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THE NORTH CAROLINA

Volume 12 Issue 3 / Summer 2016

quarterly news in north carolina family medicine

Tomorrow’s Medicare:

A Tale of

TWO Pathways pages.indd 1

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Winter Family Physicians Weekend Dec. 1-4, 2016

The Omni Grove Park Inn in Asheville, NC

~ Details on p. 20 ~

LEARN MORE AND REGISTER TODAY AT

WWW.NCAFP.COM/WFPW

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Inside 10

Tomorrow’s Medicare: A Tale of Two Pathways

4

President’s message

The Health Effects of Discrimination

health policy & advocacy

Balancing Appropriate Pain Management with Prevention of Opioid Abuse

Meetings & education

CME & Camaraderie in the Perfect Mountain Location

Residents & new Physicians

Preparing for Your Future One Step at a Time

6

student interest & initiatives

Why I Bleed Family Medicine!

20

THE NORTH CAROLINA

Practice Management

Improving Patient Communications & Engagement with Your Portal

22 24 28

DEPARTMENTS President’s Message.......................... 4. Policy & Advocacy................................ 6 Chapter Affairs.................................... 14 Membership....................................... 18

CME Meetings & Education................. 20 Residents & New FPs.......................... 22 Student Interest.................................. 24 Practice Management.......................... 28

PUBLISHED BY THE NORTH CAROLINA ACADEMY OF FAMILY PHYSICIANS, INC. R aleig h , N o rt h C aro lin a 2 7 6 0 5

919.833.2110 • fax 919.833.1801 • www.ncafp.com MANAGING EDITOR and GRAPHIC DESIGN

Pe te r Gr a be r, Communic a tions Se r v ic e s

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HAVE A NEWS ITEM WE MISSED?

NCAFP members may send news items to the NCAFP Communications Department for publishing consideration. Please send via email to pgraber@ncafp.com.

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THE NORTH CAROLINA

PRESIDENT’S MESSAGE

TO

By: Dr. Rhett L. Brown 2015-2016 NCAFP President

NCAFP MEMBERS

The Health Effects of Discrimination Family Physicians must remain vigilant in fighting personal bias in patient care

41%!

Let me repeat that number -- 41%! This is the prevalence of suicide attempts among transgender individuals, which compares to 4.6 percent for the overall U.S. population.1 (Hass, 2014) I can imagine many of you are thinking, “see this community is more mentally ill!” No! This vulnerable population suffers more discrimination (in numerous forms) and loss than almost any other marginalized group. Transgender individuals are stigmatized on a structural, interpersonal and individual level. This causes severe emotional pain, isolation and despair that most of the population does not experience. Many other groups are also stigmatized and marginalized without such increased rates of suicide attempts. So why is this happening in transgender population? There are several determining factors that play a role here. The shear small size of this population is one. Transgender or gender non-conforming people make up 0.3-0.6% of the US population (Hass, 2014). This very small number makes it hard to connect and not feel alone. Other marginalized groups have or have had safe spaces where they learned about their subculture and where they could express their authentic selves. They could experience acceptance by a larger group. For African-Americans, this was frequently the church and for gays it

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was the bars. These were places where the stigmatized individual could let down their guard, be accepted and be told they are good enough just as they are. Creating a collective identity (“I am not alone”) helps individuals feel empowered against stigma. Transgender individuals have not had this. How isolating. How lonely. In addition to this social isolation is the constant bombardment from almost all aspects of society telling you that who you are is wrong and not good enough.

forces some transgender people to travel long distances to receive care, pay out of pocket for a trained physician not covered under their insurance, or postpone care altogether. These institutional barriers, coupled with being seen as deviant by the larger society, effects how transgender people cope with themselves, their environment and can lead to internalized transgender-phobia. (Hughto, 2015) Interpersonal stigma is the discrimination,

A recent article (Hughto, 2015) in the journal Social Science & Medicine succinctly describes the overwhelming consequences of discrimination the transgender population suffers. “Structural, interpersonal, and individual forms of stigma are highly prevalent among transgender people and have been linked to adverse health outcomes including depression, anxiety, suicidality, substance abuse and HIV.” (Hughto, 2015) Structural stigma refers to the societal norms and institutional policies that constrain access to resources (e.g. public bathrooms). It can lead to restriction/barriers to health care. Currently in North Carolina, transgender is not a protected class and can be victimized without legal recourse. Many lack access to insurance (a likely product of employment discrimination) and even if they have health insurance, many private insurers exclude coverage for gender affirming medical interventions. The limited availability of trained physicians

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2015-2016

NCAFP Board of Directors Executive Officers President President-Elect Vice President Secretary/Treasurer Board Chair Past President (w/voting privileges) Executive Vice President

rejection and violence a transgender person suffers when interacting with other members of society. Transgender individuals risk losing 90% of their social support when they decide to reveal their authentic selves. Rejection by co-workers, friends and family is common and may be demonstrated through physical assault or through less overt means, such as lack of promotion by the employer or lack of emotional/financial support from family. Mistreatment in everyday settings such as healthcare is another form of discrimination commonly experienced. A patient of mine is now fearful of going to Emergency departments after being called a freak by the emergency room nurse. Nationally 28% have experienced harassment in the medical setting and 19% were refused care. And 2% experienced violence in the doctor’s office. (Hughto, 2015) Persistent and continued discrimination and stigmatization have negative health impact in multiple forms. Chronic anxiety and fear will raise blood pressure, increase cortisol levels and elevate cardiometabolic risk. Chronic stress is strongly linked to

District Directors District 1 - Mackenzie Smith, MD District 2 - Gilbert Palmer, MD District 3 - Eugenie M. Komives, MD District 4 - Shauna L. Guthrie, MD, MPH District 5 - Dimitrios “Taki” P. Hondros, MD District 6 - Cody A. Wingler, MD District 7 - Jennifer L. Mullendore, MD

anxiety, depression, suicidality and substance abuse to cope. Thus transgender individuals may be particularly at increased risk of poor health and poor health outcomes from the chronic stress and the barriers to appropriate healthcare they face. (Hughto, 2015)

At-Large Jason T. Cook, MD

What Can Family Physicians Do?

At-Large David R. Rinehart, MD

First, examine you own feelings and biases you may have toward transgender patients. Are you creating an accepting and supportive environment in your office? Being an accepting provider and office will help lessen the shame a transgender patient may have about their identity and will help them better cope with the effects of stigma.

