Volume XXVl, No. 9
The Independent Medical Business Newspaper
Preserving the safety net
Brain research Keys to healthy aging
Why it’s important
By Apostolos P. Georgopoulos, MD, PhD, and Margaret Y. Mahan
By John Tschida
BRAIN to page 10
A number of conditions can inflict brain damage. First, there are conditions that alter the local milieu in which brain cells bathe and which can adversely modify their function or cause their death. Such conditions include high blood pressure, high lipids, environmental exposure to toxic chemicals, drug abuse, and congenital disorders of metabolism (e.g., phenylketonuria, or PKU). Other direct insults include brain injury inflicted, for example,
PRSRT STD U.S. POSTAGE
Brain insults and brain health
as the result of an accident, playing rough sports, or gunshot wounds. Psychological trauma also can have serious adverse consequences resulting in brain malfunction, as in post-traumatic stress disorder. A more subtle cause of potential cell damage involves lack of neuroprotection. Neuroprotection is a relatively recent concept that has drawn considerable interest because of its potential to increase the resilience of the brain and promote brain health. The single most important neuroprotective factor is exercise. Regular physical exercise can reduce the risk for dementia by as much as 40
Detriot Lakes, MN Permit No. 2655
he brain is a huge network consisting of more than 100 billion massively interconnected and communicating cells (neurons) and support cells (glia). As a network, the brain never declines. It evolves, adapts, learns, acts; in fact, it gets better and better with time, culminating in what we collectively call “wisdom.” The problem is that the brain is made of perishable material, subject to all kinds of insults. Although repair and renewal mechanisms are present and unceasingly active, cell damage occurs and takes its toll, leading to decline in brain function because of material loss. Therefore, healthy aging translates into preserving cell biology, e.g., by avoiding disease and lifestyle behaviors that can damage cells.
y many measures, Minnesota has long been a standard bearer for promoting the health and independence of individuals (of all ages) with disabilities. The community-based safety net that has been developed over the last four decades recognizes that many of our most vulnerable citizens require many areas of public policy to be working in concert for successful community living to be fully realized. It’s not uncommon for government to play a role in supporting the health, housing, transportation, and employment needs of tens of thousands of disabled Minnesotans. But that safety net is fraying at the edges. Burgeoning budget deficits at the state and federal level have led to significant cuts in payments to providers over the past several years. Demographic pressures will only increase the need for resources to support this growing population. Multiple stakeholders are demanding changes in how the current fragmented
Senior and long-term care Page 20
SAFETY NET to page 12
26 January 2013 - 8 a.m. to 5 p.m. To Register:
www.mayo.edu/cme/psychiatry-and-psychology-2013r271 Registration fee includes morning lectures, lunch, ticket to play and post-play discussion.
Stories of Addiction and Recovery Held at the Guthrie Theater, this innovative education program is designed to enhance the understanding of addiction. It combines morning lectures from Mayo Clinic addiction experts with an afternoon Guthrie Theater theatrical performance.
Actress Melissa Gilbert, morning keynote speaker • Mark A. Frye, M.D. and Timothy W. Lineberry, M.D., Mayo Clinic Department of Psychiatry and Psychology, course directors • Visiting faculty, Susan Tapert, Ph.D., University of California, San Diego and Kathleen Brady, M.D., Ph.D., University of South Carolina.
Photo by Mark Vancleave
Join us for the day in exploring addiction and recovery in an innovative medical educational event designed for members of the general public and medical professionals. In fast-paced and interactive conversations, morning keynote speaker Melissa Gilbert, Mayo Clinic experts and visiting faculty will explore the scientific basis of addiction and its impact on individuals and families. Following the lunch included in the program, at 1 p.m. participants will see the Pulitzer Prize- and Tony Awardwinning play Long Day’s Journey into Night presented on the Guthrie’s Wurtele Thrust Stage. After the play, Euan Kerr from Minnesota Public Radio will moderate a discussion of the play’s themes to help participants reach deeper insights into the complex pathology of addiction—and the liberating hopefulness of recovery. College of Medicine, Mayo Clinic, designates this live activity for a maximum of 7 AMA PRA Category 1 Credits™.
DECEMBER 2012 Volume XXVI, No. 9
FEATURES Brain research Keys to healthy aging
MINNESOTA HEALTH CARE ROUNDTABLE
By Apostolos P. Georgopoulos, MD, PhD, and Margaret Y. Mahan
Preserving the safety net Why it’s important
By John Tschida
T H I R T Y- N I N T H
POINT OF VIEW Policies, politics, and physicians
By Robert W. Geist, MD
NEONATOLOGY Development of a young specialty
Timothy Henry, MD, FACC
By Mark Bergeron, MD, MPH
Minneapolis Heart Institute Foundation
DIABETES “Cheetos are not vegetables”
PATIENT SAFETY Creating a culture of patient safety
By Lori Wilcox, MD, and Mary Martinie, MD
By Janelle Shearer, RN, BSN, MA
SPECIAL FOCUS: SENIOR AND LONG-TERM CARE HELP for hospitalized elders
Design innovation 20
By Paula Duncan, RN, and Kasey Paulus, RN, CPHQ
Seniors and addiction Elder abuse
By Alanna Carter, Assoc. AIA, LEED-AP
By Steve Tschida, BES, LADC
By Julie Switzer, MD, and Avery Michienzi
The Independent Medical Business Newspaper
Background and focus: The next step in health care reform involves the patient becoming more actively engaged with staying healthy. New physician reimbursement models reward improved population health but bring new dynamics into the exam room. Incorporating patient attitude and lifestyle Creating measures that work choices into health care delivery is Thursday, April 25, 2013 necessary, but how 1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers should it be done? Creating conceptual and empirical clarity around this question may be best addressed by the term Patient Activation Measure (PAM).
