seek medical advice promptly. • Advise patients to inform their healthcare provider if they are pregnant or intend to become pregnant. • Prior to initiation of Trulicity, train patients on proper injection technique to ensure a full dose is delivered. Refer to the accompanying Instructions for Use for complete administration instructions with illustrations. • Inform patients of the potential risks and benefits of Trulicity and of alternative modes of therapy. Inform patients about the importance of adherence to dietary instructions, regular physical activity, periodic blood glucose monitoring and HbA1c testing, recognition and management of hypoglycemia and hyperglycemia, and assessment for diabetes complications. During periods of stress such as fever, trauma, infection, or surgery, medication requirements may change and advise patients to seek medical advice promptly. • Each weekly dose of Trulicity can be administered at any time of day, with or without food. The day of once weekly administration can be changed if necessary, as long as the last dose was administered 3 or more days before. If a dose is missed and there are at least 3 days (72 hours) until the next scheduled dose, it should be administered as soon as possible. Thereafter, patients can resume their usual once weekly dosing schedule. If a dose is missed and the next regularly scheduled dose is due in 1 or 2 days, the patient should not administer the missed dose and instead resume Trulicity with the next regularly scheduled dose. • Advise patients treated with Trulicity of the potential risk of gastrointestinal side effects. • Instruct patients to read the Medication Guide and the Instructions for Use before starting Trulicity therapy and review them each time the prescription is refilled. • Instruct patients to inform their doctor or pharmacist if they develop any unusual symptom, or if any known symptom persists or worsens. • Inform patients that response to all diabetic therapies should be monitored by periodic measurements of blood glucose and HbA1c levels, with a goal of decreasing these levels towards the normal range. HbA1c is especially useful for evaluating long-term glycemic control.

Eli Lilly and Company, Indianapolis, IN 46285, USA US License Number 1891 Copyright © 2014, Eli Lilly and Company. All rights reserved. Additional information can be found at DG HCP BS 12NOV2014 TrulicityTM (dulaglutide)


PRINTER VERSION 2 OF 2 June 2015 Minnesota Physician


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Features The Minnesota Accountable Health Model Creating community partnerships


By Rahul Koranne, MD, MBA, FACP

The e-health roadmap A collaborative effort to improve care


By Paul Kleeberg, MD







Allan J. Collins, MD, FACP

Physician burnout  ebecca Hafner-Fogarty, By R MD, MBA

Community health workers By Joan Cleary, MM



Medicare’s new payment reform plan By T  imothy A. Johnson, JD, and Julia C. Marotte, JD

Chronic Disease Research Group

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Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone 612.728.8600; fax 612.728.8601; email mpp@ We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

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DHS Outlines Plan to Address Opioid Addiction The Minnesota Department of Human Services (DHS) has outlined a response to the growing problem of death and injury associated with opioid use and overdose. Lucinda Jesson, DHS commissioner, outlined the plan in response to a letter from Sylvia Burwell, U.S. secretary of health and human services, which asked Gov. Dayton to provide an update on opioid use in Minnesota, as well as how the state is responding to the problem and its effectiveness. “This is something we’ve been working on a lot over the past year,” said Jesson. “We have great concerns and we’ve made a real push on this issue. When I got the letter, I was happy to be able to say we had a head start on this in Minnesota. We have a team already in place that’s working on this, and I was really glad to see that the federal gov-


ernment was also making opioid addiction a focus.” In the letter, Jesson noted concerns associated with over-prescription of opioids and the availability of heroin, a drug that many people addicted to prescription pain killers turn to. Among the concerns cited by Jesson: Minnesota ranked first among all states for deaths due to drug poisonings among American Indians and Alaskan Natives; about 3,000 people enrolled in Minnesota Health Care Plans (MHCP) become chronic opioid users each year; more than 80 percent of new chronic opioid users have a recent mental illness or substance abuse disorder, or both, increasing the risk of developing a dependency; more than half of pregnant women in the state who are dependent on opioids continue to receive opioid prescriptions for pain throughout pregnancy; and the number of pregnant American Indian women prescribed these drugs during pregnancy is twice as high as that of other

Minnesota Physician June 2015

Minnesotans. “It was not an easy letter to respond to,” said Jesson. “It makes you step back and think about many concerns, like the increase in heroin addiction in the state, which is ultimately driven by prescription drug abuse. We’ve seen treatment admissions for heroin addiction about double over the last five years. That’s very concerning.” Jesson’s proposed response would form a community-based Opioid Prescribing Work Group (OPWG) that would recommend protocols to address all phases of the opioid prescribing cycle. OPWG would notify providers enrolled in MHCP when they fall behind on quality improvement thresholds, require them to submit a plan to get back on track, and disenroll those whose practices are “so inconsistently extreme that they meet OPWGrecommended opioid disenrollment thresholds.” Another strategy includes changing the way opioid addiction treatment is addressed to include expansion of

medication-assisted therapies, as the traditional 12-step programs aren’t effective for some patients with opioid dependence. DHS will work with the Minnesota Medical Association to determine stricter opioid medication prescription standards. DHS also plans to address neonatal exposure to opioids, with a specific plan to address the impact of opioid addiction among American Indian women of childbearing age, including developing a culturally based model spanning prevention, treatment, and recovery and encouraging substance abuse screening for all pregnant women with a referral for treatment services when necessary. “Half of pregnant Native American women who are known to be dependent on opioids are still prescribed them for pain during pregnancy,” said Jesson. “Our goal is to work with the tribes to develop more culturally appropriate services for pregnant women so we can help them with this issue.”

Allina Health, Mayo Foundation Named Top Large Hospital Systems in U.S. Two Minnesota hospital systems rank first and second among the nation’s top five large hospital systems, according to the seventh annual report released by Truven Health Analytics. Minneapolis-based Allina Health was ranked first and Rochester-based Mayo Foundation was ranked second, followed by hospital systems in Ohio, Michigan, and Indiana. According to Truven, these hospitals demonstrate top performance in how patients are cared for through clinical measures and how the hospital performs as a business, including cost of care and operational efficiency. “Behind each of the figures they analyzed lies real people who were positively affected by the care we provided to them,” said Penny Wheeler, MD, president and chief executive officer at Allina Health. “Our employees and our hospitals are changing lives for the better and I couldn’t be more proud that we’re being recognized for this important work.” Truven analyzed data from 340 health systems and 2,812 member hospitals to determine the top five large, medium, and small health systems. Large hospital systems were defined as having annual revenue greater than $1.5 billion. No facilities in Minnesota made the top five medium or small health systems, but geographically it had the highest concentration of top health systems along with Indiana, which also had two health systems in the top 15. Overall, the top 15 health systems spent 7 percent less per care episode, experienced 1.2 percent fewer deaths, had 5 percent fewer complications in patients, had 10.9 percent better patient safety performance, and had better adherence to core measures than those that did not rank. “Superior health system leadership has become the fun-

damental impetus for success in the post-reform healthcare environment,” said Mike Boswood, president and CEO of Truven Health Analytics. “By outperforming their peers across a wide range of key clinical and administrative performance measures, the leaders of the 15 Top Health Systems have shown that it is possible to consistently deliver higher quality care at a better value. It is an honor to recognize the efforts of these leadership teams.”



MN Obesity Rates Lower than Those in Neighboring States Obesity rates in Minnesota have stayed steady, unlike other states in the region, according to a recent report from the Minnesota Department of Health (MDH). MDH analyzed data from the Centers for Disease Control and Prevention’s (CDC) Behavioral Risk Factor Surveillance System, which surveys 400,000 Minnesotans annually. They found that obesity rates in Minnesota dropped below 26 percent in 2010 and have stayed below that rate since. It was the only state in the region to bring the rate below this threshold. Meanwhile, other states in the region, which includes Iowa, North Dakota, South Dakota, and Wisconsin, saw obesity rates increase to between 29 percent and 31 percent in 2013, the most recent CDC data available. The report also shows that the number of Minnesotans that were at a healthy weight in 2013 increased by more than 60,000 since 2010. According to MDH, this is more than 11 percent higher than the U.S. overall. The reduction in obesity rates leads to significant cost savings as well. MDH estimates that the state saved $265 million in obesity-related medical expenses as of 2013. In addition, about 18,600 Minnesotans covered by state health care plans moved to a healthy weight in 2013, which MDH estimates saves up to $9 million for taxpayers each year. Ed Ehlinger, MD, Minnesota Capsules to page 12

Behavioral Health Homes A new pathway to care

Thursday, October 29, 2015 • 1:00-4:00 PM Downtown Minneapolis Hilton and Towers Background and Focus: Increasing evidence supports the link between access to mental health care and reducing health care costs. Primary care physicians often lack the expertise to diagnose behavioral health correctly and are not always able to easily refer a patient to a mental health care provider. Many initiatives nationwide are addressing this issue. It is so important that the ACA stipulated the development of the Behavioral Health Home in 2015. Some states, including Minnesota, are also creating Behavioral Health Home programs. Objectives: We will review numerous initiatives that support the development of the Behavioral Health Home. We will define this term and discuss how to incorporate it into our health care delivery system. We will examine the value it can bring and the challenges it will face. Our panel of industry experts will outline the steps that must be taken to increase the overall access to mental health care and the broad improvement in population health that this increased access will bring. Panelists include: • L. Read Sulik, MD, PrairieCare Sponsors include: • PrairieCare Please send me tickets at $95.00 per ticket. Tickets may be ordered by phone at (612) 728-8600, by fax at (612) 728-8601, on our website (mppub. com), or by mail. Make checks payable to Minnesota Physician Publishing. Mail orders to MPP, 2812 East 26th Street, Mpls, MN 55406. Please note: tickets are non-refundable. Name Company Address City, State, ZIP Telephone/FAX Card #  Check enclosed  Bill me

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Capsules from page 11

commissioner of health, reports that Minnesota’s progress on obesity rates is related to the Statewide Health Improvement Program, a program enacted in 2008 in response to increasing health care costs due to obesity. “Obesity is a complex condition with many contributing factors,” said Ehlinger. “We know diet and exercise are key, and I am confident that Minnesota’s success is closely tied to investments by the Statewide Health Improvement Program and its community and private sector partners to increase Minnesotans’ opportunities for healthy eating and physical activity.”

Hospitals Awarded for Excellence in Cancer Care Three Minnesota facilities have been recognized with an Outstanding Achievement Award

from the American College of Surgeons’ Commission on Cancer (CoC) for achieving excellence in patient cancer care, including prevention, early diagnosis, research, and education. Only 75 cancer programs in the U.S. received the award, representing about 15 percent of programs surveyed in 2014. “These 75 cancer programs currently represent the best of the best—so to speak—when it comes to cancer care,” said Daniel McKellar, MC, FACS, chair of the CoC. “Each of these facilities is not just meeting nationally recognized standards for the delivery of quality cancer care, they are exceeding them.” Park Nicollet Frauenshuh Cancer Center in St. Louis Park; St. Joseph’s Medical Center in Brainerd; and St. Francis Regional Medical Center in Shakopee received the award. “More and more, we’re finding that patients and their families want to know how the health care institutions in their

communities compare with one another,” said McKellar. “They want access to information in terms of who’s providing the best quality of care, and they want to know about overall patient outcomes. Through this recognition program, I’d like to think we’re playing a small, but vital role, in helping them make informed decisions on their cancer care.”

North Memorial Recognized for Stroke Care North Memorial Hospital has received the Get With the Guidelines Target: Stroke Honor Roll-Elite Quality Achievement Award from the American Heart Association/American Stroke Association. The award is given at three levels—Honor Roll, Honor Roll-Elite, and Honor Roll-Elite Plus, based on the average time it takes to provide ischemic stroke

patients with tPA, the drug given intravenously to reduce the effects of a stroke. Over a 12-month period, North Memorial treated at least 75 percent of its ischemic stroke patients with tPA within 60 minutes of arriving at the hospital. North Memorial was one of 559 hospitals to qualify for one of the levels of Target: Stroke Honor Roll awards. “Studies have shown that hospitals that consistently follow Get With The Guidelines quality improvement measures can reduce length of stay and 30-day readmission rates and reduce disparities in care,” said Deepak Bhatt, MD, MPH, national chairman of the Get With The Guidelines steering committee, executive director of Interventional Cardiovascular Programs at Brigham and Women’s Hospital, and professor of medicine at Harvard Medical School.