IMG Physicians Joseph P. Pye, MD Minority Physicians Benjamin F. Simmons, MD Osteopathic Family Physicians Slade A. Suchecki, DO New Physicians Jessica Triche, MD

Second, become knowledgeable about resources in your area and in the state to provide appropriate gender-affirming care for your patient(s). In the July issue of The Journal of Family Medicine there is an excellent article written by my friend Dr. Abbas Hyderi and his colleagues on providing sensitive care to transgender patients (Hyderi, 2016). Start educating yourself today. Third, support changes to policies that reduce stigma and provide equal opportunities for transgender people. Studies show that policy changes can positively impact the lives of stigmatized individuals by providing greater protections and access to resources under the law. And finally and most importantly, let you patient know they are good enough!

Works Cited Hass, A. R. (2014, January). Suicide Attempts among Transgender and Gender Non-conforming Adults. The Williams Institute. Hughto, J. R. (2015). Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. Social Science and Medicine, 147, 222-231. Hyderi, A. A. (2016). Transgender patients: Providing sensitive care. The Journal of Family Practice , 65 (7), 450-461.

Medical School Representatives Chair Warren P. Newton, MD, MPH (UNC) Family Medicine Residency Directors Viviana Martinez-Bianchi, MD (Duke University FMR) Resident Director Margarette Shegog, MD, MPH (MAHEC-A) Resident Director-Elect Alyssa Shell, MD, PhD (MAHEC-A) Student Director Jeffrey Pennings (Campbell) Student Director-Elect Angie Maharaj (Campbell) Medical School Representatives & Alternates Chair (UNC) Warren P. Newton, MD, MPH Alternate (Campbell) Charlotte Paolini, DO Alternate (Duke) J. Lloyd Michener, MD Alternate (ECU) Chelley Kaye Alexander, MD Alternate (Wake) Richard W. Lord, Jr., MD, MA AAFP Delegates & Alternates AAFP Delegate Michelle F. Jones, MD AAFP Delegate Karen L. Smith, MD AAFP Alternate Richard W. Lord, Jr., MD, MA AAFP Alternate Robert L. Rich, Jr., MD The NCAFP Family Medicine Councils Advocacy Council Robert L. Rich, Jr., MD, Chair CME Council

Alisa C. Nance, MD, RPh, Chair David R. Rinehart, MD, Vice-Chair

Membership & Workforce Practice Management Council Public Relations & Marketing

5 pages.indd 5

Rhett L. Brown, MD Charles W. Rhodes, MD Tamieka M.L. Howell, MD Alisa C. Nance, MD, RPh Thomas R. White, MD William A. Dennis, MD Gregory K. Griggs, MPA, CAE

Jessica Triche, MD, Chair Benjamin Simmons, MD, Vice-Chair Joseph P. Pye, MD, Chair Thomas Wroth, MD, Vice-Chair William A. Dennis, MD, Chair

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THE NORTH CAROLINA

HEALTH POLICY

p r a c t i c e

By: Gregory K. Griggs, MPA, CAE NCAFP Executive Vice President

a d v o c a c y

Balancing Appropriate Pain Management with Abuse Prevention

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Online at ncafp.com/advocate

went well beyond what we believed would be reasonable, and the NCAFP’s advocacy team and physician leadership put significant efforts into changing the proposal.

I

t’s all over television. It’s in the newspaper. It’s in the Legislature and in Congress. In fact, you can hardly turn around without hearing or seeing something about the opioid crisis in our country. There is certainly a need for appropriate pain management, and for years, physicians have been told that pain is the “fifth vital sign.” Yet, there are those who abuse opioids, as well as other prescriptions or illegal drugs. The Academy is working hard to help our members address this important issue and continue to provide appropriate pain management to their patients. The following outlines a few of the developments in North Carolina and beyond, and provides a few resources that may be helpful to you in your everyday practice.

NC Legislative Action Throughout this session, legislators have discussed numerous responses to the opioid abuse crisis. In fact, the Senate proposed requiring that physicians utilize the state Controlled Substance Reporting System (CSRS) EVERY time a physician wrote a prescription for ANY controlled substance, whether it was a new prescription or a refill. This proposal

Ultimately, the legislature adopted a proposal requiring all prescribers to register with the Controlled Substance Reporting System but it allows you to use your best clinical judgment for when you should access the system. However, you will need to register for CSRS within 30-days of obtaining or renewing your medical license. We would encourage you to register now rather than waiting for your license renewal. If you are not already registered with the system, you can find out details and the form needed to complete registration at www.ncafp.com/csrs-register. The legislature also funded upgrades to the system that should make the CSRS more user friendly to physicians in the future, and ultimately provide the ability to interact with registries in adjoining states going forward.

New Law Enhances Accessibility to Opioid Reversal Drug Governor Pat McCrory joined the law enforcement community and many medical proponents in late June signing new legislation making the opioid reversal drug Naloxone more accessible through a statewide standing prescription order signed by the State Health Director, Dr. Randall Williams. NCAFP Vice President Dr. Tamieka Howell represented family medicine at the signing ceremony.  The law now enables pharmacies across North Carolina to make the drug available without a prescription. North Carolina becomes only the third state in the nation to issue this standing order for a drug that has reportedly saved the lives of over 3,000 North Carolinians already.  Several published reports have noted that In North Carolina, more than 1,000 people die each year from prescription opioid and heroin overdoses, with one out of four autopsies performed by state medical

Let’s make NCAFP’s voice even in Raleigh

Contribute

Today!

FAMPAC Empowering Family Medicine

ncafp.com/fampac

~ Continued on next page ~

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examiners resulting from drug overdoses.

mation about our December Annual Meeting as it becomes available. In the meantime, the NCAFP has partnered with MAHEC, CCNC and The Governor’s Institute to offer an online option. To learn more about the program: “A Guide to Ratio-

NCAFP Letter to the Editor

ment and paired its release with a free webinar discussing how to evaluate patients presenting with chronic non-terminal pain to assess for potential opioid responsiveness and opioid risk. The toolkit includes an action plan, pain inventory, work questionnaire, medication agreement between patient and physician, an opioid risk tool and links to additional AAFP and external resources for physicians. This is another excellent resource with timely and evidence-based information.