Objectives: We will examine the development of PAM, what it means and how it works. We will explore patient engagement methods that have been successful and the role of health insurance companies and employers in this process. We will explore how PAM may be used across the continuum of care and whose job it will be to implement and track these measures. We will discuss the challenges that are inherent within the concept of PAM and how it may realize its best potential.
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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 email@example.com. 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 legal, tax, business or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 issues) are $48.00. Individual issues are $5.00.
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DECEMBER 2012 MINNESOTA PHYSICIAN
Mayo Clinic Creates Diabetes Health Atlas Mayo Clinic has created a resource that shows county-bycounty data on diabetes in Minnesota. The Minnesota Health Atlas is an online source of information about diabetes, provided in maps, charts, tables, and data downloads. The site was created and is maintained by the Decade of Discovery in Diabetes, a major initiative of the Minnesota Partnership for Biotechnology and Medical Genomics. The goal of the Decade of Discovery is to prevent, treat, and ultimately cure type 1 and type 2 diabetes, officials say. The partnership includes Mayo Clinic, the University of Minnesota, and the state of Minnesota. “As programs and projects for preventing diabetes roll out across the state, the Minnesota Health Atlas will be increasingly valuable and help inform strategies for diabetes care over large populations,” says David Etzwiler, executive director of the Decade of Discovery.
Mayo Clinic officials say the most common searches in the atlas are 30-day hospital readmission rates; total health care reimbursements; monthly rates of poor mental health days for persons with diabetes; and metrics on physical inactivity.
November Elections Mean ACA Will Move Ahead The road is clear for implementation of the Affordable Care Act (ACA) in Minnesota, with new DFL majorities in the state House and Senate. The Nov. 6 election that saw Barack Obama re-elected as president also brought the House and Senate under DFL control. With DFL Gov. Mark Dayton in charge of the executive branch, the 2012 election resulted in DFL control of both houses and the governorship for the first time since 1990. The election seems to settle the question of whether the ACA would be fully put into place, although opposition to the
sweeping health reform law remains. According to Rep. Tom Huntley, who for the past two years has been the ranking DFL member of the House Human Services Finance committee and also serves on the Health and Human Services Reform committee, the new DFL majorities in the Legislature will join with Dayton to move forward quickly on issues such as health insurance exchanges, Medicaid expansion, and state health-care payment reforms. “We’re not going to agree with the governor on every comma and semicolon, but overall, we have a similar view on where we need to go,” Huntley says. “All three groups want to move ahead with the ACA, so I think that will be done.” The state is facing federal deadlines for designing the health insurance exchanges, a central part of the ACA. Exchanges will provide coverage for individuals currently without insurance and small businesses who have not been able to offer health plans to employees. The
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MINNESOTA PHYSICIAN DECEMBER 2012
Republican-led Legislature last spring declined to work on preparing for the exchanges, despite being urged to do so by health care and business leaders. Huntley says the looming federal deadlines are a concern but expressed confidence that the new Legislature and the Dayton administration would find a way to complete work on the exchanges. “We have very difficult timelines that we’re going to have to try to meet,” Huntley says. “I think that we will get some flexibility from the federal government, but … there’s going to be a lot of work done between now and Jan. 1.” Huntley says the Legislature will work on a range of other health issues in 2013, including Medicaid expansion, medical homes, and establishing accountable care organizations. “I think the two biggest things are the medical homes and the ACOs,” Huntley says. “Both of those will reward primary care physicians and systems for keeping people with chronic illnesses out of the hospital.”
Groups Promote 39 Weeks for Healthy Childbirth
Hazelden Unveils New Program for Opioid Abuse
State health groups are working together on a public campaign to discourage births from being scheduled before 39 weeks of pregnancy. Early births can’t be avoided in many cases, but the March Of Dimes, one of the sponsors of the Healthy Babies Are Worth the Wait campaign, is urging expectant parents and their physicians to not induce labor before 39 weeks. Thirty-seven weeks of pregnancy is considered full term, but health officials say health outcomes are better for babies delivered at or after 39 weeks, with exceptions for medical need. March of Dimes officials say new research has shown that a baby’s brain nearly doubles in weight during the last few weeks of pregnancy and that important lung and other organ development occur at this time. They add that although the overall risk of death is small, it is double for infants born at 37 weeks of pregnancy when compared with babies born at 40 weeks, for all races and ethnicities. “With one in 10 babies being born premature in Minnesota, we need to do more to make sure that more babies are being born healthy, excess health care costs are being reduced, and families are being spared the heartache of having a baby born too soon,” says Glenn Andis, March of Dimes chapter board chair. March of Dimes has been working with the Minnesota Department of Human Services and the Minnesota Hospital Association (MHA) on reducing early births. The three groups have worked together to create hospital policies barring medically unnecessary deliveries before 39 weeks. MHA has also begun public education efforts with a pregnancy and birth safety program, which includes a focus on preventing elective deliveries prior to 39 weeks, patient education, and provider/nurse training in key areas.