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Minnesota Physician June 2015

Medicus Rahul Koranne, MD, MBA, FACP, board-certified in internal medicine and geriatrics, has joined the Minnesota Hospital Association as its first senior vice president for clinical affairs and chief medical officer. He has served in Minnesota health care systems for the past 16 years, beginning at a 19-bed rural hospital in Starbuck, Minn. for five years and, Rahul Koranne, MD most recently, as vice president and executive MBA, FACP medical director at HealthEast Care System for 10 years. Koranne also serves on the board of the Wilder Foundation in St. Paul and on the faculty at several schools at the University of Minnesota, including the Carlson School of Management. He attended medical school at the University of Delhi in India, completed his internal medicine residency at the State University of New York in Brooklyn, and his fellowship in geriatrics at the University of Minnesota, where he also earned a master’s degree of business administration. Terrence Cascino, MD, a board-certified neurologist at Mayo Clinic, has been chosen as the 34th president of the American Academy of Neurology (AAN), the world’s largest professional association of neurologists. He has been with Mayo Clinic since 1982, where he is professor of neurology and neuro-oncology. He has taken several leadership roles in his time at Terrence Cascino, Mayo: the vice chair of the department of neuMD rology, the chair of the Clinical Practice Committee, and the Juanita Kious Waugh executive dean for education. He earned his medical degree at Loyola University Chicago Stritch School of Medicine, completed an internship at Rush-Presbyterian–St. Luke’s Medical Center in Chicago, and a residency at Mayo Graduate School of Medicine. Cascino has already served in several leadership positions within AAN. Patrick Zook, MD, board-certified in family medicine has been named a CDC Childhood Immunization Champion for his success in increasing pertussis vaccination rates in St. Cloud through community partnerships. Zook has worked with St. Cloud Medical Group since 1977. He serves as president of the Stearns Benton Medical Society, a community of phyPatrick Zook, MD sicians that works to improve the well-being of people in Central Minnesota, and is a member of the Minnesota Medical Association. Zook earned his medical degree at Creighton University School of Medicine, and completed a residency and internship at St. Joseph Hospital in Omaha, Nebraska. Paul Hartleben, MD, MBA, board-certified in orthopedic surgery, has joined St. Croix Orthopaedics as a spine surgeon. He has practiced as an orthopedic surgeon for 30 years, and has served as a teacher and held executive leadership positions in Minneapolis and St. Paul. Hartleben is licensed to practice in Minnesota, Wisconsin, and California. He earned Paul Hartleben, MD, his medical degree at the University of MinneMBA sota, where he also completed a residency and internship in orthopedic surgery, and completed spine fellowship training at the University of California, Los Angeles. Hartleben is now seeing patients at St. Croix Orthopaedics clinics in Stillwater and Wyoming.


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Jul 5– Aug 1

Celebrate Cuba!

with Coro Entrevoces and the Minnesota Orchestra


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Singin’ in the Rain—Film

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The Temptations Sun Jul 12 7pm



Rachmaninoff and Brahms Fri Jul 17 8pm

Andrew Litton, conductor / Alessio Bax, piano

Nights in the Gardens of Spain Sat Jul 18 8pm

Andrew Litton, conductor / Alessio Bax, piano

Strauss: The Waltz King

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For a complete list of Sommerfest concerts and FREE musical events, visit us online. 612.371.5656 / Orchestra Hall Artwork based on photos by George Heinrich and Travis Anderson

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June 2015 Minnesota Physician



Improving dialysis patient care zations; and mortality rates in patients receiving care from individual nephrologists. Kidney Care Initiative. The mission of Peer is to improve the quality of dialysis It is important for Peer to disseminate data. Our webpatient care in the United States. Peer and the chief medical site and Twitter account, @peerkidney, allow us to disofficers (CMOs) of 13 participating dialysis provider ortribute Peer research for free. The most important output ganizations together analyze and interpret data to identify to date is an inaugural report, Peer Kidney Care Initiative patterns of treatment, trends in clinical outcomes, and both 2014 Report: Dialysis Care and Outcomes in the United regional and national opportunities for quality improveStates, which addresses the number and health status of ment. Peer aims to clearly describe the complex interaction new dialysis patients; hospitalization; mortality; and the of all health care providers 5-Star Quality Rating System that touch dialysis patients, for Medicare-certified dialyincluding not only dialysis sis facilities. The only way for dialysis providers facilities, but also hospito maintain revenue growth … tals, pharmacies, and phy What are the bigsician practices. Peer offers is to extend patients’ lives. gest challenges to an alternative voice in the improving dialysis formation of policy (especare? cially Medicare policy) that Adequate preparation of the new dialysis patient is a key affects both patients and their health care providers. issue. Rates of hospitalization and death are highly elevated during the first three to six months of dialysis. The majority  How did the Initiative get started? of new dialysis patients are prescribed in-center hemodialyPeer sprouted from the CMO Initiative, which began with a sis with initial vascular access via a central venous catheter. March 2013 meeting convened by physicians Doug Johnson We must do a better job of educating patients about the (Dialysis Clinic, Inc.), Allen Nissenson (DaVita Kidney different dialysis modalities that are available, including Care), and Tom Parker (Renal Ventures Management). A modalities in the home setting, like peritoneal dialysis (PD) second meeting of the CMO Initiative, held in March 2014, and home hemodialysis (HHD). For patients who choose to began to discuss a comprehensive effort to improve patient receive dialysis in-center, early creation of a permanent acoutcomes through collaborative analytics and standardized cess is important. The arteriovenous fistula is the preferred reporting, with Medicare data as the foundation. access type, but grafts may be underused in some patient subgroups, such as the very elderly, in which the probability  How did the Chronic Disease Research Group of fistula maturation is likely lower. (CDRG) become involved with this program? Another challenge is cardiovascular disease manageI was an invited speaker at the second CMO Initiative and ment. This field is generally lacking in high-quality data spoke about how the richness of data might be harnessed from randomized clinical trials. Cardio-protective drugs to track local and national progress toward improving widely used in the general population were never subjected patient outcomes. During the ensuing months, the CDRG, to trials in dialysis patients. For example, it is unknown a nonprofit research group with a long history of publishing whether ACE inhibitors and ARBs are effective therapies epidemiologic studies of chronic kidney disease, particfor congestive heart failure in dialysis patients. Lisinopril, ularly using administrative data (e.g., Medicare claims), the dominant ACE inhibitor in dialysis patients, is removed and the leaders of the CMO Initiative organized the Peer by dialysis, whereas ARBs, including losartan and valsarKidney Care Initiative. tan, are not. To this point, Canadian researchers recently published observational data that the dialyzability of indi What type of work does the Peer Kidney vidual beta blockers may be meaningfully associated with Care Initiative do? risk of death. The CDRG essentially operates a Data Coordinating Center Infection control is another major issue. Infection-re(DCC) for Peer. Peer’s most important task is to design, lated admission rates have remained stubbornly high, deperform, and interpret studies of Medicare claims to adspite increased reliance on fistulas for vascular access. How dress clinical questions that the Peer Steering Committee can we better prevent infectious disease? We administer is particularly interested in, such as the management of influenza and pneumococcal vaccines to dialysis patients, cardiovascular disease (a leading cause of morbidity and but these patients have compromised immune function. mortality in dialysis patients) and the control of infection. So the standard influenza vaccine or one pneumococcal Thus, many studies are designed to address these issues. The DCC also provides facility-level and organization-level vaccine every five years may not be enough; instead, highanalytics to Peer members. Some examples of these analyt- dose influenza vaccines and more frequent pneumococcal ics include cause-specific mortality and hospital admission vaccines may be warranted. When in-center hemodialysis patients present symptoms of respiratory infection, do they rates in patients at individual dialysis facilities; use of receive dialysis in isolation areas or do they receive dialysis cardiovascular-related medications in individual organi-

 Please tell us about the mission of the Peer

Allan J. Collins, MD, FACP Chronic Disease Research Group Dr. Collins is board-certified in internal medicine and nephrology and has more than 30 years of experience in nephrology and ESRD treatment. He is director of the Chronic Disease Research Group and professor of medicine at the University of Minnesota. Dr. Collins served as president of the National Kidney Foundation (NKF) from 2006–2008 and received the Belding H. Scribner Award from the American Society of Nephrology in 2014.


Minnesota Physician June 2015

near other patients who are otherwise healthy?  Can you analyze the problems facing Does dialysis facility staff clean all surfaces in the the Initiative from a financial perfacility, or is periodic cleaning limited to dialysis spective? machines and chairs? These are practical issues that Dialysis providers are at an interesting crossroads. demand attention. About 110,000 people start chronic (or maintenance) dialysis each year. At this moment, some What can you share with us about the where near 475,000 people are receiving chronic dialysis. The number of new dialysis patients scope of the problems faced by the per year has stabilized recently. Importantly, the Peer Kidney Initiative? reimbursement landscape appears to be tightening. In addition to clinical issues, dialysis providers currently face a number of regulatory issues. Medi- Medicare is unlikely to increase reimbursement care introduced a Quality Incentive Program (QIP) rates for outpatient dialysis treatment in the next several years ago and added a 5-Star Quality Rating five to 10 years. However, inflation in medical professional wages and dialysis supplies, including System for dialysis facilities at the beginning of 2015. Each of these systems involves a combination the drugs administered during dialysis, will likely continue. From a business perspective, the only of metrics that directly relate to the care provided way for dialysis providers to maintain revenue by dialysis providers (e.g., the distribution of Kt/V growth (and remain financially viable) is to extend and the prevalence of hypercalcemia) and metrics patients’ lives and reduce patients’ time in the that relate to global outcomes, like mortality, hospitalization, and 30-day rehospitalization. The chal- hospital. lenge with metrics about global outcomes is that they demand risk adjustment. However, the data  How do these problems impact imunderlying current risk adjustment schema are proved quality and length of life? mostly derived from Medicare claims. Although Dialysis patient survival has steadily improved in claims are a useful source of data about patient recent years. On the other hand, hospitalization health, they are not medical charts and they reveal rates have declined only modestly and, between relatively little about the severity of individual 2010 and 2012, use of the emergency and observacomorbid conditions and, critically, socioeconomic tion rooms (followed by discharge home) actually status. Peer will offer a voice in the development increased. Decreasing the burden of morbidity will and validation of important quality metrics. require better care, which requires more resources,

but without increases in reimbursement, providers will need to consider novel solutions. Participation in ESRD Seamless Care Organizations (ESCOs) may be a viable route. Delivering more dialysis in patients’ homes may be another way as well.

 How will the Peer Initiative benefit future dialysis patients? Surprisingly, dialysis providers do not have direct access to Medicare claims and, in practice, have difficulty acquiring records from acute and postacute care providers in a timely manner. Providers certainly know what happens inside their dialysis facilities, but have relatively less knowledge of the morbidity that necessitates emergency and inpatient care of their patients. Peer will provide analytics about such care to its members, so that each might target the domains in which performance is poor. The collaborative nature of 13 dialysis providers participating in one consortium also permits the free exchange of ideas that have led to clinical successes in one or more organizations.

 How can doctors refer their dialysis patients to this initiative? At this point, doctors may encourage patients to examine Peer research at In the future, Peer intends to engage patient advocacy organizations more directly.

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The Minnesota Accountable Health Model from cover

control. Sometimes the medical piece seems easy compared to the social piece. Stable housing is likely the most effective prescription for a homeless patient with diabetes. Research on what creates and shapes health indicates that only about 10 to 20 percent of health is attributable to medical care. The remaining 80 to 90 percent is often shaped by social, behavioral, and environmental factors. This connection between health and social determinants, such as financial security, safety, education, and other social supports is why collaboration has become so central to innovative attempts to improve the health of populations. Minnesota is at the forefront of these innovations with a number of private and public initiatives. Currently Minnesota’s reform efforts include a $45 million State Innovation Model (SIM)


Grant to implement and test the Minnesota Accountable Health Model. SIM and the Minnesota Accountable Health Model In February 2013, Minnesota was one of six states (Minnesota, Massachusetts, Maine, Vermont, Oregon, Arkansas) awarded a federal testing grant of $45 million to implement the Minnesota Accountable Health Model over three and a half years. The project is a joint effort between the Minnesota Department of Human Services (DHS) and the Minnesota Department of Health (MDH) with support from Gov. Mark Dayton’s office. The grant is part of the State Innovation Models Initiative through the Centers for Medicare & Medicaid Innovation (CMMI). Key aspects of the initiative include:

Minnesota Physician June 2015

• A new payment model: The Minnesota model includes a move away from a feefor-service payment model

toward financial arrangements that reward providers and communities for keeping patients healthy. The model shifts the ma-

health care system.

• Exchanging and using data: A large portion of the funds will go to giving health care providers additional support to collect, use, and exchange clinical data using electronic medical records and patient registries, and to enhance the state’s ability to provide meaningful and actionable data about the cost and Financial arrangements quality of care … reward providers and to providers. This informacommunities for keeping tion will allow patients healthy. providers to better manage the care of a population of jority of health care paypeople, and improve the ments to a shared risk and quality and cost of their shared-savings payment care. arrangement. For example, • Practice transformathe model expands Mintion: About 14 percent of nesota’s current Medicaid Minnesota’s SIM funds Integrated Health Partare dedicated to practice nerships (IHP) and other transformation. A key goal Accountable Care Orgais to transform care in nization (ACO) models in Minnesota so that every the market. Providers are patient receives coordinatheld accountable for the ed care that considers the health of their patients and whole person and is pareceive financial benefits tient centered. The model when their patients stay seeks to do this by promothealthy and out of highing short-term learning er-cost settings when not communities, practice medically necessary. facilitation through inten• Partnering with commusive internal coaching, and nities: The model also practice transformation will include incentives for grants up to $20,000 for communities and care small and rural providers. providers to partner and In addition, the project work together. The projsupports expansion of ect has identified up to 15 health care homes and the Accountable Communities development of behavioral for Health (ACH) across health homes and integratthe state that will put foring new professions into ward innovative proposals care delivery teams. and strategies for coordinating care across settings Tapping into the Minnesota and improving the health Accountable Health Model of a particular population In broad strokes, all of the of people (see the sidebar above efforts are designed to on page 17). A community support physicians in their may be a county, a resefforts to provide team-based ervation, a city housing care that focuses on the whole project, or the patients in a

patient. New payment methods can free health care teams to improve outcomes without the constant constraints of billing codes. Adding emerging professionals such as community paramedics, dental therapists, and community health workers can help expand the reach of the care team into the community. Improved electronic health information systems and improved analysis of population and care data can help physicians better tailor individual treatment plans and population-based clinic initiatives. Along these lines, standardized performance targets and quality measures coupled with useful data analytics can help clinics and hospitals understand their practice patterns and outcomes and design innovative horizontal care pathways that span the entire continuum of care. Accountable Communities for Health will help deliver services that wrap around and closely align with medical care, particularly for complex patients. Take for example, a patient in her 70s, who is slowly declining from congestive heart failure. One of her doctor’s chief concerns is whether she can care for herself when she returns to the community. This is where the ACH partners could step in as a trusted source because they know about the transportation options to take her down the street to the adult day care center and to the pharmacy around the corner. The goal is that clinicians and the ACH partners would work together to provide a full complement of services for the whole person. Or perhaps the ACH partners working in collaboration with the primary care provider help keep patients out of the clinic all together. For example, a health system might use data to identify that many of its patients with asthma live in a particular substandard housing complex. The ACH could take this data and work with local housing regulators and officials to eliminate asthma triggers