Given all the recent press coverage about opioids, the NCAFP developed a letter to the editor that appeared in several newspapers around the state under various leaders’ names. Most notably, an article by NCAFP President Dr. Rhett rugs – illegal d cularly d Brown n a n o ripti , parti th presc always simple appeared in o b e – e abus not addictiv ropioid ith the the Charlotte ons are f e ti w o lu s d in o a m s n p ble eve iv t’s t the The pro a patien al for abuse or Observer. A copy ted. Bu e n g e a n m a u c nti do to m the pote e need of the Letter are well ch ncing th edications and la a ffer mu b n to the Editor is whe pioids o to control tain m o r , e c ly f te o s urged propria included here. qualitie result, ored ap atically

Opioid

Opioid CME Requirement to Take Effect on January 1st

L

the E etter to

ditor

NCAFP Past President Dr. Robert L. (Chuck) Rich Leads AAFP Efforts Around Opioids

Finally, NCAFP's own Dr. Robert L. "Chuck" Rich has helped lead a it re emph ital sign.” As nd mon AAFP’s national efforts around sion. ians we v cribed a s ic tients s e th a r y p if p h f p ir n Whe s “the te the opioid abuse. While a member of a years, a r ig in o it a F p . m f relie suring lief to a e e r m te , and Chair of the AAFP Commisv ia needed r ain rese propr tients’ p ical to p vide ap it o r r c p sion on Health of the Public and their pa is to ent ribe ns tried anagem y presc ll m a r in e Science, Dr. Rich helped write a physicia n p e le ssib s we g ffective g. f the po ysician o in h e g p AAFP’s policy on appropriate sufferin no doubt that e r e a y b il w fam gly a ically s life. As There’s n re stron physicians typ f o a o opioid prescribing. Since that ti e lu ty w o li e ily caus ioid s ’s qua ve. Fam sort, be non-op ing one e n ti time, he has represented AAFP s r e a e t h g d s p e lu o la n min and as a at inc s, aceta topioids a positive atment plan th D at numerous national meetI e th tr A o S y b r N eve ral tre es – outcom erapy, o t always cover t with a ings on the subject, including n th e l a m n e o g na ay no cupati c m o s r n pain ma d o with the FDA, the CDC and la l te p ina lth physica But hea ave elim eat that h . e ts such as n W others. a s r. ette pres nd tr

The NC Medical Board has updated its CME rules based on legislation passed in 2015. The legislation requires certain de dly, a r the b and anti training in opioids for ed nce dea lives fo . o r in s u a a o p w prescrib h d r t e e wha htfully r ment fo es have chang g all licensed prescribers. u wit u c The Bottom Line: The o s u to th e to be ways icin rovid d d d p e e n y e u M n ll o f a s and u e As a result, beginning in e s n v use and abuse of opioids is in ti a id n ic h io o d e p c e s; w to o ons ut m ers disease natives ssociati January, every physician ured. B r w a c e s under more scrutiny today l n lt e a a a b n t k t, ’ io an men s quic rofess which c who prescribes controlled manage t alway than ever. The NCAFP . Our p o in d n a e r p e o r a it te n ia re and mo d appropr But the substances, except those and AAFP will continue tient an abuse. n about f o o ti a s c n en a pa to u e ig s ts ed tw n e holding a residency training e e iz to advocate to minimize b ti n a gue hes. ur p recog en dialo nt on o approac p u lhow to o o a ll c license, will be required to u a d e the constraints and s n id a it w indiv nest fact, size f g their at an ho or one ical. In in it th p take at least three hours of r c administrative burdens lo w e o is v n k de sician We do ith us in le. w b CME, from the required 60 are phy a s c r on physicians treating il e a y r v tn a a is im t par their pr ids, help your family. d hones hours of Category 1 CME, n io a their patients with p t o h h ig r . of wit be forth care solutions e health uggling that is designed specifically to tr th s chronic pain. But we d is n h a e lt n a ealth ved o ized he address controlled substance t your h ath forward. also urge you to use your lo u o r b o a u e o st p If y e car prescribing practices. The d the be ctor. W as many resources o in d f r u u o o y help Call y l il controlled substance prescribing w as possible to help e r, w Togethe CME must include instruction on identify when abuse is controlled substance prescribing happening, from the CSRS practices, recognizing signs of to the education and toolkits that are availthe abuse or misuse of controlled able to you today. nal Opioid substances, and controlled Prescribing for Chronic Pain” substance prescribing for chronic pain or to register for the online program, go to: management. http://www.aheconnect.com/newahec/cdetail. The NCAFP, as well as many other physician organizations, have been providing CME over the last few years that should meet this requirement. In addition, we will continue to offer opportunities in the future to meet and fulfill this CME requirement. Look for infor-

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asp?courseid=mahec7

AAFP Chronic Pain Management Tool Kit Recently, AAFP has published an excellent member-only resource on chronic pain manage-

THE NORTH CAROLINA FAMILY PHYSICIAN • Summer 2016

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THE NORTH CAROLINA

SURVEILLANCE

By: Peter Graber NCAFP Communications

Tomorrow’s Medicare:

A Tale of

TWO Pathways F

amily medicine practices of every stripe are navigating a turbulent and ever changing practice environment. The landmark Medicare Access and CHIP Reauthorization Act of 2015 -- MACRA for short -- added another major wrinkle by setting in motion fundamental changes to Medicare Part B’s payment approach. The consensus by physicians and health payment experts is that MACRA will usher in a payment era anchored on quality and value that will extend far beyond Medicare. Payment change is soon going to be everywhere. Glimpsing this major transformation, the AAFP and NCAFP are both hard at work educating members and practices. This past

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May, the AAFP formally launched a major educational initiative known as MACRA Ready designed to inform members on the law’s ins and outs. In North Carolina, the NCAFP has already incorporated MACRA learning sessions into its conferences and is planning additional segments on MACRA and value-based care strategies in its future meetings.

all payments. While MACRA spells out a yearly .5% increase to Medicare’s base schedule until 2019, each physician's performance or the pathway they follow will dictate their own payment increases after that. From years 2026 onward the base schedule will again increase at different rates depending on the payment pathway, but the same rule applies for tomorrow's Medicare: incomes will be driven by outcomes.

A Tale of Two Payment Pathways At the heart of MACRA's value-based transformation are two payment tracks: the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM). Both pathways will begin in January, 2019, and each will rely on the base Medicare fee schedule as the foundation for

MACRA’s two pathways feature a similar commitment to incentivizing physicians for improved quality and value, but diverge primarily in the way each provides them. While it's expected that a majority of family medicine practices will enter the MIPS pathway in 2019, many practices may qualify for the more stringent APM path. The follow-

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ing paragraphs review both paths, highlighting their key differences and aspects. Please note that given the breadth of MACRA and each payment pathway, not all specifics are listed; comprehensive information for family physicians can be found at www.aafp.org/macraready.

Activities (CPIA). CPIA will seek to quantify patient access, patient engagement, population health management, care coordination, and patient safety. Each of these measures will be combined in different percentages based on payment year to calculate a physician’s Composite Performance Score (CPS).