Hazelden, the Center City-based addiction treatment and education organization, has launched a major new effort to address a growing rate of addiction to prescription painkillers and to stem the number of fatalities related to overdose from such opioid drugs. “Deaths from drug overdose, driven by the increase in prescription painkiller abuse, now outnumber those caused by car accidents,” says Marvin Seppala, MD, Hazelden’s chief medical officer. “This is an unspeakably tragic public health crisis—one that demands up-to-date, evidence-based treatment protocols that offer the brightest promise of recovery.” Hazelden officials say the death toll from prescription painkiller overdose across the U.S. has increased more than fivefold in the past decade (from 3,000 deaths in 1999 to 15,500 in 2009), prompting the Centers for Disease Control and Prevention to define the problem as an epidemic. In Minnesota, the Minnesota Department of Human Services (DHS) identified opiate addiction as a growing problem in its semiannual report monitoring drug abuse trends. In the June report, DHS officials said use of heroin and opiates (a term often used interchangeably with opioids) was on the rise. “That opiate treatment admissions are second only to alcohol admissions is unprecedented and should be of great concern,” Human Services Commissioner Lucinda Jesson said at the time. Hazelden officials report that their facilities have seen a corresponding increase in the number of patients seeking treatment for opioid addiction, including a dramatic jump in admissions for young people. As part of a comprehensive response to this crisis, Hazelden will offer medication-assisted treatment for opioid dependence along with a focused Twelve
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NECC Injectables Still a Concern for Health Officials Minnesota health officials said in November that injectable drugs made by the New England Compounding Center (NECC) continue to cause health problems in Minnesota. NECC drugs have been linked nationwide to serious cases of meningitis, with 461 cases of illness—including meningitis, stroke, and peripheral joint infections—reported since September. Nationally, there have been 10 deaths linked to the outbreak. In Minnesota, 13 people had been sickened as this issue went to press, but no deaths had been reported. On Nov. 15, the Minnesota health officials reported a new case of osteomyelitis, a bone
infection that is linked to the NECC drugs. Officials say patients who received NECC steroids and have persistent symptoms should see their providers, and they add that providers should watch for infections in the bone and for abscesses.
Researchers Develop New Therapy For Bulimia Researchers in Fargo, N.D., and Minneapolis have developed a new therapy for bulimia. The therapy was developed over a period of more than 10 years by researchers at the Neuropsychiatric Research Institute (NRI) in Fargo and at the University of Minnesota in Minneapolis. The eating disorders research team was led by Stephen Wonderlich, an NRI director and a researcher at the Sanford Eating Disorders and Weight Management Center in Fargo, and by Carol Peterson, an investigator with the University of Minnesota’s Department of
Psychiatry. University of Wisconsin-Madison researchers also participated in the effort. The results are described in a report comparing a new psychotherapy treatment for bulimia nervosa, integrative cognitive-affective therapy, with an established treatment from England. “In a scientifically controlled comparison with the treatment developed by Chris Fairburn at Oxford University, which is the most scientifically supported treatment available for adult individuals with bulimia nervosa, this new treatment performed comparatively well,” says Wonderlich. The study found the new approach had one of the lowest dropout rates ever seen with a bulimic population. “Just about everyone who started the trial completed the treatment, which with these patients is important—just getting people to complete the treatment.” “When we did the scientific comparison, there was no difference between our treatment and the established treatment in
terms of outcomes; they were comparable, or equal, in their efficacy,” Wonderlich says. “This is good news for the field because now there is another promising alternative treatment available which is a little different in nature than the Oxford treatment.” The new treatment focuses more on changing eating habits, researchers say, as well as looking at emotional triggers to bulimic behaviors. “Our treatment is basically saying that we think that emotional processes—feeling badly— are very important in triggering bulimic behaviors,” Wonderlich says. “People actually engage in the bulimic behaviors because they feel better momentarily.” The new approach allows patients to report on negative feelings via smart phone applications, and to receive support to make healthy choices.