Accountable Communities for Health The SIM initiative funded 15 Accountable Communities for Health through a competitive process. Grant awards went to communities in all regions of the state and at different levels of participation in accountable care models. 1. Allina/Northwest Metro Healthy Student Partnership, Minneapolis 2. CentraCare Health Foundation, St. Cloud 3. Essentia Health–Ely Clinic, Ely 4. Generations Health Care Initiatives, Duluth 5. Hennepin Health, Minneapolis 6. Hennepin County Medical Center, Minneapolis 7. Lutheran Social Service of Minnesota, St. Paul 8. Mayo Clinic, Rochester 9. New Ulm Medical Center, New Ulm 10. North Country Community Health Services, Bagley 11. Otter Tail County Public Health, Fergus Falls 12. Southern Prairie Community Care, Marshall 13. UCare Minnesota, Minneapolis 14. Unity Family Healthcare, Little Falls 15. Vail Place, Hopkins

from the housing facility. Change is underway This transformational journey has begun and the work is already underway. The SIM project is close to achieving its goal of having 200,000 Minnesota Medicaid enrollees receiving care from an Integrated Health Partnership. SIM has also distributed grants for e-health, practice transformation, emerging professionals, and Accountable Communities for Health. In the area of e-health, the initiative awarded 12 e-health grants to community collaboratives for a total of $3.8 million. A $600,000 contract was awarded to partner with MDH and the Minnesota e-Health Initiative to develop e-health roadmaps. Two grants focused on privacy, security, and consent management for the electronic health information exchange were also awarded. In the area of practice transformation, the initiative awarded 10 grants for a total of $194,768 and has released a second round to fund 10 to 15 projects with a maximum of $300,000 in available funds. The ACH grants started between November 2014 and

February of this year and will be in effect through December 2016. ACH grants stress the involvement of community

members such as social service organizations and consumers in a collaborative effort to improve health for a target population in a holistic way. They are to provide a full spectrum of supports and services (besides medical services) that an individual might need for health including access to healthy food, physical safety, mental health or chemical dependency counseling, housing, home care, or rehabilitation services. For example, the Hennepin Health ACH grant project connects individuals within the Hennepin County correctional system with health care programs, housing, jobs and training, healthy food, and other supports necessary for staying out of jail. Project goals are to reduce homelessness and recidivism among jail and adult correctional facility clients, improve key indicators of health such as blood pressure and The Minnesota Accountable Health Model to page 46 | Minneapolis | St. Cloud | Fargo, ND | Washington, DC

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June 2015 Minnesota Physician


The e-health roadmap from cover

ue-based payments. By the end of 2016, 30 percent of payments will be tied to these models. By 2018, 50 percent will be. HHS also plans to tie 90 percent of all traditional Medicare payments to quality or value by 2018 through programs like Hospital Value-Based Purchasing and Hospital Readmissions Reduction. One colleague recently shared that 70 percent of his clinic’s patients are already coming in as pay-for-performance. The future of payment reform is definitely upon us. Physician offices and hospitals need to work more closely with partners across the care continuum to ensure the best care for their patients overall and as patients transfer between settings. Federally Qualified Health Centers (FQHCs) will tell you that they are living these changes now and trying to fix issues on the fly. In the absence of having access to patient med-

ical records due to the lack of connectivity to other providers who have cared for the populations they serve, one FQHC clinic used claims data as a crude substitute. Although not current, the data still made a difference in the clinic’s ability to serve patients by giving them

The future of payment reform is definitely upon us.

a rudimentary medical history. Having an accurate history is why all providers need to work together using better tools, such as e-health. Each physician is one of many players on the team that supports a patient’s care. Other caregivers and community members are also integral to supporting the best health for patients. It is important to consider the community when it

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Minnesota Physician June 2015

e-health to improve care The Minnesota e-Health Roadmaps will provide a framework for the four settings of long-term and post-acute care, local public health, behavioral health, and social services. It will help them effectively implement health information exchange (HIE) and electronic health record (EHR) systems to support patient care internally and across the care continuum. The roadmaps will aid these settings in adopting interoperable health information technology and improving everyone’s ability to provide coordinated care and manage population health. I am an advocate for the adoption and effective use of health information technology (HIT). My experience with these systems as a physician in a clinic and hospital has convinced me of its ability to facilitate better care, improve health care quality, increase patient safety, reduce health care costs, and enable individuals and communities to make better health decisions. It is important that all players in the health care continuum have access to these tools and use them effectively. The good news is that EHR adoption rates for clinics, hospitals, and local health departments are well over 90 percent in Minnesota. Nursing homes come in just under 70 percent. The Minnesota e-Health Roadmap Project will conduct an environmental scan of each of the four settings to determine their e-health status and begin to understand EHR use in behavioral

health and social services. On the flip side, a 2013 Minnesota Department of Health (MDH) study documented a significant gap for local public health in health information exchange with both hospitals and primary care clinics. While nearly all of Minnesota’s community health boards, which run the local health departments, identified the need to exchange information with hospitals and clinics, less than half actually exchanged data with partners. EHRs and health information exchanges are key tools that facilitate communication and promote coordinated care. Communication among health care professionals and their patients and families is necessary. It ensures that everyone understands the care plan, including the patient’s responsibility for self-care, and that they are able to identify any additional help that may be needed such as respite care. Communication among teams of health and social service professionals is also important, particularly when individuals transfer between care settings. Recognizing this, the Minnesota e-Health Initiative identified the four settings as being instrumental in moving the state toward coordination and collaboration. There is clear evidence that we physicians need to understand more about our patients. The 2014 Institute of Medicine (IOM) report, Capturing Social and Behavioral Domains in Electronic Health Records, recommended inclusion of social and behavioral health domains in EHRs. IOM believes this data is vital to providers treating individual patients; to health systems and public health officials about the health of populations; and to researchers studying the determinants of health and the effectiveness of treatment. Some of this data—like food and housing insecurity, depression, social connections, and social isolation—might best come from our partners providing care in other settings like social services and behavioral health to help shine a light on more of our patients’ needs.

If care is to be coordinated effectively, all communication must be timely and include the information that all team members need so the care they provide is aligned with a patient’s goals and desires. The Minnesota e-Health Roadmap Project The Minnesota e-Health Roadmap Project is a collaborative effort to describe a path forward for using e-health more effectively to deliver high-quality, coordinated care and healthier communities in the settings of behavioral health, local public health, long-term and post-acute care, and social services. As part of the Minnesota Accountable Health Model, this work is funded by a $45 million State Innovation Model (SIM) cooperative agreement, awarded to the Minnesota Departments of Health and Human Services in 2013 by the Center for Medicare & Medicaid Innovation. The roadmaps will include

concrete, achievable shortterm goals and longer-term aspirational goals. This work, facilitated by Stratis Health and the Minnesota Department of Health, is being led by workgroup co-chairs who are leaders in their respective settings. About 60 people are participating in four setting-specific workgroups to develop the roadmaps. Additionally, over 800 individuals have asked to be kept apprised of this work through email updates—that level of interest reflects the broad implications for this work. A foundational part of the roadmap work will be to develop use cases of typical patient scenarios. Use cases will highlight the various factors that come into play as a patient moves across settings of care. For example, the care coordination of an 83-year-old female with limited income and assets, who is enrolled in a managed care program, will be understood in relation to business drivers, consumer engage-

ment, technology, information needs, mandates and reporting requirements, legal issues, workforce development, and other components. From these scenarios, the workgroups will develop approaches for successful care delivery in the use cases, noting how e-health can play a role. These approaches will be combined to develop strategies for the roadmaps. The roadmaps are not intended to be detailed implementation guides. Instead, they will describe a path forward and identify the steps to be used by providers, organizations, leadership, the state, EHR and HIT vendors, and other stakeholders. The roadmaps will produce greater collaboration within the network that supports patients. It’s certain that the paths described in the roadmaps will identify key roles for physicians as part of the interconnected community that supports patients in Minnesota. We can stay informed about the progress of the Minnesota e-Health

Roadmaps Project by signing up to get email updates (http:// or reading the roadmaps when they come out in spring 2016. The recommendations for policymakers, payers, service providers in the four settings of care, health IT vendors, and others will have implications for all of us. Organizations across the country are watching Minnesota’s leadership in furthering these settings’ use of e-health. Accelerating e-health adoption and effective use has the potential to enhance individual and community health. We physicians should be watching too. Paul Kleeberg, MD, is a family phy-

sician who has practiced rural family medicine and has implemented and used several EHR systems. He is chief medical informatics officer for Stratis Health, a nonprofit quality improvement organization based in Bloomington and clinical director for the Minnesota/North Dakota Regional Extension Assistance Center for HIT. He chairs the Healthcare Information and Management Systems Society (HIMSS) board of directors.

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Physician support services

“As much as physician burnout is discussed, it seems administrators sweep it under a rug. I have received two onepage handouts from the Physician Retention Committee. That is their net contribution to physician support.”

Physician burnout A growing problem By Rebecca Hafner-Fogarty, MD, MBA

do a better job and invest more resources into both preventing the burnout from occurring in the first place, and identifying and caring for physicians at the first sign of burnout.

Burnout prevention all respondents identified them- Both society and the individual his morning as I was physician make huge investopening up my computer, selves as moderately to severely ments of time and money to stressed; and 46 percent specia Medscape email headtrain a doctor. We need to fied severe stress and burnout. line caught my eye, “Physician consciously and thoughtfully Burnout Increases 16 Percent in “Poor hospital safeguard this investment by Just Two Years.” Unfortunately, Why pay attention to this? administrators who explicitly teaching resilience similar alerts and headlines are Stressed out and burned out are not supportive of and self-care skills to medical becoming increasingly comphysicians are more likely to physicians are one of the students and residents, and mon in both the medical and leave the profession. In addigreatest challenges we face make burnout prevention a popular press. A 2015 survey priority for in health care today.” by VITAL WorkLife hospitals, and Cejka Search “Greater support by clinics, and showed that stress administration. Society health sysand burnout is not tems. needs to go back to the only prevalent, but Burned out physicians are more is increasing (see basic principle that Educalikely to leave the profession. Figure 1 on page 21). respect goes both ways.” tion is one Almost 66 percent way to help of the over 2,000 reprevent spondents indicated burnout. 2015 Physician Survey they experienced Respondents According to more stress and burnout than tion to the imminent bubble Elizabeth Grace, MD, medical in the 2011 study; 88 percent of of retiring baby boomer physidirector of the Center for Percians, the departure of burned sonalized Education for Physiout physicians may compound cians (CPEP), “CPEP believes looming physician shortages. stress and burnout contribute Burned out physicians can to the professional difficulbecome angry and disruptive or ties many of our participants can develop mental health and experience. It is disturbing to chemical dependency probsee such a large percentage of lems. This pattern can lead to health care providers experidecreased quality of care where encing stress and burnout. UnQuality Transcription (located in Minnesota) errors could potentially harm fortunately, the upward trend maintains a professional office environment, patients. For the physician, the in the percentage of health care thus the confidentiality of your work is strictly ultimate result of this downprofessionals experiencing such Setting maintained. We provide medical transcription ward spiral may be career damhigh levels of stress will likely services on a contract or overload basis. the aging or end in disciplinary continue for the foreseeable Our equipment is state of the art with 24 hour action by state medical boards. future, due to the rapid rate of standards dictation lines and nationwide accessibility. change and increasing deThe 2015 VITAL Workfor We are experts in our field. We deliver on mands on physicians’ time.” Life and Cejka Search survey time. We have experienced staff. We monitor excellence the quality of our work. indicates physician stress and Normalizing work/life balburnout continues to increase ance—what it is, how to achieve We provide services tailored to your needs and at virtually every level, yet only it—is another way physicians will do whatever it takes to get the job done. a small number of respondents, and their organizations can 18.5 percent, report that their safeguard against burnout. organizations have initiatives in It ties directly to what most place to deal with stress and/or physicians say they want—a burnout (see the sidebar on this better work/life balance. Yet, Quality Transcription, Inc. 8960 Springbrook Drive, Suite 110 page). These findings are up this is the most difficult thing Coon Rapids, MN 55433 from 15.7 percent in 2011. The to achieve. Encouraging physiTelephone 763-785-1115 continued rise in burned out cians to achieve healthy behavToll Free 800-785-1387 physicians suggests these initia- ior through training for wellFax 763-785-1179 tives are either not enough, not ness, changing ingrained habits e-mail relevant, not accessible, or unand perceptions, and adopting Website known to physicians. It seems cultural change are important physicians and patients would steps. This change must also be be better served if we could all supported by changes in their