The MIPs Pathway MACRA's Merit-Based Incentive Payment System (MIPs) anchors on what’s called the Composite Performance Score of each qualifying physician. This score simplifies and combines three of Medicare’s existing quality programs -- PQRS, the Value-Based Payment Modifier and Meaningful Use -and combines it with a brand new measurement called Clinical Practice Improvement

See figrue below. Based on this annual CPS score, a physician's Medicare payments will be adjusted either up or down from the base fee schedule in comparison to a 'performance threshold’ determined by CMS. ~ Continued on next page ~

Weighting By Category

1

2019

2020

2021

Quality

50%

45%

30%

Resource Use

10%

15%

30%

Advancing Care Information

25%

25%

25%

CPAI1

15%

15%

15%

- “Certified” patient-centered medical home will receive the full 15 points for CPIA MIPS APM Participants will get half credit

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During the first two years of implementation -- 2019 and 2020 -- the Secretary of CMS is authorized to set the performance threshold. In subsequent years, this threshold will be the mean or median of composite performance scores during the previous year. Each physician's payment adjustments to Medicare Part B -- bonuses or penalties -- will be based on their performance relative to this threshold.

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The most nerve wracking, yet promising part of the MIPS pathway is what it will mean for physician payments. Each physician’s payment adjustments will have the potential to be sizeable, ranging from as high as a 27% positive adjustment for very top performers to as much as a 9% penalty for those in the lowest 25% percentile. Any physician meeting the established performance threshold will experience 'stable' payments at the established fee schedule. However, MACRA clearly states that any positive and negative adjustments to physicians be delivered in a budget neutral fashion (with the exception of top performers). As a result, there will be winners and losers in this new payment game. The most immediate consideration for physicians concerning MIPS is getting ready for performance scoring, a process that CMS is scheduled to begin in 2017. Scores that CMS will gather will build a physician’s composite score and affect their payments in 2019. The AAFP has been actively lobbying CMS for this initial performance year to be moved to either July, 2017 or preferably 2018. Short of any change, however, the AAFP and the NCAFP are advising practices to prepare as if 2017 will be an important measurement year. Beyond these aspects, there are a specifics related to MIPs eligibility that may preclude some physicians for having to participate, like overall Medicare payment volume, and participation year. See AAFP's MACRA Ready webpage for additional information.

The Alternative Payment Model MACRA’s other payment pathway is the Alternative Payment Model or APM for short. The APM is marked by more stringent participation criteria and more attractive financial awards. At a high level, the APM pathway requires physicians and providers to be a ‘qualifying APM participant’ by satisfying three specific requirements. These include practicing within a qualified APM model as listed in the MACRA legislation, meeting certain eligibility requirements as they participate in these models, and attaining a volume threshold of Medicare patients or Medicare payments. If each are satisfied, the APM provides automatic payment incentives of 5% each year through 2024, no risk to MIPS-based payment adjustments, and incentives based on a higher fee schedule going forward. First, several models qualify as advanced practice models according to the MACRA legislation. These include a Medicare Shared Savings Program (MSSP), an expanded CMS Innovation Center Model, a Medicare Healthcare Quality Demonstration model, or a demonstration required by Federal law. Within these types of models, additional eligibility criteria must also be met according to CMS. These include the reporting of quality metrics similar to MIPS, requiring the use of certified EHR technology, and either bearing ‘nominal risk’ or being classified as a medical home expanded under the Center for Medicare & Medicaid Innovation. Current models that meet these requirements include any Medicare Track 2 or 3 Shared Savings Program, a Next Generation ACO Model, a Comprehensive ESRD Care (CEC), the Comprehensive Primary Care Plus (CPC+) program, or the Oncology Care Model. Last, a provider (or a provider’s group) must also reach certain volume thresholds in either Medicare payment or patients through the model to be a 'qualified APM participant' according to CMS. In 2019, this percentage is set to be 25% of Medicare payments or 20% of patients.

EOE/AA

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YES

Am II In In an A Am QualifyingAPM? APM Advanced

NO

Enough Am I In A Patients or Qualifying APM Payments?

NO

Am I In a Qualifying APM?

NO

First Year in Medicare or Below Volume Treshold?

Not Subject to MIPS-FFS

Qualified APM Participant

Subject to MIPS

5% Bonus Payment 2019-2014 Higher Fee Schedule 2026+ APM-Specific Rewards Excluded from MIPS

Keep in mind that specifics of each payment pathway continue to be finalized by CMS. CMS issued draft rules in April that will be finalized this fall. See more on this process above.

Start Preparing Now Practices that have yet to report quality metrics through PQRS, the Value-Based Modifier program, or through Meaningful Use, the AAFP's 'Preparing for MIPS' (http://www.aafp.org/ practice-management/payment/medicare-payment/ mips-checklist.html) is an excellent starting point. Additionally, Medicare's chronic care management codes (CCM) provide

MACRA’s Qualified APM Participant Algorihm A decision tree determines if a physician qualifies as a ‘Qualifed APM Participant’ under MACRA. Doing so, allow physicians to capture a number of payment advantages versus the MIPs pathway. Source: AAFP

NO

Favorable MIPS Scoring APM-Specific Rewards

another mechanism for increasing revenue to support needed transformation investments. There's also transformation help available to practices with fewer than 15 eligible providers or those operating health professional shortage areas. Each can receive free technical assistance through NC's QIO and Regional Extension Center. Practices can also draw on the services of CCNC’s Practice Transformation Network that's currently getting started across the state as well.

Ongoing Advocacy by AAFP In late April 2016, CMS released its proposed rule for MACRA implementa-

tion. The AAFP responded with a lengthy analysis of CMS’s proposal and communicated its perspectives on several key issues. AAFP's central point in its analysis was how critical it is for CMS to implement MACRA ‘as thoughtfully, carefully and as simply as possible’ given the law's wide ranging effects on the healthcare system. Chief among AAFPs concerns is the proposed delay in the implementation of ‘virtual groups’ designed to enable small practices to join together for the purpose of MIPS performance scoring. In addition, AAFP is urging CMS to simplifythe rule and move the measurement date back at least six months if not 12 months. At the time this article was being written, CMS had begun to hint that their implementation schedule may change, and members of Congress were pushing to simplify the rule. However, final details will not be done until sometime this Fall when CMS actually releases the final rules governing MACRA. Stay tuned.

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THE NORTH CAROLINA

CHAPTER AFFAIRS

By: Gregory K. Griggs,

MPA, CAE

NCAFP Executive Vice President

EXECUTIVE’s DESK

The Intersection of Public Health and Family Medicine NCAFP is hard at work across key strategic areas

I

n the past year, you have probably heard about “The Practical Playbook,” an effort to advance collaboration between public health and primary care to improve population health. In fact, this publication highlighted the effort in our Autumn, 2014 edition (p18). The effort is a collaboration of the CDC, the de Beaumont Foundation and the Department of Community and Family Medicine at Duke University. The initiative has developed both web and printed resources that give very practical guidance to help further the collaborative efforts of public health and primary care.