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Michaela Tsai, MD, has joined Minnesota Oncology. In addition to practicing at the group’s Minneapolis clinic, Tsai will hold the endowed Martha Bacon Stimpson Chair in Medical Oncology at the Virginia Piper Cancer Institute. Tsai’s areas of special interest include clinical research, leukemia and lymphoma, and genetic counseling for breast and ovarian cancer syndromes. Tsai holds a medical degree Michaela Tsai, MD from Harvard Medical School and completed her fellowship in medical oncology, hematology, and transplantation at the University of Minnesota. Byron Marquez, DO, has been named senior medical director and chief of community primary care at Hennepin County Medical Center (HCMC), and is now seeing patients at Whittier Clinic in Minneapolis. In addition to direct patient care, Marquez will work with clinicians in six community primary care clinics, two convenience clinics, and one worksite-based clinic to improve continually the care Byron Marquez, DO they provide their patients. Marquez graduated from the College of Osteopathic Medicine of the Pacific in Pomona, Calif., and completed a family medicine residency in Detroit. He worked as a family physician for 12 years in Madison, Wis., before joining HCMC. Martin Freeman, MD, FASGE, was honored by the American Society for Gastrointestinal Endoscopy (ASGE), receiving the 2012 Master Endoscopist Award. The award recognizes a physician who spends the majority of his or her time in patient care and is recognized regionally or nationally for his or her expertise and longitudinal contributions to the practice of gastrointestinal endoscopy. Freeman is a professor of medicine at the University of Minnesota Medical School in the Division of Gastroenterology, Hepatology, and Nutrition, with specialties in gastroenterology, islet transplant medicine, pancreatectomy, and islet autotransplant medicine. The American Academy of Otolaryngology—Head and Neck Surgery presented the organization’s Honors Award to Tina Huang, MD, at its 2012 Annual Meeting in Washington, D.C. in September. The award recognizes medical professionals for meritorious service through the presentation of instructional courses and scientific papers, and participation in the organization’s committees or leadership. Huang is an otolaryngologist and neurotologist practicing at the Ear, Nose and Throat Clinic, and Lions Children’s Hearing and ENT Clinic at UMPhysicians. Okeanis Vaou, MD, has joined the Noran Neurological Clinic in Minneapolis. She graduated from Semmelweis University in Budapest, Hungary; continued her training in neurology at New York Medical College; and completed fellowships in movement and sleep disorders at Boston University Medical Center. Vaou is boardcertified in neurology and board-eligible in sleep medicine. Her clinical interests include Parkinson’s disease, dystonias, autonomic nervous system disorders, essential tremor, and sleep-related disorders. The West Metro Medical Foundation of the Twin Cities Medical Society has honored two physicians with the Charles Bolles BollesRogers Award: Joseph J. Westermeyer, MD, and Anthony A. Spagnolo, MD. The award recognizes a physician’s professional contribuOkeanis Vaou, MD tion to medicine on the basis of medical research, achievement, or leadership. Westermeyer, a psychiatrist at the Minneapolis VA Health Care System, is a clinician, teacher, researcher, author, and international expert in cross-cultural psychiatry. Spagnolo, a primary care physician, cofounded the Shakopee Medical Clinic, which merged with Park Nicollet Clinic in 1985. He retired earlier this year.
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From the bench to the bedside ■ Please tell us about the Minneapolis Heart
Timothy Henry, MD, FACC Minneapolis Heart Institute Foundation Timothy Henry, MD, FACC, directs research at the Minneapolis Heart Institute Foundation. He is an interventional cardiologist at the Minneapolis Heart Institute/Abbott Northwestern Hospital, a professor of medicine at the University of Minnesota Medical School, and is known nationally for his leadership in cardiovascular research. Henry has served as national principal investigator of multiple large, multicenter trials in acute coronary syndromes, myocardial infarction, and angiogenesis, including ongoing cardiovascular stem cell trials. He is also principal investigator for one of seven NIH Clinical Cardiovascular Stem Cell Centers nationwide.
The Minneapolis Heart Institute Foundation is the research and education arm for the Minneapolis Heart Institute at Abbott Northwestern Hospital. It has been here for 30 years. It was started by a group of cardiologists and cardiovascular surgeons that felt that providing cutting-edge research and education would enhance patient care. All the physicians in the Minneapolis Heart Institute work here, so the foundation is the way we do our research. For me, it’s indistinguishable from the Minneapolis Heart Institute; it’s the research and education arm of the practice. We have 120 to 130 cardiovascular research trials ongoing at any one time, and we publish more than 100 peer-reviewed papers per year. Our goal is to be the preeminent clinical cardiovascular research institute in the country. A lot of research is done through the University of Minnesota and the Mayo Clinic, which is much more focused on basic research. What’s unique about us is our focus on clinical research [which involves] patients versus animal research or basic Petri dish research.
were 200 miles away you didn’t. We now have outcomes that are unsurpassed, with a really low rate of mortality. ■ Stem cell research has been associated at
times with embryonic stem cells. Is there still controversy around that? It’s not an issue now. Embryonic stem cells are not being used in people. They’re probably never going to be used in people. Everything we use are adult stem cells. There are no trials going on in the world with embryonic stem cells. It’s not because of political reasons; it’s because when you put an embryonic cell in the body, it becomes a tumor called a teratoma. Not too many patients want to have teratomas. I think embryonic research is basic research that helps teach us about the function of stem cells, but it’s not currently being used in people.
Research is critical to making clinical care better.