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Minnesota Physician June 2015

work environments and how they do their jobs. Creating a better work/life balance ensures that physicians are healthier, happier, more productive, and satisfied with their current jobs and roles. While some physicians simply choose to leave the profession completely, others seek educational support to learn better skills. CPEP offers a number of personalized education programs for physicians, incorporating a burnout inventory as part of a clinical competence assessment. This helps participants gain insight into the impact of burnout on their practice. Caring for colleagues experiencing stress and burnout Organizations can help physicians understand it is okay to ask for help and provide confidential and convenient resources to accomplish this. Many physicians are reluctant to ask for help, yet they’re often in desperate need of a compassionate listener, mentor, or coach who understands the professional, personal, and family challenges they face. When organizations invest in their physicians and health care providers by offering support and well-being solutions, they differentiate themselves as caring and concerned and may experience lower physician turnover. Some organizations, ranging from health systems to medical societies, are developing their own physician burnout prevention and care programs. The number one solution physicians believe will help reduce stress and burnout is a better work/life balance. Some organizations are doing an excellent job of helping individuals and teams reduce stress and burnout through internal programs and education. Others may contract with outside organizations to provide this service or provide effective, preventive support programs to not only educate, but to also provide resources, counseling, mentoring, or peer coaching. An example of an innovative

and effective Figure 1. Change in physician reported stress approach for helping physicians deal with increasing levels of stress and burnout comes from Lake Region Health (LRH) in Fergus Source: VITAL Worklife, Inc., 2015 Falls. Patricia Source: VITAL Worklife, Inc., 2015 Lindholm, MD, FAAFP and former presiRebecca Hafner-Fogarty, MD, over $500,000 on average for dent of the Minnesota Medical MBA, is the chief medical officer each physician not retained Association states, “Burnout is Why pay attention to this? of Zipnosis. She is also a long-time (based on the cost of recruiting created in an environment of member of the Minnesota Board of and onboarding, plus fees for high responsibility/demands on Medical Practice, serving president Stressed out and burned out physicians are more likely toasleave the sourcing, advertising, intera health care provider coupled in 2009, and is currently chair of viewing, relocating, and signing the Licensure Committee. She has with a low sense of control over their workload. This only also been an member of the profession. Inbonuses). addition to the imminent bubble ofactive retiring baby worsens with the increased Minnesota Medical Association for Physicians are a precious reporting required of our pracover 35 years and has held numerresource the and they are suffering. boomer physicians, departure of burned out physicians may ous leadership positions within the tices and doctors. Meaningful When physicians suffer, the organization. Dr. Hafner has served use measurements for EHRs downstream effects are magnia physicianout consultant for VITAL can and meeting quality reporting looming compound physician shortages.asBurned physicians fied across the entire medical WorkLife, Inc. (formerly known as measurements are especially community, impacting patient Physician Wellness Services) since time consuming.” Dr. Lindholm safety and satisfaction, risk 2010 and is a member of their Advibecome angry and disruptive or can develop mental health and continues, “At LRH I started a sory Team. management, staff retention, group with our chaplain several and recruiting. chemical years ago and invited certain dependency problems. This pattern can lead to decreased physicians to attend. This group has expanded and quality developedof care where errors could potentially harm patients. For the over time, but is periodically in need of new infusions of energy. The group physician, has been a the ultimate result of this downward spiral may be career We are specialists in Apple devices (including iPads career saver and lifesaver for and in iPhones) and software. also support Windows some of our physicians where or end damaging disciplinary action We by state medical boards. they can be supported and and Windows to Apple integration. We are certified heard in a safe and confidential through the Apple Consultants Network serving individsetting. The LRH administrauals and businesses inquiring about moving to Apple, tion has been supportive from or how to improve existingSearch systems. 2015 WorkLife and Cejka survey indicates the beginning. We The are given a VITAL private meeting room and meal Services include: costs are covered. physician In visiting stress and burnout continues to increase at virtually every • On-site training – in your other communities, I find that it clinic, hospital or at home seems very difficult to get these level, yet only a small number of respondents, 18.5 percent, report groups started because some• Group Workshops one needs to take the initiative, • Expedited Computer and physicians already that feel their organizations Repairs have initiatives in place to deal with stress overwhelmed. Organizations providing this level of support • Data Recovery can be the catalyst to positive • System upgrades change.” 2

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Dr. Lindholm’s program is effective, but not expensive. By contrast, turnover due to physician stress and burnout is increasing for health care organizations and is an expensive problem. Annual physician turnover is at an all-time high. The expense and challenge of recruiting new physicians and the cost of onboarding a new physician can add up to

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2015 health care architecture honor roll 22


innesota Physicianâ&#x20AC;&#x2122;s 2015 Health Care Architecture Honor Roll recognizes 10 outstanding projects in urban and suburban Minneapolis and in Hudson, Wis. This yearâ&#x20AC;&#x2122;s Honor Roll projects include new clinics, medical office buildings, a hospital renovation and addition, a long-term care facility, and senior housing. The medical services range from routine clinic visits to specialized care. Populations served include the standard roster of patients seen at outpatient clinics as well as specialized groups such as children, women, and seniors. Although the facilities differ in intended use and population served, they share a focus on providing a healing environment, cuttingedge technology, and patient privacy. Several projects incorporated sustainability and elements of nature into their designs. Senior accommodations have been designed to encourage independence and a sense of community. Minnesota Physician Publishing thanks all those who participated in the 2015 Honor Roll.

Minnesota Physician June 2015

Interlude Restorative Suites Type of facility: Transitional care unit addition to Unity Hospital Location: Fridley Client: B  enedictine Health System (owns 90 percent) and Allina Health (owns 10 percent)

Architect/Interior design: Horty Elving Engineer: Steen Engineering (mechanical/electrical); Pierce-Pini + Associates (civil)

Contractor: McGough and Yanik

Opposite page: Main entrance Top: Reception desk and bistro Right: Lobby and fireplace

Completion date: January 2015 Total cost: $12,169,080 Square feet: 47,418


nterlude Restorative Suites is a three-story addition to Unity Hospital designed as a premier transitional care unit that focuses on exceptional care, quick recovery, and staff efficiency. Guest rooms were designed with a “no wake” policy in mind so patients can sleep without disturbance. Nurse servers let staff stock supplies for patient rooms from the hallway limiting interruptions. Bathrooms have sliding doors to keep swinging doors out


Episcopal Church Home–The Gardens Type of facility: S  killed nursing home/long-term and memory care Location: St. Paul Client: Episcopal Homes of Minnesota Architect/Interior design: T rossen Wright Plutowski Architects

Engineer: Lindell Engineering (mechanical/electrical); BKBM Engineers (structural); Civil Site Group (civil)

Contractor: Benson-Orth Associates Completion date: January 2015 Total cost: $19 million Square feet: 46,200

he Gardens is a seven-story, 60-unit skilled care residence offering long-term and memory care in St. Paul. It is the first nursing home in Minnesota to follow the Green House Model of Care. The residence was designed with six “homes” of 10 residents each, with one home on each floor of the building. Residents have private bedrooms and bathrooms arranged around a central commercial kitchen, dining area with a large, communal table, a hearth room, den, and sunroom. This arrangement encourages interaction between residents and

of the room, and roll-in showers let patients bathe in private. Each floor has an open serving kitchen and personal chef who will cater to a guest’s needs. The therapy space has direct elevator access, so patients can come and go without traveling through public areas. The focus on hospitality and the whole patient experience makes it easy for staff to provide excellent care.

their caregivers. In this setting, residents and staff benefit as they develop meaningful relationships in their daily activities. The Gardens shares a warm-water therapy pool, fitness center, salon, theater, pub, bistro, secure outdoor garden, business center, and meeting spaces with other residences on the Episcopal Homes of Minnesota campus.

Right: Atrium Bottom: Home interior

June 2015 Minnesota Physician


Honor roll 2015 The Cooperage Senior Housing Type of facility: Senior housing Location: M  inneapolis Client: CommonBond Communities Architect/Interior design: LHB Engineer: Steen Engineering (mechanical/electrical); Mattson Macdonald Young (structural); Stantec (civil)

Contractor: Watson-Forsberg Completion date: October 2014 Total cost: $8,785,000 Square feet: 64,338


Top: The Cooperage Senior Housing Bottom: Sunroom

ccessibility, affordability, privacy, and engagement with a larger community were the priorities for the siting, design, and development of The Cooperage Senior Housing project. This 60-unit, energy efficient housing development provides seniors with secure and independent living accommodations. Energy efficient HVAC and lighting systems, rooftop solar panels, and a high-performance building envelope reduce long-term operating costs. Materials were chosen to increase the lifespan of

the building, while reducing the amount of maintenance required. Residents can enjoy sitting in the large sunroom or out in the garden. The private one-bedroom apartments with full kitchens allow for independence. Shared areas such as a serving kitchen, sunroom, and computer lab encourage interaction among residents and build a feeling of community. The Cooperage has heated underground garage spaces and access to the Minneapolis light rail system and the Hiawatha Bike Trail.


Creating Healing Environments for 35 Years Shared Vision • Innovative Design

specializing 4 5 Y E A Rin S h Oealth F E X CcEare L L EF Nacilities CE Congratulations EpisCopal HomEs on your Honor roll award!

medical oFFices and clinics health care campuses research Facilities long term care Facilities rehabilitation and physical therapy Facilities new construction or remodel “We wouldn’t hesitate to work with Engan Associates again.” (Matt Reinertson, Heartland Orthopedic Specialists)

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Minnesota Physician June 2015

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Hudson Hospital/HealthPartners Medical Office Building Type of facility: Medical office building Location: H  udson, Wisconsin Client: Hudson Hospital and HealthPartners Architect/Interior design: Perkins+Will Engineer: BKBM Engineers (civil/structural) Contractor: McGough Completion date: November 2014 Total cost: Withheld Square feet: 40,000


udson Hospital and HealthPartners wanted a new building on the hospital campus that would accommodate community growth for years to come. Separate from, but physically connected to the hospital, the building accommodates a variety of specialty clinics and outpatient centers operated by Hudson Hospital along with several independent practices. Designed with an expanded sense of space, the building incorporates Feng Shui concepts for a calming environment. A water feature under the stairway to the second

level brings a little bit of nature inside. The atrium has floor-to-ceiling windows to bring in lots of natural light, which invites healing. Wood ceilings assist with wayfinding and hallways are lined with rotating artwork from local artists to promote a healing environment. Exterior design was intended to complement existing hospital buildings and earth tones were chosen to reflect plants, earth, water, sky, and fire. Top: Main entrance Bottom: Atrium

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Honor roll 2015 Minnetonka Medical Center Type of facility: Medical office building Location: M  innetonka Client: MMB Medical Partners Architect/Interior design: bdh+young interiors | architecture Engineer: Krech, Oâ&#x20AC;&#x2122;Brien, Mueller & Associates Contractor: Timco Construction Completion date: October 2014 Total cost: $18 million Square feet: 63,500

M Top: Main entrance Bottom: Waiting room and fireplace

innetonka Medical Center incorporates many sustainable aspects into its design. It has a LEED qualified storm water system, rain gardens to prevent runoff, an abundance of green space, and an efficient building envelope that optimizes energy performance. Low-emitting interior building materials improve indoor air quality and assure a healthier interior. To let an abundant amount of natural light inside, the center core of the building features a two-story

anodized metal curtain wall. The exterior features regional building materials including a natural stone base and brick. The front entrance has a large drive-under canopy that shelters patrons from the weather. The sun-filled lobby features a fireplace, artwork from local artists, a waiting room, and an open staircase. The building houses an urgency center, a family practice clinic, and a specialty clinic with a multimedia conference room at their disposal.


U+B architecture & design, an award-winning studio based in Minneapolis, is driven to challenge conventional healthcare architecture. We are committed to understanding physician, staff and patient needs and developing groundbreaking healing environments. Please contact us to learn more. 612.870.2538


Minnesota Physician June 2015

HealthPartners Woodbury Clinic Type of facility: Family practice clinic Location: W  oodbury Client: HealthPartners Architect/Interior design: Pope Architects Engineer: Karges-Faulconbridge, Inc. Contractor: Kraus-Anderson Construction Company Completion date: April 2014 Total cost: $3,300,000 Square feet: 32,350 sq. feet of renovated space; 11,960 sq. feet of new construction


he HealthPartners Woodbury Clinic needed more space to meet high patient volume, improve patient care, and optimize staff efficiency. Registration and patient flow issues were solved by orienting the registration desk so patients are greeted directly when they enter the clinic and then guided to the next spot in line. Architectural elements keep patients separated for privacy during registration. Circulation and flow has been

improved within the clinic and more efficient staff areas and a larger lab were added. Exam rooms have flexible systems furniture so the layout can be changed, which improves patient/provider interaction. New flow stations get physicians out of closed offices so they can collaborate with colleagues and staff. The design lets natural light into the clinic and offers views of the outdoors, which offers a better healing environment.