Legislative Advocacy Public health truly drives many of our advocacy initiatives. Just over a month ago, we were proud to have NCAFP Vice President Dr. Tamieka Howell attend the signing of legislation and a statewide standing order that allows any pharmacy in the state to provide naloxone, just by a person

I say all this as a precursor to an overview of how the NCAFP intersects with public health almost on a daily basis. From having Board members and other leaders involved in public health (Dr. Shauna Guthrie, the medical director for the Vance-Granville Health Department and Dr. Jennifer Mullendore, the medical director for Buncombe County Health and Human Services are just two examples) to your staff’s regular interaction with the state Division of Public Health, overall public health efforts permeate the work of the Academy. In fact, public health is really interwoven with almost all of our key strategic objectives. Let me take a few minutes to explain.

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indicating that they know a friend or family member who may be at risk for an opioid overdose. The move is somewhat unprecedented, basically giving the state Health Director authority to prescribe for anyone throughout the state. Yet we advocated for it as a commonsense approach to helping combat the epidemic of opioid abuse in our state and nation.

Public Health

THE NORTH CAROLINA FAMILY PHYSICIAN • Summer 2016

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On the legislative front, we have also supported efforts to obtain funding for the state’s “Healthy Corner Store Initiative,” an effort to bring fresh fruits and vegetables to food deserts that lack traditional grocery stores or other sources of healthy food.

Immunization Coalition

But much of our advocacy in public health comes outside of the legislative arena. It deals with our work and relationships with the state’s Division of Public Health and our local health departments. Just in 2016 alone, either your staff or physician representatives have been involved in a tremendous number of coalitions around public health issues. A few we have been involved with this year include:

• The NC Colorectal Cancer Round Table

• The Justus-Warren Heart Disease and Stroke Prevention Task Force • The NC Advisory Committee on Cancer Coordination and Control • The Improving Perinatal Health in NC Collaborative • The NC

Whether it is our “Health is Primary” campaign efforts last year or revisions we are now undertaking to our communications plan, much of what we have discussed really centers around making the pubic healthier.

• Eat Smart Move More NC • The Fostering NC Initiative, to ensure every foster child has a medical home

Just one example is our work with the NC Colorectal Cancer Round Table. That group has targeted key areas of the state with either a large number of cases of colorectal cancer or a high incidence of colorectal cancer. We are helping connect the state and the American Cancer Society to local physicians in these targeted areas to improve public education and increase the screening rate for colorectal cancer. You may have heard of the 80-by-18 Initiative. Its goal is to increase colorectal screening rates to 80 percent by 2018, and our state still has a long way to go to do so. In these particular target areas, students from the UNC School of Public Health will be undertaking community scans this fall in order to develop a game plan on how to better communicate the risks of colorectal cancer and how screenings are a key way to prevent or minimize bad outcomes.

• The NC Prescription Drug Abuse Advisory Committee • Talk It Out NC, the NC Initiative to reduce underage drinking • The NC Public Health Association And many, many more.

Public Relations and Marketing Another area of our strategic plan that intersects well with Public Health is public relations and marketing. Our overarching goal in this strategic area is to educate the public and key leaders on the value of primary care and prevention.

Primary Care

The NCAFP will continue to be involved in communication efforts just like this one. We will work to amplify messages through our communications to you (our e-newsletter, NCAFPNotes and this magazine), but we will also use our social media platforms to highlight areas of concern just like the need to increase colorectal cancer screening. And these efforts will continue.

Practice Management Much of the work of our Practice Management Council is currently designed to help prepare our members for changes in healthcare such as value-based payment and population management. As we move from a system based on volume to one based on value and outcomes, there is a strong connection with public health and the social determinants of health. ~ Continued on next page ~

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15

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Managing a population requires a broader look at the community, the environment and more. So once again, public health and the work of the NCAFP align nicely.

Chapter Briefs

Membership and Workforce

NCAFP’s Dr. Elizabeth Baxley Elected as Chair-Elect of The ABFM

Our primary goal for our Membership & Workforce Council is increasing the pipeline of primary care physicians to the most needy areas of our state. This summer, the NCAFP is helping provide nearly 30 medical students with clinical experiences between their first and second year of training. 20 of these medical students are participating in a two week rural program based in eastern and western NC, that includes shadowing a rural family physician for a week and working with a residency program for a week. We hope these experiences will attract the next generation of medical students to rural and underserved areas of the state. Typically, many of the public health crisis areas in our state parallel areas with both physician and other healthcare provider shortages.

Dr. Elizabeth Baxley, a professor of Family Medicine and the Senior Associate Dean for Academic Affairs at the Brody School of Medicine at East Carolina University, has been elected as Chair-Elect of the American Board of Family Medicine. Dr. Baxley has served ECU since 2012, but previously spent 18-years at the University of South Carolina School of Medicine where she was Residency Director, and also Chair of the Department of Family and Preventive Medicine. With her election, Dr. Baxley will serve the ABFM on the Executive Committee, the Bylaws Committee, the Credentials Committee, the Examination Committee, the Audit/Finance Committee, the Research & Development Committee as its Chair, and the Certification Committee.

We also have been involved in another non-profit’s efforts -- Med-Serve -- to attract students to rural areas. In this case, 12 recent college graduates have been paired with medical offices in rural counties. For the next two years, they will serve as Medical Assistants or other support staff in these clinics, ranging from Federally-Qualified Health Centers to Rural Health Centers to private clinics. During their orientation program, we helped provide speakers on the value of primary care and the business of medicine to this outstanding group of learners. The 12 individuals selected this year represent a wide range of universities from Yale to Brown to Duke to UNC, NC State and UNC-Pembroke. All of these students hope to ultimately enter health professional careers, and we (along with the leadership of Med-Serve) hope they will serve underserved and vulnerable populations. Two medical students actually developed the program, modelling it after the “Teach for America” initiative. You can learn more about this effort at www.med-serve.org. The bottom line, we are continually working to build the pipeline of future family physicians to care for our most vulnerable citizens throughout the state of North Carolina.

CME/Education And certainly last but not least are our efforts around Continuing Medical Education. Many of our educational programs have a public health slant, and some of our faculty comes from our engagement with public health. Whether the topic is cancer or something as specific as cardiovascular disease in firefighters, much of our ongoing education also comes with overall population health and public health in mind.

Prevention. Public Health. Primary Care. Population Health. Maybe rather than ABCs, we just should have the Ps of healthcare. It’s pretty simple: without a greater emphasis on these areas, we will never be able to lower cost and improve quality. But I believe we can meet that aim right at the intersection of family medicine and public health.