■ What are some of the projects the foundation
has been working on? We have the largest clinic for patients with refractory angina. These are people who have ongoing chest pain but are not candidates for further surgery. We call it the OPTIMIST program. Our goal is to provide a comprehensive approach to the problem, so we want to learn about the natural history, we want to learn about what the risk factors are, then we want to have the best available therapies. We’ve treated more than 300 people with stem cell therapy at Minneapolis Heart Institute, more than anyplace else in the U.S. We’re using this therapy for people with heart attacks, heart failure, refractory angina with severe blockages, and in people with peripheral arterial disease. We’re also creating the largest network in the U.S. for patients with heart attacks. We call it the Level 1 program. If you have a heart attack and arrive in, say, [a hospital in] Hutchinson, you get treated with the standardized protocol and then you get transferred here. If you have a heart attack in any of about 30 places in Minnesota, we fly you to Abbott Northwestern and you get angioplasty and stenting to open up your artery. It’s an approach to bringing patients in quickly for the best care. We’ve treated nearly 4,000 patients over the past nine years with this program. This network allows us to treat people quickly, and it’s really incredible because there used to be significant rural-urban disparities. If you were in Minneapolis you would get good care, but if you
MINNESOTA PHYSICIAN DECEMBER 2012
■ We often hear about the translation of research
from the lab to accepted standards of medical practice; what can you tell us about that concept? What we believe is that, to have the best patient care, you need to involve the most cutting-edge research. As you progress in treatments for heart attacks or treatments for atrial fibrillation or treatments for preventive cardiology, you need to make advances. We’re involved in taking those advances from the bench to the bedside, applying them in people. Our job is to do that safely and effectively. ■ What can you tell us about your recent trip the
American Heart Association conference? We had a very good meeting. We had over 40 presentations, with a couple of very important things. We had a late-breaking trial that looked at stem cell therapy for acute MI, for acute heart attacks. We also presented a study that looked at heart failure admissions through the Allina system, primarily at Abbott. We showed that when patients were taken care of by a heart failure team, you had fewer readmissions, which leads to decreased costs. So more specialized care with a heart failure team led by a cardiologist resulted in decreased readmissions. ■ Does the Affordable Care Act affect research?
Do you see an effect from health care reform law in your work? We don’t see an effect yet, and it’s difficult to know what the effect will be. What you can say is that, in general, research is critical to making clinical care better. And one of the problems and challenges we face in the U.S. is that clinical research is being done increasingly outside the U.S., particularly in India and China. That’s a major challenge to our
health care system. We need to find a way to continue to do outstanding clinical research in the U.S. because this is our patient base and we need to know, does it work here? It’s been disappointing to me that, in all of the health care discussions, there has been very little discussion of how we fund and how we continue to do cutting edge clinical research in this country. Personally, I think that’s a challenge that we face. ■ Have you seen any improvement in the
timeline for FDA approvals? It’s safe to say we’re more challenged than other countries, in particular for devices. With the percutaneous valve, for instance, the U.S. was one of the last countries to have it approved. The majority of the world had percutaneous valves approved prior to us. So that led to medical tourism; many Americans were actually going overseas to get their valves, which I don’t think is what we want. ■ What steps has the foundation taken to
help other physician groups establish research efforts? One of our values is not only to do good clinical research but to do good education. We’ve spent a lot of time training other systems. We just published several articles about our research structure to help other people learn how to do strong clinical
research. From a clinical standpoint, more and more community-based practices are interested in being involved in clinical-based research. I think people understand that to do outstanding patient care, you need to be familiar with the cutting edge of clinical research. ■ What advances do you see overall for car-
diology in the next 10 to 15 years? A number of areas are game changers where we’ll see dramatic changes. No. 1, I think we’ll see continuous advances in percutaneous valve replacement and repair. For both aortic and mitral valves, a lot of what we now do surgically we’ll be able to do clinically. No. 2, from the standpoint of cardiovascular cell therapy, we’ll see an increasing number of cell therapies addressing cardiovascular diseases. No. 3, we’ll continue to see innovation in preventive cardiology. This will include changing population health to improve cardiovascular care from a preventive standpoint, like the Heart of New Ulm project. That’s critically important. The U.S. faces an epidemic of obesity and diabetes. From our viewpoint, it’s critical that we develop community-based preventive care.
■ How do you feel about those kinds of
preventive care efforts so far? Right now, there are a lot of companies, individuals, institutions doing it on a caseby-case basis. It will be even more effective when we can do it cooperatively. But even doing it individually is helpful because at least that teaches you what works and what doesn’t. Heart of New Ulm, for example, focuses on one community but hopefully what you learn from that project is what’s effective and what’s not effective, so you can apply it in cities throughout Minnesota. ■ What advice do you have for primary care
providers who might have patients with cardiology issues? At the Minneapolis Heart Institute, we have close relationships with 35 clinics throughout Minnesota, and we work hard to partner with them to provide up-to-date cardiovascular information. Partnership is important because it’s such a rapidly changing field. It’s important for internal medicine groups to have close relationships with their cardiologists. When we go to Hutchinson, or Mora, or Cambridge, or Akin, or New Ulm, most of the care is given by primary care physicians. And that’s what we want. But our goal should be to help them put protocols in place that work effectively. It should be a partnership.