Top: Woodbury Clinic Bottom: Waiting room

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Contact: Mark L. Hansen, AIA, LEED AP BD+C 952.426.7400 |


June 2015 Minnesota Physician


Honor roll 2015 Methodist Hospital–Family Birth Center Type of facility: Hospital Location: S  t. Louis Park Client: Park Nicollet Health Services Architect/Interior design: AECOM Engineer: MBJ Consultants Contractor: RJM Construction Completion date: February 2014 Total cost: $8,325,541 Square feet: 40,000


Top: Main lobby Bottom: Labor/delivery/recovery suite

he Methodist Hospital–Family Birth Center was remodeled to provide a comfortable, state-of-the-art environment based on research into what millennial moms want in a birth center. Taking design cues from hospitality and residential design, the renovated center offers a spa-like aesthetic. Patient rooms are equipped with a sofa bed so partners can spend the night in comfort and innovative headwalls keep medical equipment out of sight. Some labor/delivery suites offer water-birth tubs and

hotel-style bathrooms with walkin rain showers. The post-partum, triage, and special care nursery rooms use a wall-mounted, modular cabinet system for optimal function, appearance, and flexibility. Family amenities include a small café and a lounge with a fireplace. The center includes an expanded newborn intensive care unit and a remodeled nursery. A multifunctional conference and presentation lounge provides a comfortable place for visiting prospective parents to learn about the birth center.

What are you looking for in a HEALTHCARE DESIGN TEAM? Alan Dostert AIA Principal Architect Design Architect

Wayne Dietrich AIA Principal Architect Design Architect

Stan Schimke CID Gloria Larsgaard AIA NCARB Director of Healthcare Project Manager Services/Medical Planner



Functional and Space Programming


Hospital, Clinic and Senior Living Facilities of the Future, Sustainable and Evidence-Based Design Solutions

Dan Abeln Assoc AIA LEED AP BD+C Project Manager

Leap Chear AIA NCARB LEED AP BD+C Sustainability Specialist

Linda Edgar ASID Healthcare Interiors

Rick Failing Director of Healthcare Support Services

Chad Frost Lean Specialist

Jim Tyler PE Mechanical Engineer

Anthony Corcoran PE CGD LEED AP Mechanical Engineer

Cory Vaughn PE LEED AP Electrical Engineer


Minnesota Physician June 2015

What sets us apart is our ability to integrate seamlessly with the healthcare architectural process. Through evidence-based and time-tested approaches, our HC Team can fully integrate strategy, planning, programming, operations and quality improvement with regionally renowned design.

Grand Forks, Fargo, Bismarck, Minot, Williston, ND; Sioux Falls, SD; Bemidji, MN;

Kiran Stordalen and Horst Rechelbacher Pediatric Pain, Palliative and Integrative Medicine Clinic Type of facility: Outpatient clinic Location: M  inneapolis Client: Children’s Hospitals and Clinics of Minnesota Architect/Interior design: U+B Architecture & Design Contractor: McGough Completion date: December 2015 Total cost: $3.1 million Square feet: 10,777


he “healing environment” of the Kieran Stordalen and Horst Rechelbacher Pediatric Pain, Palliative and Integrative Medicine Clinic on the campus of Children’s Hospitals and Clinics is the first of its kind in the U.S. Architects were faced with the unique challenge of creating a calming and anxiety reducing holistic environment. The innovative design incorporates natural wood floors and walls, large-scale landscape images, and a grotto with an interactive virtual waterfall designed

as a sensory escape for patients. Sounds of nature permeate the clinic and lighting throughout is soft, indirect, and mimics the light and dark periods of the diurnal cycle to create a serene environment. The innovative Snoezelen room is a multisensory space where lighting, sounds, and textures can soothe and stimulate a patient’s senses and reduce anxiety, pain, and stress. The clinic also accommodates integrative therapies such as biofeedback, aromatherapy, massage, and acupuncture.

Top: Lobby and waiting room Bottom: Snoezelen room

Healthcare Planning and Design Twenty-five years have passed since Dr. Seuss’s final words to us were published. His last book—with its powerful images—are truly the capstone of his career. This exhibition artistically highlights the scores of places and eras Dr. Seuss takes us with his incomparable collection of artwork.

Today is your day. You’re off to Great Places! You’re off and away! The show runs Saturday June 6 through June 20. St. Joseph Medical Center - Waiting Area

612.338.4333 | 800.336.9924 4811 Excelsior Blvd., St. Louis Park, MN 55416 612.338.2029 | 218.727.8446

™ & © 2015 Dr. Seuss Enterprises, L.P. All Rights Reserved.

June 2015 Minnesota Physician


Honor roll 2015 North Memorial Minnetonka Clinic and Urgency Center Type of facility: P rimary care clinic/specialty care clinic/ urgency center Location: M  innetonka Client: North Memorial Health Care Architect/Interior design: Pope Architects Engineer: Dunham Contractor: DJ Kranz Co. Completion date: November 2014 Total cost: $2,900,000 Square feet: 32,000


Telephone Equipment Distribution (TED) Program

Top: Self check-in kiosks Bottom: Lobby

he Minnetonka Clinic and Urgency Center occupies the main level of the larger Minnetonka Medical Center. The facility was designed by separate core and shell, and interior teams with Pope Architects designing the interior fit-up of the 32,000 square foot main level. This new facility utilizes technology and accessibility to make staff and operations more efficient. Patients enter a modern lobby that resembles an Apple store and check themselves

Do you have patients with trouble using their telephone due to hearing loss, speech or physical disability?

‘Proudly serving the medical community’

If so…the TED Program provides assistive telephone equipment at NO COST to those who qualify. Please contact us, or have your patients call directly, for more information.

1-800-657-3663 Duluth • Mankato • Metro Moorhead • St. Cloud The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services


in at kiosks with touchscreen computers that are linked to staff iPads. Patients discuss the reason for their visit in exam rooms rather than in a public lobby. A large waiting area offers digital video boards, laptop plugins, and child activities. Blending an Urgency Center staffed with emergency physicians with a primary care clinic fitted with innovative technology and concierge-oriented services creates a new health care option for patients.

Minnesota Physician June 2015

…in business for over 35 years • 651-681-0200 1100 Mendota Heights Road • Mendota Heights, MN 55120

Ness Plastic Surgery Type of facility: Clinic/surgical center Location: W  ayzata Client: Ness Plastic Surgery/John A. Ness, MD Architect/Interior design: ESG Architects/Nate Enger Engineer: Anderson Urlacher (structural) Contractor: Welsh Construction Completion date: August 2014 Total cost: $2,272,000 Square feet: 11,250


ooking to expand Ness Plastic Surgery, John A. Ness, MD, purchased a two-story, rundown, overlooked building in Wayzata. The renovation involved cosmetic updates for a modern look and alterations to make it suitable for medical use. The front façade of the building got an updated look including new windows, a sunscreen, and wood siding. The design capitalized on the existing fully mature trees surrounding the property. Wood was used as

a primary element both inside and out to soften the edges of the space, and to visually connect the building to its site. The elevator was enlarged and upgraded, and all the stairs were replaced. The main staircase features wood paneled walls and ceilings. The building features a plastic surgery clinic, a cosmetic surgical center with an accredited surgical suite, and more room for medical spa services.

Top: Lobby/waiting room Bottom: Main entrance

NOW ON SALE – ORDER TODAY Season ticket packages of 3 or more concerts now available, starting at only $30! With performance venues throughout the Twin Cities, we are sure to be near you.


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SEASON TICKET HOLDERS ENJOY MANY PRIVILEGES ALL SEASON LONG: FLEXIBILITY: Free and flexible ticket exchanges—if you can’t make it to a concert in your series, simply call us before your concert and exchange into a different one or use our convenient online exchange form PRIORITY: priority seating before the general public, guaranteed same seats for each concert in your series where available, and advance ordering for additional tickets and special performances CONVENIENCE: Option to purchase prepaid parking for Ordway evening concerts






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June 2015 Minnesota Physician


Special Focus: Medical Facility Design


The Green House Project

he term, “nursing home” has so many negative connotations that many nursing homes have taken to calling themselves “care centers” instead. You probably already know what those negative connotations are, and now there is research to confirm your thoughts. The Green House Project is a national movement transforming the quality of life for elders. The model addresses typical concerns about nursing homes more fully. Each Green House home looks and feels like a real home and elders receive four times more care than they would in a traditional nursing home. This personal attention and the homelike setting encourages residents to socialize and maintain their independence, which gives their family members peace of mind.

How it’s changing long-term care By Deb Veit the concerns that most caregivers have about their loved one living in a conventional nursing home. We think the results of this study probably reflect your concerns and priorities too:

In September of 2012, The Green House Project completed an in-depth study of family caregivers. The study showed

• Eighty-three percent are concerned about the lack of individualized attention. • Eighty-two percent are concerned with isolation and loneliness. • Eighty-two percent are concerned with the institutional atmosphere. • Eighty percent are concerned with loss of independence.

Read us online Wherever you are! 32

Minnesota Physician June 2015

• While cost and convenience were factors, they were lower on the list. We all agree that we want the people we love to live in their own homes for as long as they can. But when that is no longer an option, we want them to get the best possible care in a setting that is as close as possible to a real home. What does “as close as possible to a real home” mean in today’s marketplace? There are two ways to look at this question: From a physical plant perspective and from an operational perspective. The physical plant perspective Architecturally, conventional nursing homes have been designed like mini hospitals with nursing stations and long hallways, shared rooms and baths, and large central dining rooms. No matter how pleasantly decorated these facilities may be, they look and feel institutional. For family and friends, visiting mom at “the home” is very much like visiting mom at a hospital. Our organization knows this from our own experience. Up until 2009, Episcopal Church Home was a conventional nursing home. The physical plant was a product of its time when it was built in the early 1970s, but times have changed since then. Past Episcopal Homes of Minnesota board president Jean Probst was well aware of that and stated, “This place was built for my generation. We’re a goalong generation. We’ve spent our lives rolling with punches and accepting whatever cards we were dealt. But when members of the Boomer generation get to the age where they need us, they’re not going to put up with this.”

In 2007, our management and board set about answering the question, “How can we make our nursing home less like an institution and more like a real home?” As options were explored, they found that reimagining the physical plant was inextricably linked to reimagining the model of care. The explorations led to an organization called Action Pact ( and the Household Model of Care. Their message resonated with our team: “In most nursing homes, and in many assisted living services, a very important element has been forgotten: home. Without it, our elders experience a loss of joy and meaning in their lives. We know you believe that they deserve better. So do we. Action Pact can see you through every step of transforming an institution into a true home, and restoring the pleasures of daily life to our elders.” That sounded good on paper and online, but how did it work in the real world? Management staff and board members visited a nursing home in Perham, Minnesota, to find out. Perham Living implemented the Household Model of Care under the tutelage of Action Pact. Upon returning from the visit, Marvin Plakut, Episcopal Homes president and CEO, said, “It would be immoral for us not to do this.” In 2008–2009, Episcopal Church Home underwent an 18-month, $11 million transformation. As the physical plant was being divided into six distinct households with 12 to 20 residents per household, the staff was being trained in the Household Model of Care. Our observation is that some providers stop at the physical plant level and continue to operate their “households” as miniature conventional nursing homes. All staffers have the same titles, roles, and responsibilities that nursing home staffers have always had.“That’s not my job,” is an all-too-common refrain. This underscores the importance of exploring options from the other perspective.

The operational perspective If a provider’s goal is to make a nursing home “as close as possible to a real home,” the model of care is every bit as important as the physical plant. The conventional nursing home model of care is “hospital light,” hence intrinsically institutional. All staffers have clearly-defined roles and responsibilities. While the provider’s marketing materials may tout being “resident centered,” in reality, every aspect of daily life is organized around the needs of the provider, not the resident. Residents are told when to rise, when to eat, when to bathe, and when to have fun. One size fits all. How homelike is that? The Household Model of Care that Episcopal Homes implemented is vastly more “resident centered” than the old model. Daily life is organized around the wants and needs of each household’s residents, individually and collectively. Residents decide when to rise, when to eat, when to bathe, and what kinds of activities (meaningful engagement) they want to engage in. That’s how families in private homes chart their courses, and that’s how the families in each of our households do too. When our transition from the conventional nursing home model of care to the Household Model of Care was complete, we thought we had finally achieved nursing home nirvana. Residents who had only pecked at their food in the old central dining room developed healthy appetites in the more homelike surroundings of their household dining rooms. They could rise when they wanted without missing their breakfast. They could bathe when and how often they wished. And they could engage in activities they really cared about. In other words, they got to call the shots much as they always had. Could anything be better than this? The answer turned out to be yes! The Green House Model of Care In 2012, Episcopal Homes began planning the biggest

expansion since its founding in 1894—a $46 million senior living complex that would house three distinct residences. One of them was to be a new 60-bed nursing home that we now call

to earn the title of “Shahbaz” (after a mythical royal Persian falcon that protected, sustained, and nurtured its people). “Think of them as family caregivers who really know what they’re

Conventional nursing homes have been designed like mini hospitals. The Gardens. Each Green House home in The Gardens has 10 residents and two certified nursing assistants (CNAs), as well as one nurse for every two homes. A past Episcopal Homes Minnesota board member, Lois Cutler, PhD, a widely-traveled research gerontologist who is with the University of Minnesota’s Long-Term Care Resource Center, introduced our management and board to the Green House Model of Care. “The Green House Project has developed what I consider to be a perfect, synergistic integration of physical plant and model of care,” Cutler says. “They are very specific about every physical and operational detail, and since we were starting with a blank sheet of paper, we had the opportunity to go for it. We did, and The Gardens opened in January 2015. It is Minnesota’s first implementation of the Green House Model of Care in a skilled setting. The game has just changed.”

doing,” says Cutler.

and can choose the activities they want to participate in. Residents can sleep late and have breakfast whenever they want. They have private rooms so can spend time by themselves. Staff can read or talk to residents, play games, or bake cookies. Residents can help cook meals, do personal chores like folding clothes, go to concerts or lectures, and watch movies. There are six outdoor gardens and residents are encouraged to garden if they want.