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UNC Department of Family Medicine Cuts Ribbon on Redesigned Clinic After a four-year planning effort and construction process, the UNC Department of Family Medicine formally cut the ribbon on its newly redesigned Family Medicine Center in early June. The center’s redesign has been described as the Department’s most ambitious effort yet to embrace patient-centeredness throughout its entire clinical operation. UNC’s new clinical space supports a completely redesigned patient care workflow founded on the concept of ‘care by design.’ Care by Design aims to foster close collaboration between MAs and physicians and helps to engage patients in their own care. An article describing the breadth of UNC’s vision with the redesign appeared in the Winter 2015 edition of the NC Family Physician (V11, N1, p24). An archived copy is available at www.ncafp.com/ncfp. Photo by UNC

Duke University’s Department of Community & Family Medicine Celebrates 50th Anniversary The Duke University Department of Community & Family Medicine recognized a major milestone in July that brought together both past and present department leaders, faculty, and employees spanning five decades. The department’s 50th anniversary celebration featured addresses by founding chair Dr. E. Harvey Estes, Jr., past chair Dr. George Parkerson, MPH, and current chair Dr. J. Lloyd Michener. Each shared their perspectives on the department’s 50-year journey and their unique experiences and memorable anecdotes. Additionally, current NCAFP Residency Directors Constituency Chair Dr. Viviana MartinezBianchi, Duke’s Family Medicine Residency Director, shared comments on her experience with the department and its residency program. A large number of past and present department members were in attendance. For sights and scenes from the event, visit www.ncafp.com/fr

THE NORTH CAROLINA FAMILY PHYSICIAN • Summer 2016

8/3/2016 4:39:38 AM


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8/3/2016 4:39:39 AM


THE NORTH CAROLINA

MEMBERSHIP

By: Tara Hinkle NCAFP Membership Coordinator

AAFP MEMBERSHIP NEWS

Changes to National AAFP CME Requirements The AAFP Board of directors recently approved a change to the AAFP’s CME membership requirement. Previously, members could claim a maximum number of credits for individual activities such as published research, clinical research, paper presentations, exhibit presentations, medical writing, peer review, and writing test questions. Effective immediately, these activities can be reported simply as scholarly activities and will qualify as Prescribed credit. Members may claim a maximum of 100 credits in this area per re-election cycle. As a reminder, AAFP members must also obtain a minimum of 25 credits from live learning activities every three years to meet the AAFP’s CME membership requirement. If you have questions about this CME requirement change, you may email the AAFP at aafp@aafp.org or call (800) 274-2237. Answers to common CME questions may be found online at www.aafp.org/cme.  You may also view/update your CME transcript and determine your re-election cycle at this site.

4.5 Prescribed Credits

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8/3/2016 4:39:55 AM


THE NORTH CAROLINA

EDUCATION

By: Kathryn Atkinson NCAFP Meetings & Events Manager

C O N F E R E N C E S

&

E V E N T S

2016 Winter Family Physicians Weekend —

CME and Camaraderie In the Perfect Location During the Best Time of the Year! You might still be breaking in this year's new flip flops and enjoying the summer months, but we are already in full-swing with the planning of our annual Winter Family Physician's Weekend scheduled for November 30 - December 4th at the Omni Grove Park Inn in Asheville, NC. Attended annually by over 700 family physicians and primary care providers, this event is one that you definitely do not want to miss. Hosted in the beautiful Blue Ridge Mountains during the best time of the year, it's the perfect kick-off for your holiday season!

expert guest speakers, this year's schedule includes 25+ AAFP Prescribed Credits on several evidence-based lecture topics including Dermatitis, What's New in Pharmacology, Diabetes, Sleep Health, Social Media & Healthcare, Asthma, Novel Therapies for HFrEF, Hepatic Encephalopathy, Physician Wellness, Adult Immunizations, Transgender Patients and much, much more.

Our Program Chair, Dr. James W. McNabb and our Program Vice-Chair, Dr. Erika Steinbacher have assembled a great line-up of topics for this year's conference. Brought to you by knowledgeable and

Watch our conference website (www. ncafp.com/wfpw) for updates and information on the many optional CME Workshops also being presented. Timely and requested CME workshops include a SAMS Study Working Group, Skin Biopsies, Common Sleep Disorders, Practice Management 201, and Mastering Joint Injection Procedures. Additional CME and non-CME opportunities are still in the planning stages, so watch your email for updates and information.

Register Online Now at

www.ncafp.com/wfpw 20 pages.indd 20

Plan to get the scoop and be prepared for MACRA with a free 2-hour CME workshop on Friday, December 2nd. Whether we like it or not, change is happening. Private payers and public payers are demanding it. Employers paying health insurance for their employees and the general public are demanding it. Be prepared and be in the know. Don't miss this FREE CME opportunity to learn more about MACRA and how it will affect you. Finally, this annual weekend isn't just about CME, it's about fun and camaraderie! Enjoy quality time with friends and family with fun optional tours around Asheville,

THE NORTH CAROLINA FAMILY PHYSICIAN • Summer 2016

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Online at ncafp.com/cme

including a candlelight tour at our national treasure, The Biltmore House. Enjoy a special afternoon-getaway in the Grove Park Inn's award-winning spa or grab your favorite beverage and relax by the giant fireplace in the Great Hall. Saturday evening includes our Presidential Gala when we install Dr. Charles W. Rhodes as our 20162017 President and our new Board members. To help us celebrate, we've invited back one of our favorite bands, Too Much Sylvia. Come dressed in your holiday best and bring your dancing shoes! Please visit our conference website at www.ncafp. com/wfpw for additional schedule details and conference information. Or, contact Kathryn Atkinson, Manager of Meetings & Events, at 919-833-2110 (800-872-9482 NC Only) or via email at katkinson@ncafp.com.

EARLY BIRD SAVINGS The ‘Early Bird’ registration deadline for CME attendees ends Monday, October 10th, 2016

Register Early and Save!

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Got FM Research? Participate in the NCAFP Foundation’s 2016 Research Poster Presentation The NCAFP’s 23rd annual Research Poster Presentation will be held this December during the Academy’s Winter Family Physicians Weekend (Dec. 1-4, 2016). Research posters may also address any topic relevant to family medicine, including practice-based research. Judging categories include family medicine residents and medical students. Complete details including online submission can be found at the NCAFP website at www.ncafp.com/poster-presentation.