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Brain from cover percent, though the mechanism by which exercise promotes brain health is not understood. Finally, cell damage is also caused by a host of explicit brain diseases (e.g., Parkinson’s disease, Alzheimer’s disease, multiple sclerosis, stroke), including diseases of genetic origin (e.g., Huntington’s disease), which may or may not be amenable to treatment to various degrees. A key aspect of brain health is that the effects of insults to the brain are cumulative and interacting. For example, the symptomatology of Alzheimer’s disease can be much more devastating on a brain subjected to long-standing, untreated hypertension or atherosclerosis. This cumulative aspect of brain damage compounded by multiple injuries is very important, as illustrated recently by the devastating effects of successive traumatic brain injuries inflicted by sports injuries (called chronic traumatic encephalopathy). This type of damage is the
The interplay between genetics and environment is key.
direct result of the brain injury–compounding effect. The reason is that brain tissue does not really regenerate, so that residual brain damage remains after each injury and is compounded after multiple injuries. Therefore, the recipe for healthy brain aging is simple: • Avoid/reduce brain insults as early as possible and by the best possible means. • Prevent diseases such as hypertension, atherosclerosis or treat them early. • Avoid negative conditions or habits (e.g., smoking). • Support positive lifestyle behaviors such as exercise. The brain and genetics
A different factor that affects brain health is our genetic
makeup. In the worst case, brain diseases due to certain genetic abnormalities can be fatal, as with Huntington’s disease. Other genetic abnormalities involve inborn errors of metabolism that, if diagnosed early, can be taken into account and brain health achieved despite them. For example, eliminating the amino acid phenylalanine in the diet will prevent brain damage in individuals who have the genetic disorder PKU. However, apart from such clear-cut cases, genetic makeup can influence in subtle ways the way the brain works, its sensitivity to specific insults, its resistance to injury, and the efficacy of its repair mechanisms. This is what is meant collectively by the concepts of “vulnerability” and “resilience,” meaning susceptibility and resistance to insults, respectively, in speaking of brain health. Identification of such genetic influences will have a major effect in considering brain health and in guiding and steering individuals toward graceful brain aging. The interplay between genetics and environment is key: If we knew which part of our individual genetic makeup makes a difference, we could better protect ourselves from insults to which we might be most vulnerable. In fact, the Minnesota Women’s Healthy Brain Project (HBP) aims at exactly those broad goals, by identifying factors that are associated with and promote healthy brain aging. The Minnesota Women Healthy Brain Aging Project
The Healthy Brain Project started in 2010 as a joint initiative of a group of women in the Twin Cities (led by Sally Kling, Anita Kunin, and Barbara Forster) and a group of investigators at
MINNESOTA PHYSICIAN DECEMBER 2012
the Minneapolis Veterans Affairs Health Care System (Minneapolis VAHCS) and the University of Minnesota. Study subjects are recruited through the Women’s Health Center of the Minneapolis VAHCS, where women veterans receive routine health care. Testing is done at the Brain Sciences Center at the Minneapolis VAHCS. The first subject was studied on Oct. 16, 2010. Since then, we have studied 145 women (age 31–97 years), of whom 62 (54–97 years) have been studied again after a year. We conduct comprehensive assessment of brain, cognition, language, and genetics. We acquire comprehensive, multimodal data from each subject to derive composite descriptors of brain status and associate them with cognitive, language, and genetic information. Testing and assessment
Assessing brain function. The brain’s job of information processing is accomplished by the continual communication among neuronal populations. We evaluate this neural communication with the highest fidelity using magnetoencephalography (MEG), a high-tech method that measures tiny magnetic fields (one-billionth of the magnetic field of the earth) generated when ensembles of neurons communicate. We complement this functional evaluation with structural information from structural MRI, white matter integrity information from diffusion MRI, brain chemistry information from magnetic resonance spectroscopy, and brain neurovascular coupling from functional MRI. A major challenge is to integrate all this information in order to derive a “brain health index”—essentially, a forecasting tool that can be used in a clinical assessment. Assessing cognition and language. The brain measurements above are coupled with an assessment of cognition and language. For the former, we use the Montreal Cognitive Assessment (MoCA) to score performance on visuospatial,
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executive, naming, memory, attention, abstraction, delayed recall, and orientation functions. For language, we assess phonemic and semantic fluencies (“Tell us as many words as you can that start with the letter A” for phonemic fluency and “Tell us as many animals as you can” for semantic fluency). Assessing lifestyle factors. Lifestyle plays a most important role for overall health and for brain health. Regular exercise, healthy diet, and preventing and treating medical conditions (such as hypertension and atherosclerosis) are all crucial components conducive to healthy brain aging. We are fortunate in our study to have access to such records of our participants from several years back. We are currently in the process of retrieving, coding, and quantifying the various components of lifestyle for further use in our analyses. Analyzing genetic factors. We draw blood for DNA analysis. We plan to start by looking at effects specific polymorphisms (i.e., gene variations)
might have on the various measures above and, ultimately, on the brain health index. Preliminary analyses are promising in that direction. Study design
The design of our project comprises both cross-sectional and longitudinal components. In the former, we collect data from as many subjects as we can (aiming for 100 subjects per year), whereas in the latter we reexamine the same subjects every year. The cross-sectional data will enable us to develop hypotheses regarding healthy brain aging, and the longitudinal data will help validate (or modify) the hypotheses. To date, we have collected data from 145 subjects cross-sectionally and from 62 subjects longitudinally. We have just entered the third year of longitudinal acquisitions. We expect this project to continue in perpetuity: the