The ratio is one Shahbaz per five elders. The result is four times more personal attention than in conventional nursing homes. The Shahbazim (plural) prepare all meals from scratch with the elders helping as they are interested and able. The elders and their caregivers all dine together at the same table like the family they are.

The Green House Project is a national movement that has been transforming the quality of life for our elders for over a decade. To date, it has reached 32 states—including Green House Homes operated by the Veterans Administration. For the whole story, visit www.

Residents are treated with respect and their wishes and requests are met. They have input into their daily schedule

Deb Veit is director of community

relations at Episcopal Homes of Minnesota and has over 25 years of nursing experience with an emphasis on geriatrics and nursing home care.

Each Green House home is designed with private rooms and private baths for 10 elders. The choice of housing only 10 elders is by design. The rooms surround a central living room with a fireplace, a big family-style dining table, a homelike open kitchen, and additional lounge spaces. In accordance with The Green House Project guidelines, the staff room is “a tight fit for one person and impossible for two people,” so staff spend only necessary time there and more time with the residents. Each home is served by two primary caregivers. They are CNAs who have received 130 hours of additional training June 2015 Minnesota Physician


Special Focus: Medical Facility Design


Medical education

ver the past decade, there have been significant developments in the health care delivery system, particularly in the growth of outpatient surgery centers, specialty clinics, retail health clinics, and urgent care facilities. Health care is no longer limited to hospitals or primary care clinics. As a result, medical education influences the role that physicians and other health care professionals play, encompassing patient care as well as convenience, flexibility, patient satisfaction, and collaboration.


How design can improve learning By Heidi Costello, CID, LEED AP ID+C, IIDA • Technology • Collaboration • Flexibility • Sustainable health Technology The evolution of technology is growing at a rapid rate and personal technology, such as iPads, laptops, and smartphones have turned today’s students into visual, proactive, hands-on learners and made paper textbooks and large lecture halls outdated and largely ineffective because of a shift to real-world scenarios and flexible team-based learning. Today’s health care students need to understand the procedures they’ll be performing after graduation and learn and perfect these skills in a realistic and safe way. In medical education, it’s important

How physicians and other health care providers are educated and trained and the environments in which that education and training occurs must also advance. By engaging professors, the community, alumni, and students early in the design process, architects and designers are able to meet the needs of today’s medical students and more fully prepare them for their future careers. There are four key design factors that can improve medical education today and patient outcomes tomorrow:

Restoring function to patients with chronic neck and back pain. 5 Convenient Twin Cities Locations

to have ongoing feedback from day one so when students approach clinicals they do not fear the immersion. Designers and architects need to stay current when it comes to evolving health care technology and develop spaces that accommodate these shifts. We, also, need to ask the client the right questions when starting a project. Medical simulation allows students to acquire clinical skills by practicing in a simulated environment on high-fidelity mannequins that provide immediate feedback on their performance. Simulation technology also lets students role-play the full spectrum of patient care from bedside manner to procedural acuity in a collaborative environment. In addition, simulation helps bridge the gap in the number of accredited health

care providers despite limited onsite residency opportunities. At Perkins+Will, we have designed simulation spaces that mimic a patient room with moveable equipment and functional headwalls; home environments with a kitchenette and living room to simulate home care nursing; ERs with bays of beds and a central nurse station; exam rooms; and flexible spaces that can be reconfigured to whatever other simulation scenarios are needed. Practicing students are viewed in an adjacent observation room where an instructor controls the simulations and offers instruction. Simulation technology encourages personalized learning, engages students, and creates a real-world education so students retain what they’ve learned and apply it in practice. Collaboration Often, the most effective health care outcomes are the result of collaborative care. Innovative classroom teaching styles are emerging through interdisciplinary instruction where professors

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Minnesota Physician June 2015

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co-teach classes with professors from different disciplines, allowing a universal approach to learning. This style sets an example for how students should work in their profession. Technology Enabled Active Learning (TEAL) is a teaching format that merges lecture, simulations, and hands-on desktop experiments to create a rich collaborative learning experience. These spaces in medical education environments are designed so small groups can share tables topped with desktop computers and engage in group problem solving and discussion. Typically, this room is surrounded by projection screens or monitors with the professor situated in the center of the room to promote active learning and encourage more student engagement. Today’s most innovative medical education facilities teach collaboration by co-locating interdisciplinary departments to create learning environments—chemistry students and professors working side-by-side with people in nursing, dentistry, or language

pathology. When planning and designing a building, we work with clients to create adjacency diagrams of how faculty and students from different departments can benefit by proximity of placement to each other. These learning environments blur the

University of North Dakota’s new 181,000-square-foot School of Medicine & Health Sciences is organized around large stacked learning communities that anchor each end of the building connected by a large corridor. Architecturally, these learning communities are designed to be similar A building should be flexible to a high enough to accommodate future school “home technology and changes. base” with assigned locker storage, lines between departments in an moveable tables for collaboration, effort to spark new ways of thinksmall, enclosed rooms for group ing, problem solving, and deliveror individual study, and a kitching superior patient care. Fosterenette/dining area for large group ing this teamwork in an academic interactions. setting also encourages deeper collaboration in the professional Flexibility environment. These collaborative Health care, health care delivery spaces can exist in public loungsystems, technology, and students es, hallways with built-in seating all continue to evolve. This ongoor benches and white boards, or ing evolution requires flexibility libraries with spaces designed for and adaptability in the design group or individual study. and delivery of the education and

training of health care professionals. A building should be flexible enough to accommodate future technology and changes. A diverse student population may require areas in and outside of the classroom where they can work alone, engage with faculty, or collaborate with colleagues. Architecturally, we are designing spaces with operable walls for reconfiguration, rooms with ample electrical connections for proactive technology changes, a variety of classroom types to allow for flexible teaching styles (fixed technology, flexible classrooms, and tiered lecture settings). Designers often recommend that furniture and equipment be on wheels so it’s easy to move things from space to space. Simulation suites and multibed skills rooms are often designed with operable walls along with flexible headwalls to easily change the room size or function and reposition electrical and gas outlets. Flexible simulation suites can expand by sliding a wall open to simulate ER bays or a labor/ Medical education to page 36

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Medical education from page 35

delivery/recovery room with an adjacent nursery. In a flipped classroom, students actively study and learn the material independently and then come together in a classroom to complete assignments collaboratively with fellow students while the professor acts as mentor. This classroom is typically designed with moveable furniture that can be configured for individual or group classes. The room must have ample writeable surfaces, electrical connections, and backpack storage so the professor can easily move around the room. This differs from traditional lecture halls with podiums and a projection screen at the front. Flipped classrooms offer more active, personalized teacher/student interactions and the kind of engaging learning experience that leads to greater retention and improved real-world application. Sustainable health Medical education facilities have a strong focus on health and

well-being; that is, educating future health care professionals to improve the health of their future patients. But the truth of the matter is that those same facilities often do little to improve the health and well-being of their students. Wellness can be affected by a person’s physical, emotional, and social state. Wellness can also be affected by your physical surroundings. When someone walks into a space that has no daylight, low ceilings, uncomfortable temperatures, and a lack of wayfinding, they feel uncomfortable and will spend minimal time there. Medical education facilities that incorporate daylighting, natural ventilation, staircases, sustainable building materials, and green spaces see a boost in student morale and motivation, greater student physical activity, and accelerated learning. The design should intuitively encourage a healthy environment by placing staircases as grand focal points, which encourages exercise and exploration. Increasing the amount of daylight into a space creates a strong connection to

the outdoors, offering views and minimizing the use of interior artificial lighting. Using building materials that emit few chemical irritants has a positive impact on indoor air quality. Especially in medical education environments, students who believe their own health and well-being has been taken into consideration are more likely to consider environmental factors that impact human disease, and are more likely to drive conversations about sustainable health with their future patients. North Hennepin Community College’s Biosciences and Health Careers Center was completed in June 2014. The 62,000-squarefoot facility meets Minnesota B3 Standards meaning the building fulfills sustainable goals for site, water, energy, indoor environment, materials, and waste. Beyond meeting these standards, the building’s spatial organization focuses on bringing natural daylight through the building footprint and into the learning environments. This helps emotional stimulation and positively impacts energy, while intuitively

educating the students on the benefits of sustainable design. Some colleges post the sustainable design drivers as you enter specific spaces to be transparent and celebrate the importance of sustainable health and well-being. Conclusion With the ongoing changes in health care and health care delivery systems, medical education facilities have both a responsibility and an opportunity to ensure their students are poised to positively impact their patients, their workplaces, and their communities. These four design drivers represent some important ways that innovative health care design can better meet the needs of today’s students and, as a result, tomorrow’s patients. Heidi Costello, CID, LEED AP ID+C, IIDA, is an associate project interior designer with the Minneapolis office of Perkins+Will. She has more than eight years of design and planning experience and has played a key role in a number of medical education projects throughout the Upper Midwest.

WE ARE EXCITED TO ANNOUNCE... The integration of St. Croix Orthopaedics and Twin Cities Orthopedics!

The integration allows for us to expand the services we offer across the entire metro area and into western Wisconsin with a team of more than 100 orthopedic surgeons and 35 locations. Both St. Croix Orthopaedics and Twin Cities Orthopedics share a similar vision of providing exceptional care and outstanding service. Visit or to learn more


Minnesota Physician June 2015

National Health Service Corps Loan Repayment Potential



Northern Minnesota Physician Opportunities

Ski, hike, run, fish, canoe, kayak, camp, or hunt in your own backyard or in the Boundary Water Canoe Area, Voyageur’s National Park, Superior National Forest and countless State Parks


Located throughout beautiful Northern Minnesota, Scenic Rivers Health Services is a provider-driven not-for-profit organization. Currently, we are seeking a Family Practice Physician at our location in Cook, MN. This position focuses on local family healthcare, in a wellestablished modern facility helping to support our growing patient needs. You will quickly develop a gratifying panel of patients. Participation in on-call schedule, inpatient and afterhours care is shared (no OB), BC/BE and current or eligible for MN license required.

Work – Life Balance: • 4 day work weeks • Significant starting and residency bonuses • Competitive salaries • Full benefit package • 20 vacation days • 12 sick days • 10 CME days • 6 holidays • 3 personal days

Eric Scrivner, MD

For more information or Cook Area Health Services, Inc. to send a resume: Travis Luedke

20 5th St. SE, Cook, MN 55723 | | 218-361-3190 April 2015 Minnesota Physician




ccording to national health rankings, Minnesota typically rates as one of the nation’s healthiest states. However the Minnesota Department of Health’s Center for Health Equity reports that despite our excellent averages, the state faces some of the country’s worst ethnic and racial health disparities. As our population ages and grows more diverse, our health system is challenged to achieve equitable and optimal outcomes for all communities.

Minnesota’s community health workers (CHWs) are trained and trusted frontline health personnel, often from the communities they serve, who bridge barriers between underserved patients and health and social services systems, leading to improved health access and outcomes. CHWs serve many different roles. They help people overcome barriers to getting cancer screening, find medical homes, ease their distrust of the health care system, and tackle

Community health workers Expanding an important role By Joan Cleary, MM cultural concerns. They conduct home visits to patients with complex health needs, build self-management skills, address basic needs, link patients to essential services, and help them navigate the health system. Addressing health disparities Increasingly, community health workers (CHWs) are being recognized as an integral part of the solution to addressing some of the major challenges facing our health care system. CHWs help address health disparities, advance the Triple Aim, and expand and diversify our health care workforce.



Erik Dovre, OB/GYN

Lakewood Health System is seeking to expand the care team for its progressive and patient-focused clinics and hospital. Located in Staples, Minnesota, Lakewood is an independent, growing healthcare system with five primary care clinics, a critical access hospital and senior living facilities. Practice consists of 14 family medicine physicians and 10 advanced practice clinicians, as well as a variety of on-staff specialists. Competitive salary and benefits. Relocation and sign-on bonus available.