The deadline for submissions is Friday, October 1st, 2016. Prospective presenters can direct any and all questions to Tracie Hazelett at thazelett@ncafp.com

8/3/2016 4:40:00 AM


THE NORTH CAROLINA

RESIDENTS

Online at

ncafp.com/residents

& NEW PHYSICIANS P r o f e s s i o n a l

D e v e l o p m e n t

Preparing for Your Future One Step at a Time By: Margarette Shegog, MD, MPH NCAFP Resident Director

W

here are you in 5-10 years? This is a question most residents had to answer since the first medical school interview. As physicians in training, we are accustomed to thinking extensively about the future: the next class, shift, rotation, or year. Becoming a physician involves anticipating the outcome of a 10-year trajectory, after accounting for pre-med courses, medical school, and residency. The answer is likely constantly changing with the stage of training as we discover what we enjoy in family medicine. The trajectory of 5-years after July 1st of your intern year will look significantly different than July 1st after graduation. Preparing for “the rest of your life” can often seem daunting, but it doesn’t have to be overwhelming. Here are some of the things we have learned along the way.

PGY1- PGY2: Dr. Alyssa Shell The choice to practice OB, sports medicine or palliative care may only become clear after experiencing these fields. For all you interns out there, don’t fret too much about figuring out next steps – a lot will become clearer simply by walking the path. At the same time, three years of residency can blow quickly by, turning small chunks of elective time into crucial laboratory experiments: How jazzed do you really get about colposcopy? Does developmental pediatrics pull at your heartstrings? With limited time, a strategy for weighing diverse interests can help make the decision making process easier.

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Alyssa M. Shell, MD, PhD NCAFP Resident Director-Elect

tunities, I intend to reflect them back onto my To this end, a good mentor can assist 5-year vision. Such an approach feels far more dramatically with career puzzles. Why stop doable than pinning down the detail of each at one? A set of mentors with diverse experiyear moving forward. ences will offer that much more insight into your questions and considerations. Finding good mentors, however, is not easy. PoPGY3- Fellow/Jr. Attending tential advisors often have busy schedules, Dr. Margarette Shegog other advisees, and their own career quesWhile rotations seem to last forever, tions to ponder. Thus, getting the most out residency actually goes by fast. It is easy to get of a mentor relationship may depend upon lost in the day to day and miss out on great you – are you prepared with questions? Have experiences. While it is important to make you sent a meeting reminder? Have you your Milestones -- which will ultimately go todropped by their office? Have you cajoled ward graduation -- residency is a great time to them with honorific assessments of their tailor your education to what you really want prowess? The latter is likely unnecessary to experience. Maybe you always wanted to since most faculty are invested in our future spend time in the NICU, learn how to perform success, but still, it can’t hurt. abortions, work on This past spring, your Spanish, or I experienced my go to DC and learn own epiphany Preparing for “the rest of your life” about health policy. about career Residency is one of plans. For the past can often seem daunting, but it the last times you few years I have can explore medidoesn’t have to be overwhelming. struggled to idencine easily. There is tify the perfect more wiggle room order of postthan most people residency steps think. Everyone between competing academic and clinical has an IEP (Individualized Education Plan). interests. If I go off into the world, will Make it work for you and discuss it with your research doors close behind me? If I start advisor. If there is something major you feel in a fellowship, will the train just keep on like you missed, don’t fret. That is what CME moving? Fortunately, a few weeks ago my (Continuing Medical Education) is for. There “aha” moment arrived: I want to complete a are procedure workshops, CME conferences, research fellowship and an international and online courses to continue to explore immersion experience within the first medicine and have the resources 5-years after residency. I want to know what to treat your patients. each sphere is like and think I will regret It is easy to lose yourself in medicine, but not experiencing them both. I don’t know life does not stop. Most people in my class and which will come first but that dilemma feels I had major life events during the three years. way less important now that I can see the It is not the end of the world if you need more bigger picture of my short-term goals. As I than the 36-months. Sometimes, in order to do move forward and encounter career oppor-

THE NORTH CAROLINA FAMILY PHYSICIAN • Summer 2016

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the things you want during your residency, you have to offer a compromise. Discuss these things as early as possible; it is likely that 2-20 other people’s schedules may need to change. As family medicine people, we tend to be fairly reasonable and understand that there is a world outside of our hospitals and clinics. Still if you need time out for any reason - babies, families, or mental health - it helps to be willing to add time on in other ways - weekends, nights, or added time. Being proactive in work-life balance is a part of professionalism, and does not stop after residency. As hard as it seems, it is important to include those things you enjoy in life now. Somehow during intern year I managed to work out 5-7 days. I completely lost this habit second year, and picked it back up again this past year. I am much happier and a more reasonable person when I’m dancing. It makes me a better doctor. Mentors are indeed helpful to clarify your path. Anyone can be a mentor. If someone is doing something you are interested in, seek them out. Others will volunteer if you make your desires known. As soon as I finished my Behavioral Health rotation my second year I started talking about a 4th year fellowship. The more I talked about it, the more people either directly wanted to be on my team, or were able to guide me to others to join. By the time I was in my 3rd year I had a working team to discuss, consult, and organize with the revitalization of my residency’s Behavioral Health Fellowship. Discussing my goals frankly with attendings allowed for improved feedback and actual steps to help me obtain my goals. There are projects and opportunities available, but you may not hear about it unless others know your interests. Similarly this allows people to join your projects. I started to make a fuss about including social justice into our didactic curriculum around the end of my first year; now we have a whole committee across multiple divisions working to make this happen. Where will you be in 5-10 years? You may not know now, and that is fine. Use your time in residency to explore medicine. Mentors can help guide on the way. Include experiences that are important to you. There is a life outside of medicine and sometimes that requires compromise. Let people know what you are interested in, and sometimes mentors come to you. Your vision will change over time. So often we are looking for the next transition event (e.g. residency graduation). However in medicine there is no clear destination, it is always a journey. Family medicine allows for many twists long the road.

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8/3/2016 4:40:02 AM


THE NORTH CAROLINA

STUDENTS b u i l d i n g

Online at ncafp.com/students

s t u d e n t

i n t e r e s t

Visiting Family Physician Leader —

Why I Bleed Family Medicine By: Tracie Hazelett NCAFP Family Medicine Interest Initiatives Manager

I am unapologetically an idealistic social justice doc, who bleeds family medicine. It’s imperative I continuously try to build a path for myself that allows me to wake up every day feeling joy and love for my part of the work it takes to make the world a better place. I hold myself accountable to feel that joy so I can add productively to the village I have committed and invested myself to live, work, and play in.