more data that are available, the better and more solid the hypotheses, and the better the predictions for longitudinal validation. Finally, it is possible that some of our participants may develop a brain disease, and it would be interesting to investigate whether such a disease onset could have been forecast by our prior measurements on that subject. The future is the lifespan
Our plan is to open this project to include men and women of all ages, from 8 years (the earliest age group we can study with the MEG) to 100+ years of age. A problem we have encountered is that research funding for healthy aging does not seem to be a priority of federal agencies (e.g., National Institutes of Health, Veterans Administration), which typically are focused on diseases. It is puzzling that with all the emphasis on health mainte-
nance, healthy aging is practically ignored as a field of legitimate research. Therefore, we still rely on private philanthropy to fund our project, and this precious support is paying off for the benefit of everyone. More information about the Healthy Brain Aging Project can be found at www.healthy brainproject.org. Apostolos P. Georgopoulos, MD, PhD, is McKnight Presidential Chair in Cognitive Neuroscience; American Legion Brain Sciences Chair; and professor of neuroscience, neurology, and psychiatry at the University of Minnesota Medical School; and is director of the Brain Sciences Center at the Minneapolis Veterans Affairs Health Care System. Margaret Y. Mahan is a graduate student in the Biomedical Informatics and Computational Biology Graduate program at the University of Minnesota. She is working on the Minnesota Women Healthy Brain Aging Project for her dissertation, for which she has received a National Science Foundation Graduate Research Fellowship.
Do you have patients with trouble using their telephone due to hearing loss, speech or physical disability? 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 www.tedprogram.org 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 DECEMBER 2012
Safety net from cover system of supports is operated and reimbursed, and multiple efforts are underway to make it more responsive and accountable to those it is designed to serve. The demand for savings
An open question now being asked by some state Capitol policymakers is: How much independence can we afford? Many of the support needs for people with disabilities are Medicaid-funded services. This state-federal program is consuming an increasingly larger portion of governmental budgets. The expense trajectory for this program is unsustainable. At the state level, 30 cents of every taxpayer dollar is funding health services for those who are impoverished and/or disabled. (This is second only to Kâ€“12 education funding in terms of dollars spent.) A disproportionate share of this budget is devoted to the needs of the elderly and disabled. Whenever the state faces a budget deficitâ€”as the Minnesota Management &
Budget Office predicts it will again in 2013â€”it is nearly impossible to balance the overall budget without additional cuts in this area. It is important to note that these are not just medical services being purchased. In fact, the fastest growing portion of the Medicaid budget supporting people with disabilities is community-based social supports that are critical to achieving overall health. These include services like in-home supports and training, and service coordination. The demand for value
Since the state Health Reform Act of 2008, Minnesota has been laying the groundwork for a significant shift in how we pay for medical services in both the public and commercial market. The goal is to stop paying for a service just because it is delivered and instead reward the better health outcomes those services may (or may not) achieve. While much of the stateâ€™s employer-based coverage is now moving rapidly toward
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MINNESOTA PHYSICIAN DECEMBER 2012
total cost of care (TCOC) financingâ€”meaning health plans and large provider systems have a shared financial incentive to manage health and costsâ€”neither the health plans nor the state has figured out a way to pay for the most expensive population using the health system: people with disabilities. The 2011 Legislature mandated that people with disabilities within the Medicaid program join a managed care plan. This was done purely as a costsaving move. But every health plan serving this population is losing money serving the disabled. Many of the stateâ€™s health plans are refusing to enter the market to serve this population. The state has also delayed bringing children into this managed-care financing arrangement because (1) the health plans have no experience in this area and (2) the state is unsure how to build successful (and sustainable) financial models to fund it. But the changes in paying for medical services and the move to managed care still donâ€™t touch the growing long-term care or social support services needed by the elderly and disabled. These managed care plans are responsible only for the medical services needed by people with disabilities. Remember, this is the fastest growing part of the state health budget. In this area, how do we know who the good providers are and what outcomes they are achieving with taxpayer dollars? Which programs and services are reducing the need for expenditures in other areas of the state budget? The short answer is: We donâ€™t know. This must change. The demand for new service delivery models
The safety net for people with disabilities largely has grown out of the deinstitutionalization of people with developmental disabilities in the early 1970s. It has been successful in promoting community integration, largely through a four-bed group home model and through day-service programs that provide meaningful activities and