Visit, or contact Brad Anderson at 218-894-8587 or


Minnesota Physician June 2015

Typically from the communities they serve, CHWs bring their attributes, shared life experience, community knowledge, and training to bridge cultural, linguistic, literacy, and other barriers to good health, with a focus on low income, underserved people. As trusted, knowledgeable frontline health professionals, they apply their unique understanding of the experience, culture, and/or language of the communities they serve to provide culturally-competent outreach, patient and community education, advocacy, care coordination, and systems navigation in a variety of clinic, home, and community settings. They also serve as cultural resources and mediators for their teams and organizations. Minnesota CHWs reflect our state’s growing diversity, with representation from communities of color, immigrant and refugee populations, and other cultural groups such as the deaf population. CHWs go by many different titles such as care guide, care coordinator, peer educator, outreach worker, promotore(a) de salud in the Latino community, and community health representative in the American Indian community. In 2010, the Department of Labor Standard Occupational Classification system recognized CHW as a distinct profession. New to many health providers but characterized by a long history and deep community roots, the CHW role is starting to move into mainstream health care settings. Recognized by leading health authorities such as the American Public Health Association, the Centers for Disease Control and Prevention, and the Institute of Medicine, CHW strategies are supported

by a growing evidence base for their effectiveness in improving access to coverage and care, improving screening rates and disease outcomes, and reducing costly emergency room visits and avoidable hospital readmissions. By fostering accessible, affordable, and culturally-appropriate care, CHWs—and the health and social services organizations that employ them—help reduce persistent health disparities for vulnerable populations and create healthier, more equitable communities. At a time when many newly insured are accessing care, the growth of the CHW role also expands and diversifies our health care workforce. Clinics are moving to patient-centered team-based models in which everyone needs to “work at the top of their license” and accountability for outcomes requires effective care coordination and culturally-appropriate education that extends well beyond the exam room and the brochure rack. CHWs build trusting relationships, fill gaps, and serve as valuable extenders in outreach, education, and home visits, as well as connecting people to care, coverage, and other services. Scope of practice and education Minnesota is the only state in the U.S. to develop and implement a statewide, competency-based CHW curriculum based in higher education. With funds from the Blue Cross and Blue Shield of Minnesota Foundation and the Robert Wood Johnson Foundation, the model curriculum was designed through a collaborative process involving CHWs, educators, health providers, and people from other health disciplines who also developed a CHW scope of practice for the state. Launched in 2006, the standardized certificate program requires an internship and 14 credits, including core competencies as well as health promotion and disease management competencies. Six post-secondary schools offer the certificate program, including in-person

as well as online formats that are designed to expand CHW training into rural communities to improve access to health care for the state’s rural population. “Minnesota’s CHW certificate program was placed in higher education so that credits earned could be applied by CHWs to continue their education and enter other health careers such as nursing or allied health. In this way it is designed to be an educational pathway— not a dead end,” explained Anne Ganey, MPH, who founded the online CHW Certificate Program at South Central College, Mankato. “We’ve found that CHW students, often the first in their families to enroll in post-secondary schools, both inspire and guide relatives and other community members to pursue higher education. It’s another key benefit because we know that people with more education earn more and live longer.” More than 500 CHWs have completed this training so far, earning a certificate of completion. While this certificate is not currently required for CHW employment, it is increasingly identified as a preferred credential for job applicants. Reimbursement While other states are exploring and piloting CHW payment, until recently Minnesota and Alaska have been the only states to date that have Medicaid authorization. Diagnostic-related patient education services provided by CHW certificate holders under clinical supervision are covered under Minnesota Health Care Programs (MHCP) including Medical Assistance and MinnesotaCare—both fee-for-service and managed care. MHCP guidelines identify physicians, advanced practice nurses, mental health professionals, dentists, and certified public health nurses working in a unit of government (such as a local public health agency) as authorized CHW supervisors. CHW patient education provided on a one-to-one or group basis is covered. Home visits are includ-

ed. The Minnesota Community Health Worker Alliance and its partners are now exploring replication of the nationally-recognized, evidence-based Pathways Community Hub model which is covered by Medicaid managed care plans in Ohio

in CHW strategies through the state’s Eliminating Health Disparities Initiative, the Emerging Health Professions initiative, and its new Accountable Communities for Health project; the latter two come under the federally-funded State Innovation

Six post-secondary schools offer the certificate program.

with excellent birth outcomes among high risk women—an area where Minnesota needs to improve. Teaming up for better outcomes Health providers, social service agencies, schools, and community-based organizations are finding CHWs to be critical links with the communities they serve. For example, community clinics and mutual assistance associations employ CHWs to facilitate enrollment in public programs, conduct outreach, and provide health education services to uninsured and underinsured patient populations. According to Deb Holmgren, president of Portico Healthnet, “CHWs working as MNsure navigators have facilitated the enrollment of hundreds of uninsured and hard-to-reach individuals and families into coverage options under our state’s health insurance exchange.”

Model (SIM) Initiative. CHWs reduce the demand on overburdened providers by promoting healthy behaviors and helping patients understand how to access and use care appropriately. “Providers appreciate what we do,” explained CHW Mariela Ardemagni-Tollin at HCMC’s East Lake Clinic. “In a short visit, it’s impossible for the physician to do everything—we need a care team. Our Health Care Home (HCH)

“Partnering with CHWs is an effective way for pediatricians serving foreign-born families to improve cultural competence as well as increase rates of well-child care such as immunizations,” reported Katherine Cairns, executive director of the Minnesota Chapter of the American Academy of Pediatrics (MNAAP). MNAAP has supported a CHW pilot at several Twin Cities and St. Cloud area pediatric practices to improve preventive care for Somali Community health workers to page 40

Urgent Care We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. We are seeking BC/BE fullrange family medicine and internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice.

Increasingly, CHWs are being hired by hospitals, clinic systems, and local public health agencies to strengthen teambased services to patients and families. CHWs are integral members of clinic care teams at Hennepin County Medical Center, NorthPoint Health and Wellness Center in north Minneapolis, and HealthEast Care System in the east metro. In Greater Minnesota, CHWs work on teams at CentraCare Health in St. Cloud, Essentia Health– Ely Clinic, and Mayo Clinic, Rochester. The Minnesota Department of Health has made investments

program promotes team-based holistic care, and health education and coaching to improve health outcomes and reduce ER visits and hospital admissions. HCMC’s HCH program has expanded rapidly since its implementation in 2010, and CHWs, as members of our care teams, develop trusted relationships with our patients which help bridge or eliminate barriers to good health.”

For consideration, apply online at and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE

healthpar tners .com © 2014 NAS (Media: delete copyright notice)

MN Physician 4" x 5.25" 4-color

June 2015 Minnesota Physician


Community health workers from page 39

children with a federal grant from the Health Resources and Services Administration. Measurable impact Growing evidence and recognition of CHW contributions to better outcomes indicate an increasing role for CHWs in the health system of the future. “Research shows that CHWs improve health outcomes among minority and immigrant populations and they do so in a cost-effective and culturally-sensitive way,” said Kathleen Call, a professor at the University of Minnesota School of Public Health. For example, studies of CHW programs show significant improvement in patient use of preventive services such as mammography and cervical cancer screening among low income and immigrant women. Economic analysis published by the Amherst H. Wilder Foundation in June 2012 found that

every dollar invested in CHW cancer outreach and prevention results in a savings to society of $2.30. A review of national studies found a return on investment of 3:1. Another example of the benefit of CHWs is found in Boston, Chicago, Seattle, and other

promoting healthy housing, leading to better health and lower costs,” reported Amanda Reddy, director of Programs and Impact at the National Center for Healthy Housing, whose affiliate Healthy Housing Solutions offers specialized training for CHWs on healthy housing

CHWs reduce the demand on overburdened providers.

cities where CHW interventions improve childhood asthma in low-income neighborhoods, reducing symptom days as well as costly hospital admissions and ER visits. Trained CHWs conduct home visits to reinforce provider messages about asthma control, identify and address family needs, and provide home interventions. “CHWs play an effective role in teambased asthma interventions and

practices through local agencies such as the Sustainable Resources Center in Minneapolis. In order to help address our state’s serious child asthma disparities and improve quality of care, MN Community Measurement has supported the development of a new web-based tool on CHW integration for asthma care providers and home visiting programs with funding

from the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative available at asthma. A key to healthier communities “As a best practice for tackling health disparities, CHWs are an essential component of Minnesota’s health reform strategies,” emphasized pediatrician Peter Dehnel, MD, past president of the Twin Cities Medical Society, which has endorsed the role. “Integration of teambased CHW strategies will help clinics achieve better results with patients facing barriers to good health related to culture, language, literacy, and income.”

Joan Cleary, MM, is executive director of the Minnesota Community Health Worker Alliance, a broadbased partnership of CHWs, health providers, health plans, nonprofits, and public agencies (

Olmsted Medical Center, a 220-clinician multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Opportunities available in the following specialties: Family Medicine Spring Valley Clinic

Nursing Home Physician Rochester and Surrounding Communities


Hospital – New Women’s Health Pavilion

Psychiatrist – Child & Adolescence

Rochester Southeast Clinic

Pain Medicine

Rochester Northwest Clinic

Send CV to: Olmsted Medical Center Human Resources/Clinician Recruitment 210 Ninth Street SE, Rochester, MN 55904

email: • Phone: 507.529.6748 • Fax: 507.529.6622 40

Minnesota Physician June 2015

At Allina Health, we’re here to care for the millions of patients we see each year throughout Minnesota and western Wisconsin. From rural to urban settings, you’ll find a practice and community that is right for you, with ideal staff support and the widest range of clinical practice options, physician leadership opportunities and competitive benefits. EO M/F/Disability/Vet Employer

Make a difference. Join our award-winning team. 1-800-248-4921 (toll-free)


Join our team

St. Health Cloud VA Care System Brainerd | Montevideo | Alexandria

Opportunities for full-time and part-time staff are available in the following positions: • Associate Chief of Staff

• Internal Medicine/ Family Practice

• Compensation & Pension Physician

• Ophthalmologist

• Dermatologist • Hematology/ Oncology

• Physician (Pain Clinic)/ Outpatient Clinic • Psychiatrist • Radiologist Applicants must be BE/BC.

Family or Internal Medicine Physician An ideal balance between your professional and personal life. Provide comprehensive care in a clinical and hospital practice. ER coverage available, but not required. GRHS is a progressive 19 bed Critical Access Hospital with two clinics. Glenwood is a family oriented community with an excellent school system. Recreational opportunities include boating, hiking, excellent fishing and hunting. We are halfway between Fargo and the Twin Cites. For more information Call Kirk Stensrud, CEO 320.634.4521 Mail CV to: Kirk Stensrud, CEO 10 Fourth Ave SE Glenwood, MN 56334 Email CV to:

US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BE/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. Possible recruitment bonus. EEO Employer. Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.

For more information: Visit or contact Nola Mattson, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301 June 2015 Minnesota Physician




n January 2015, the Centers for Medicare and Medicaid Services (CMS) announced new and ambitious goals in how it will reimburse providers. Specifically, the goals call for CMS to shift more of its reimbursement from volume based, such as fee-for-service, to a value-based methodology. While the goals have been deemed a promising improvement by some, others are singing the opposite tune. Based on historic performance, there is some skepticism in the provider community as to whether CMS will actually achieve these goals.

Medicare’s new payment reform plan What physicians need to know By Timothy A. Johnson, JD, and Julia C. Marotte, JD of the services). As part of the ACA, CMS identified four primary categories of provider reimbursement: • Category 1: Fee-for-service (FFS) with no link of payment to quality

Current status One of the primary underpinnings of the Affordable Care Act (ACA) was the objective of moving the Medicare program provider reimbursement from a fee-forservice environment (where providers are reimbursed solely on the volume of services provided) to a value-based reimbursement model (where providers would be compensated more on the quality, effectiveness, and affordability

• Category 2: Fee-for-service with a link of payment tied to quality • Category 3: Alternative payment models billed on a fee-for-service architecture • Category 4: A populationbased payment methodology In adopting the four categories, CMS grouped them into

Family Medicine St. Cloud/Sartell, MN We are actively recruiting exceptional full-time BE/BC Family Medicine physicians to join our primary care team at the HealthPartners Central Minnesota Clinics - Sartell. This is an outpatient clinical position. Previous electronic medical record experience is helpful, but not required. We use the Epic medical record system in all of our clinics and admitting hospitals. Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Several of our specialty services are also available onsite. Our Sartell clinic is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with traditional appeal. HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. We offer a competitive compensation and benefit package, paid malpractice and a commitment to providing exceptional patient-centered care. Apply online at or contact Call Diane at 952-883-5453; toll-free: 800-472-4695 x3. EOE 42 MN Physician 4" x 5.25" 4-color

© 2014 NAS Physician (Media: Minnesota delete copyright notice)

June 2015

“value-based’ reimbursement payments, which include all CMS reimbursements under Categories 2 through 4 and the “alternative payment” models that only include CMS reimbursements under Categories 3 and 4. Prior to 2011, virtually all payments to Medicare providers were classified under Category 1, where reimbursement was only tied to volume of services provided without any requirement that providers demonstrate a quality or effectiveness component. But under the ACA, CMS began adding additional quality of care requirements, mandating that some fee-for-service payments be linked to some type of quality requirement. For example, while hospitals generally continued to be paid based on diagnostic related groups (DRGs), CMS started adding “quality requirements” wherein hospitals would be penalized based on the hospital’s patient infection rates and readmission rates. According to CMS’s January pronouncement, its goal is to have at least 30 percent of the Medicare payments in the alternative payment models (Categories 3 and 4) by the end of 2016 and at least half of all services by the end of 2018. Furthermore, CMS aims to have 85 percent of all of its provider payments have some type of value-based component (Categories 2 through 4) by the end of 2016 and 90 percent of its provider payments by the end of 2018. This is an ambitious goal considering only 20 percent of the Medicare fee-for-service payments in 2014 had value-based payment requirements.