employment in nonresidential settings. But new and innovative service models are neededâ€”for both medical and long-term care supports. In the future, services for individuals with disabilities will be more flexible and based on individual needs. Consumers will also have more control over how their service dollars are spent and a better understanding of what their support budget looks like, in order to decide what mix of services works best in the short and the long term. How will these changes occur and when? The state Department of Human Services (DHS) has requested permission from the federal government to redesign how long-term social supports are accessed and delivered. This was done with the extensive input of multiple stakeholders and is part of a broader reform effort underway at the state level to deliver the right services at the right time, and (ideally) for lower cost. (More details on the Medicaid reform efforts can be found at www.dhs.state.mn.us.) New service models are also expanding in the medical services area, with many centered on the health-care home model. This primary care-based approach involves comprehensive care planning and coordination of services for people with disabilities. Courage Center has created just such a model that incorporates comprehensive care planning, strong primary care, and coordination of medical and social services from an interdisciplinary team of providers. A rigorous, multifaceted evaluation also examines how willing and ready patients are to take control of their own health, whether their mental health is stable or improving, and how many fewer hospital days and emergency room visits they are experiencing. This highly complex target population has an average of nine chronic conditions and has spent nearly two weeks of the year hospitalized (on average) prior to choosing Courage Center as their primary care clinic. The data show that since this model was imple-
mented, hospitalizations have fallen for Medicaid recipients by nearly 75 percent. (More details on outcomes can be found at www.couragecenter.org.) Additional provider-based networks, similar to the accountable care organization models (ACOs) created by the federal Affordable Care Act, are also being tested by DHS. These groups of providers are hoping to share in the savings generated by delivering positive health outcomes for Medicaid recipients at a lower overall cost. The current system is fragmented and unaccountable. No one medical provider suffers financial consequences if the health status of an individual with a disability declines— or dies. The demand for new payment models
Nearly a decade of budget cuts at the state level have left most players in the disability services system reeling—including the people with disabilities who rely on it in order to achieve their goals in life.
Today’s era of fiscal austerity means an increased level of accountability is needed to ensure the state preserves the safety net.
equacies of the fee-for-service payment system that provide no incentive for physicians to do anything but avoid people with disabilities in their clinics and practices. A fragile commitment
Providers have seen reimbursement levels for services delivered decrease dramatically. Government agencies at the state and county level have seen similar budget challenges, meaning they are administering and regulating programs with an increasing population, but with far fewer employees and other resources. To combat the falling reimbursements that are happening under the current fee-for-service system, innovative providers are asking a series of questions of both health plans and the state: How can we package service together for a fixed price? How can we change the menu of services to achieve optimal success for the people we serve? The only way to get providers to behave differently is to
pay them differently. Rewarding individual providers for their contributions in maximizing the health and independence of those they serve must happen if the safety net for the state’s most vulnerable citizens is to remain intact. This is especially true for the most complex and costly individuals in our taxpayer-funded Medicaid program. Private sector strategies like TCOC have not yet arrived for this population. Predictive modeling programs used by health plans and large provider systems can’t accurately gauge the future expenditures of these Medicaid enrollees, nor do they address their complex social support needs. New measurement tools and financing strategies are needed if we are to leave behind the systemic inad-
What protections exist to ensure that the state maintains its historic commitment to those who rely on the fragile and fraying safety net? In 1999, the U.S. Supreme Court, in what is now commonly referred to as the Olmstead decision, determined that individuals with disabilities had a right to live in the “least restrictive setting” possible. Since this ruling, most states have aggressively moved toward a standard that Minnesota has long since adopted: People in need of governmental assistance should be served in integrated, community-based settings rather than in institutions. This was easy to do in the flush years following the turn of the millennium, when Gov. Jesse Ventura was mailing SAFETY NET to page 38
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2013 Winter Conference
Announcing: Minnesota Medical Group Management Association
2013 Winter Conference Tuesday – Wednesday, March 5-6 Please join us at our semiannual meeting as we discuss a wide range of health care business topics. $275 members $500 non-members Saint Paul RiverCentre, St. Paul, Minnesota For registration or more information,
please visit our website at: www.mmgma.org or call 612-999-5359 DECEMBER 2012
PAT I E N T
reating a patient safety culture has become a priority for hospitals since the 2000 publication of â€œTo Err is Human: Building a Safer Health System,â€? an Institute of Medicine (IOM) report. The report estimated that 44,000 to 98,000 people die in hospitals each year from preventable medical errors. Subsequent IOM reports have cited inadequate health care systems and processes as the root of most medical errors and have recommended improving the culture of safety within health care organizations as essential to preventing or reducing errors. Joint Commission leadership standards today require hospitals to create a culture of safety and to measure safety with indicators that focus on communication, identifying patients at risk, medication safety, and preventing infections and surgical errors. In addition, the nonprofit National Quality Forum (NQF) has developed 34 safe-practice recommendations for hospitals to measure their safety culture
Creating a culture of patient safety Hospitals focus on teamwork, leadership, communication By Janelle Shearer, RN, BSN, MA and conduct interventions to reduce the risk of medical errors. Indicators measure a variety of factors, including
number of registered nurses, licensed practical nurses, and unlicensed caregivers on staff, in addition to the number of
Critical access hospitals in Minnesota are stepping up to the challenge of changing their attitudes, behaviors, and practices to ensure their patients are receiving care in a safe place. mortality rates, medication errors, falls, infections, and pressure ulcers, as well as behavioral health. NQF workforce indicators measure the
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