Are the goals even attainable? Given the severity of the goals and CMS’s historic track record to date, many providers are

skeptical that CMS will achieve these targets. A primary goal of the ACA is to create a variety of provider reimbursement models that shift away from the fee-forservice reimbursement model and towards a model that rewards providers for providing quality, affordable, and effective care. There is universal agreement that the current fee-for-service provider payment model needs to change—based on recent statistics, the Medicare Trust Fund faces insolvency within 20 years unless there is a reduction in payments to providers. The new provider payment goals set by CMS are part of this reform effort. Some of CMS’s value-based reimbursement goals seem attainable—it should not be too difficult for CMS to add one or more quality requirements to its fee-for-services payments, such as penalizing providers for missed diagnoses or repeat visits for the same illness. However, the goal of having over 50 percent of all provider payments under some form of alternative payment model appears overly optimistic, and the ability of CMS to meet these aggressive new goals will be difficult. First, the shift to a value-based or alternative payment model will require both the commercial market as well as employers to embrace the model and offer similar types of arrangements. Any type of provider reimbursement model where commercial payers and employers continue to pay providers on a fee-for-service model while the government adopts a more aggressive, alternative payment model is destined for failure. While some commercial payers have adopted some alternative payment models such as narrow networks, carve-outs, and bundled payments, such reimbursement arrangements have only been successful in very limited situations. Second, to achieve Medicare’s goal of moving to value-based or alternative payment arrangements, providers will need to participate in care coordination models like Accountable Care Organizations (ACOs). Under the Medicare’s new payment reform plan to page 44

MAYO CLINIC HEALTH SYSTEM is a family of clinics, hospitals, and other health care facilities serving over 70 communities in Minnesota, Iowa, and Wisconsin. Sharing Mayo Clinic’s primary value of “the needs of the patient come first,” Mayo Clinic Health System links the expertise of Mayo Clinic in practice, education, and research with the health-delivery systems of our local communities. Today, more than 1000 physicians practice in the health system. Mayo Clinic offers a highly competitive compensation package, which includes exceptional benefits, and has been recognized by FORTUNE magazine as one of the “100 Best Companies to Work for.” The Northwest Wisconsin Region opportunities include: Dermatology

Occupational Medicine

Emergency Medicine


Family Medicine


General Surgery



Psychiatry (Adult & Child)

Internal Medicine

Pulmonary/Critical Care


Urgent Care



Mayo Foundation is an affirmative action and equal opportunity employer and educator. If you wish to learn more or to express interest in these positions, please contact us at 800-573-2580; email; or apply at http://

Join the Leader in Correctional Health Care FEDERAL BUREAU OF PRISONS

Full-Time Psychiatrist – FMC Rochester, MN Full Time Clinical Director – FCI Sandstone, MN

Join the top ranked clinic in the Twin Cities A leading national consumer magazine recently recognized our clinic for providing the best care in the Twin Cities based on quality and cost. We are currently seeking new physician associates in the areas of:

• Family Practice • Urgent Care We are independent physicianowned and operated primary clinic with three locations in the NW Minneapolis suburbs. Working here you will be part of an award winning team with partnership opportunities in just 2 years. We offer competitive salary and benefits. Please call to learn how you can contribute to our innovative new approaches to improving health care delivery.

Please contact or fax CV to:

Joel Sagedahl, M.D. 5700 Bottineau Blvd., Crystal, MN 55429

763-504-6600 Fax 763-504-6622

It’s your life. Live it well.

Learn more at:

Family Practice with OB Our independent, physician-owned clinic is seeking a BC/BE physician with OB for our family practice facility. 1:9 Calls. Competitive salary/benefits, with opportunity for ownership within 1 year. Paid malpractice, health and dental insurance, 401(k), CME and more. Cloquet is an historic, vibrant community just 15 minutes from Duluth and 10 minutes from Jay Cooke State Park. Adjacent to the St. Louis River, Cloquet has hiking, biking and ATV trails; skiing; boating; fishing; parks; and the only white water rafting in Minnesota. Residents enjoy locally performed plays, concerts and the arts; community festivals; dining and more.

Send CV to: 218.879.1271 • 417 Skyline Blvd. • Cloquet, MN 55720

June 2015 Minnesota Physician


Medicare’s new payment reform plan from page 42

ACO model, providers are held accountable for the total cost of care provided to a set group of patients. This is not a new reimbursement model, and is very similar to the capitated model used by health maintenance organizations (HMO). The adoption of ACOs has been met with limited success. Similarly, the growth in the adoption of ACOs have only been in those ACO arrangements that share in the success and savings of treating patients—there have been fewer providers willing to participate in arrangements where they also participate in ACO losses. Thus, a stark increase in ACO participation could be challenging. There are three primary reasons for the limited success of the ACO model. First, the ACO provider network does not necessarily know with certainty which patients are covered under the ACO payment model. Second, ACO network providers do not have any authority to require

patients to only seek care within the ACO provider network. The third and perhaps most pertinent reason is the difficulty in reim-

is a challenging change for providers, and may impact how, and to what extent, these new models will be adopted.

A stark increase in ACO participation could be challenging.

bursing providers based on the “quality” of care they provide. In most scenarios, quality of care cannot be measured immediately. Rather, it is generally measured based on both the patient’s outcome as well as the patient’s overall cost of care. Because it is virtually impossible to measure quality promptly after care is delivered, the reimbursement model requires that its success be measured over a long period of time—typically a minimum of one year. Accordingly, providers are generally compensated one year following the provision of care. This delay in compensation

Practical steps—what should physicians do now? Although the goals may seem daunting, the shift from volume to value is gaining momentum. On April 16, President Obama signed the Medicare Access and CHIP Reauthorization Act of 2015. This new law echoes the shift from volume to value by directing the Secretary of Health and Human Services to establish a new Merit-based Incentive Payment System (MIPS) under which eligible professionals (including physicians) receive payment increases or decreases based on performance. MIPS combines

three existing quality-incentive programs: the EHR incentive program, the Physician Quality Reporting System, and the value-based payment modifier. MIPS implementation begins January 1, 2019. While MIPS is separate and distinct from CMS’s new reimbursement plan, the takeaway is that physicians should not dismiss CMS’s goals. Physicians should spend some time thinking about their practice and how the shift from volume to value will impact operational aspects as well as the provision of care. Physicians should become familiar with the new Medicare goals and requirements, assess the options that are available, and plan a course of action—because while the ambitious goals may not ultimately be attained, the transition to value-based reimbursement is here to stay. Timothy A. Johnson, JD, is a principal at Gray Plant Mooty. Julia C. Marotte, JD, is an associate at Gray Plant Mooty. Both are members of Gray Plant Mooty’s Health & Nonprofit Organization Practice Group.

Physician Practice Opportunities Avera Marshall Regional Medical Center is part of the Avera system of care. Avera encompasses 300 locations in 97 communities in a five-state region. The Avera brand represents system strength and local presence, compassionate care and a Christian mission, clinical excellence, technological sophistication, an array of specialty care and industry leadership.

Avera Marshall Regional Medical Center 300 S. Bruce St. Marshall, MN 56258

Currently we are seeking to add the following specialists: • Psychiatrist

• Family Medicine

• Psychologist

• Internal Medicine

• Orthopedic Surgeon


• General Surgeon

For details on these practice opportunities go to For more information, contact Dave Dertien, Physician Recruiter, at 605-322-7691 • 44 Minnesota Physician

June 2015

Family Medicine with Clinic OB Physician-owned Gateway Clinic seeks a family medicine physician to join our new Hinckley clinic. 3 or 4-day week practice with shared hospital call. Full-scope primary care and clinic OB practice (prenatal and postpartum care in clinic, option for colleagues to cover OB call and deliveries). Generous salary with sign-on and retention bonus, outstanding benefit package, 15% retirement contribution. Shareholder opportunities available. Gateway Clinic has locations in Moose Lake, Sandstone and Hinckley. Centrally located between Mpls/St. Paul and Duluth, the area provides an excellent family focused, quality of life opportunity in a rural setting with good public schools and abundant with lakes, rivers, state parks, and ideal hunting - all within an hour to metropolitan conveniences.

For additional information, contact Dr. Kathy Brandli, President, at or Eric Nielsen, Administrator, at or 218.485.2000

The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties: • ENT • Family Medicine • Gastroenterology • General Surgery • Geriatrician • Outpatient Internal Medicine

• Hospitalist • Infectious Disease • Internal Medicine • OB/GYN • Oncology • Orthopedic Surgery • Pediatrics

• Psychiatry • Psychology • Pulmonary/ Critical Care • Rheumatology • Sleep Medicine • Urgent Care

F O R M O R E I N F O R M AT I O N :

Kari Lenz, Physician Recruitment | | (320) 231-6366 |

Sioux Falls VA Health Care System Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package. The VAHCS is currently recruiting for the following healthcare positions in the following location.

Sioux Falls VA HCS, SD Endocrinologist

Orthopedic Surgeon


Primary Care (Family Practice or Internal Medicine)

Emergency Medicine Geriatrician (part-time) Neurologist Oncologist/Hematologist

Psychiatrist Pulmonologist Urologist (part-time)

• Allergy/ Immunology

• Geriatric Medicine

• Orthopedic Surgery

• Dermatology

• Hospitalist

• Pain Medicine

• Emergency Medicine

• Hospice

• Psychiatry

• Family Medicine • General Surgery

• Internal Medicine • Rheumatology • Med/Peds

• Sports Medicine

• Ob/Gyn

(605) 333-6852 Applicants can apply online at June 2015 Minnesota Physician


The Minnesota Accountable Health Model from page 17

weight, and reduce substance abuse and domestic violence. An ACH in St. Cloud headed up by CentraCare Health, a nonprofit network of six hospitals and 17 clinics in central Minnesota, will work to reduce the incidence of unmanaged diabetes in the Hispanic and East African patient population of Stearns County. The project will string together the collective bodies that serve these populations in economic, education, and health care capacities to deliver one unified approach. This is a test A key fact about SIM is that though it provides resources to providers and communities, its central charge is to test the hypothesis that ACOs, ACHs, practice transformation, and health IT will help Minneso-

ta achieve the Triple Aim of lower costs, improved care, and patient satisfaction. This means that Minnesota is in the midst of a large test, focusing on integration and collabora-

providers of all types can better work together to coordinate care, share data and resources, encourage wellness, treat illness, and prevent disease, thus ultimately pushing in the same

By 2016, it is expected that nearly 3 million Minnesotans will receive care through some Accountable Health Model.

tion. By 2016, it is expected that nearly 3 million Minnesotans will receive care through some Accountable Health Model. By taking this approach, Minnesota is learning how government, communities, social services organizations, public health departments, and health care

direction to improve the health of the communities and residents that call Minnesota home. Our collective hope is that as we move forward we will gain a clearer picture of which collaborative efforts work and which ones we must bring to scale across Minnesota. As a physi-

A Diverse and Vital Health Service

cian leader who has been very active with the various SIM committees and work groups, including having the privilege of recently chairing the Data Analytics workgroup, I strongly encourage health care providers of all types (physicians, clinics, hospitals, post-acute care, etc.) to become knowledgeable and engaged in this statewide transformation in order to learn, share, and innovate together. Minnesota has a rich history of being able to lead transformation in health by authentically partnering across stakeholder types and we can do it yet again through this model. Rahul Koranne, MD, MBA, FACP, is board-certified in internal medicine and geriatric medicine. He is the senior vice president for clinical affairs and chief medical officer of the MinBoynton Health Service nesota Hospital Association, which represents 143 hospitals and health systems across Minnesota.

Boynton Health Service

Welcome to Boynton Health Service Located in the heart of the Twin Cities East Bank campus, Boynton Health Service is a vital part of the University of Minnesota community, providing ambulatory care, health education, and public health services to the University for nearly 100 years. It’s our mission to create a healthy community by working with students, staff, and faculty to achieve physical, emotional, and social well-being. Boynton’s outstanding staff of 400 includes board certified physicians, nurse practitioners, registered nurses, CMAs/LPNs, physician assistants, dentists, dental hygienists, optometrists, physical and massage therapists, registered dietitians, pharmacists, psychiatrists, psychologists, and social workers. Our multidisciplinary health service has been continuously accredited by AAAHC since 1979, and was the first college health service to have earned this distinction. Attending to over 100,000 patient visits each year, Boynton Health Service takes pride in meeting the health care needs of U of M students, staff, and faculty with compassion and professionalism.

Gynecologist/Clinical Supervisor Boynton Health Service is seeking a gynecologist or primary care physician with extensive experience in women’s health to serve as Assistant Director of Primary Care in charge of the Women’s Clinic. The Assistant Director will provide clinical services, ensure staff adherence to relevant regulations, assure the highest professional and ethical standards, and work with the Director of Primary Care and Chief Medical Officer to formulate long range planning and policies. This position offers a competitive salary and a generous academic status retirement plan. Professional liability coverage is provided. Apply online at, select “External Applicants” and then search for keyword: Gynecologist. Job ID#: 300363 To learn more, please contact Hosea Ojwang, Human Resources Director 612-626-1184, The University of Minnesota is an Equal Opportunity, Affirmative Action Educator and Employer

410 Church Street SE • Minneapolis, MN 55455 • 612-625-8400 •


Minnesota Physician June 2015

Physicians, are you SIcK of: Feeling like you work for insurance companies instead of patients? Declining reimbursements while your patients pay higher premiums? Hospitals dictating where you refer patients? Patients delaying or avoiding much needed care because of high deductibles?

is looking for primary and specialty physicians who want to help create a cure for the common coverage.

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Medical Space For Lease Plymouth Medical Building 3007 Harbor Lane North Plymouth, MN 55447 Building Size: 30,000 sq. ft. Space Available: 20,000 sq. ft.

Eagle Point Medical Building 8515 Eagle Point Boulevard Lake Elmo, MN 55042 Building Size: 29,700 sq. ft. Space Available: 11,500 sq. ft.

Helene Houle Medical Center 1155 East County Road E Vadnais Heights, MN 55110 Building Size: 56,700 sq. ft. Space Available: 10,915 sq. ft.

Crystal Medical Center 5700 Bottineau Boulevard Crystal, MN 55429 Building Size: 44,865 sq. ft. Space Available: 8,613 sq. ft.

Contact Us: Jill K. Rasmussen, CCIM, SIOR 612.341.3247 |

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Minnesota Physician June 2015  

Health care infomation for Minnesota doctors Cover: The Minnesota Accountable Health Model: Creating community partnerships by Rahul Koranne...

Minnesota Physician June 2015  

Health care infomation for Minnesota doctors Cover: The Minnesota Accountable Health Model: Creating community partnerships by Rahul Koranne...

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