Dr. Manisha Sharma

A

s part of the NCAFP Foundation's efforts to increase student interest in family medicine, four of our state's medical schools were treated to passion-filled lectures, visits and discussions with Dr. Manisha Sharma. Dr. Sharma's path to medicine was anything but typical. She made it clear she had no intentions of following in her parents' footsteps and becoming a physician. She was determined to “heal the world” through music and dance. She fully acknowledges she was a booty shaker, who made it to Berklee College of Music and was in the music business. Her claim to fame was being a back-up dancer to Prince. And yes -- the news of his death broke when she was in NC -- those who spent time with her following that news know her world was shaken that day. In her early 20’s, the music and dance

24 pages.indd 24

trajectory came to an abrupt halt when Dr. Sharma was struck by a car while walking in a crosswalk. Over seven years, she underwent four major hip surgeries and extensive physical therapy. Since her accident was a hit and run involving an unidentified third party, her battles against a faceless health insurance company began in an effort to cover her all-of-a-sudden “pre-existing condition” and medical bills. She saw scores of other patients who endured similar struggles and realized this was a bigger fight than her. They inspired her to become a patient rights advocate. Since a patient’s best advocate is his or her doctor, she decided to become a doctor in her early 30’s. Dr. Sharma made a promise to herself that if she was going to do this “thing” called medicine, the type of doctor she was going to be was a doctor for, with, and by her community – a family doc; the truest and most natural form of being an advocate, an activist. Family medicine was the specialty that naturally incorporated social justice into the

art of medicine for all people. She wanted to redefine “good health” in her practice of medicine as not just the absence of disease, but about where people live, work, and play. "We are the smartest doc around. WE ARE NATURAL BORN LEADERS, team players, advocates and activists. The scope of family medicine is flexible, you can determine what you want to do. You can dip in and out. WE are in demand. Dr. Sharma's path to, through and after medical school and residency training continued to be anything but typical. However, through it all she stayed true to the promise she made to herself and her patients. She took one year off between medical school and residency and during this time the country was in the thick of political change, especially in health. There was a new president and a call to organize and fight for healthcare reform. Dr. Sharma used her previously discovered knack for community organizing and became a grassroots physician leader in organizations like National

THE NORTH CAROLINA FAMILY PHYSICIAN • Summer 2016

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Physicians Alliance (NPA) and Doctors for America (DFA). She helped to build a national coalition of community organizers, politicians, physicians, health professionals and labor unions, to dynamically capitalize on and foster the growing momentum of the country to improve health access. These experiences led her to a family and social medicine residency program at Montefiore Medical Center. She loved residency and as she says, she rocked it! Following residency Dr. Sharma's first job was with Evergreen Health Care, an affiliate of Evergreen Health Cooperative, Maryland’s only non-profit health insurance cooperative, authorized by the Affordable Care Act. There she was the first Medical Director and designed a comprehensive primary care team model to serve its health exchange population, she served as the clinical lead in building Evergreen’s four health centers from scratch. Dr. Sharma then moved on to serve as a clinical innovator for Iora Health, a mission driven, integrative primary care and technology company, which values "blowing up status quo primary care" and being a health disruptor. Iora created a 3-pronged unapologetic approach to primary care through their innovations in: payment, technology and most importantly their care model of delivery. Her charge has been to build a physician and nurse practitioner pipeline that fosters a culture that cultivates trusting, meaningful relationships with patients and communities with true collaborative team-based care. Care where everyone’s touch to a patient is just as important, if not more important than a provider to create a mission of true service with humility. Dr. Sharma hires for attitude and invests in training for skill. She leverages strengths of team-based care and looks for the right docs who believe and can act on that mission.

Student and Resident

Leadership Opportunities  

Elections for new Student and Resident leaders will take place during their respective business sessions on Saturday, December 3, 2016 at the NCAFP Winter Family Physicians Weekend in Asheville, NC. NCAFP’s Student and Resident sections each elect a Director-Elect to the Academy Board of Directors and two students and two residents to serve as Trustees on the NCAFP Foundation Board of Trustees.  Deadline to submit materials for these elected positions is November 15, 2016.

In both Evergreen and Iora, and everything else she touches, Dr. Sharma honors her purpose of “why I am a family doctor”. Her charge to medical students and all who meet her: “Find your why! When you know your own why, you will know what and how you can contribute to building that environment you want to live, work, and play in.” -Manisha Dr. Sharma's next professional adventure begins this fall when she moves to Memphis, TN, where she will join CareMore. For more information about Dr. Sharma or to follow her: Twitter: @dr_msharma and LinkedIn: www.linkedin.com/pub/manishasharma-m-d/5/59b/216

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Visit: www.ncafp.com/students/leaders or www.ncafp.com/residents/leaders for details If you have questions please contact Tracie Hazelett at 919-833-2110, or thazelett@ncafp.com

8/3/2016 4:40:03 AM


A D V ERTORI A L

COMMUNICATION, COLLEGIALITY, AND CARE By Bill O’Neill, Director of Communications and Outreach for CPEP

given a lower priority. When tempers Pitfalls and Perils on Medical PHYSICIANS HELDTeams LIABLEbeFOR PATIENTS’ CRIMINAL In recent years, changes to the structure of medical teams, intended to improve communication, sometimes have the opposite effect. As medical teams become less hierarchical, some physicians feel threatened. According to Matt Steinkamp, MSW, lead faculty for CPEP’s Improving Inter-Professional Communications seminar, “Physicians often have feelings of loss: loss of their role as a leader, loss of respect and prestige, and perceived loss of influence. These feelings can manifest as anger and frustration with their colleagues.” The practice of medicine is stressful, which can lead to friction on a medical team. Dr. Michael Yochelson, Chief Medical Officer at MedStar National Rehabilitation Hospital, notes, “As a physician leader, this is something you have to deal with perpetually, and it occurs with both attending physicians as well as residents. Sometimes the friction can be peer to peer, but other times it occurs between a physician and a nurse or even a patient. Unfortunately, physicians may be able to get away with behavior that other team members cannot. Many are highly trained in very specific sub-specialties and are difficult to replace.” Steven Defossez, MD, Vice President of Clinical Integration at the Massachusetts Hospital Association, adds, “A busy work day or environment just accentuates a ‘head’s down’ focus on the task at hand and can heighten tensions with others. If you’re constantly in a hurry, you’re already set up for failure when it comes to interprofessional communication.” Mr. Steinkamp agrees that time management, along with other factors, can complicate team dynamics. “Many physicians tend to be black and white, task-oriented, and can be perceived as ‘too direct,’ while nurses are often more process and relationship oriented. These styles can grate against one another.” Training issues, and the competitive nature of medical school and residency programs, may foster this “direct” style. Competitiveness and self-reliance are both required and rewarded, while teamwork may

flare, the words “I’m sorry” may be in short supply. Says CPEP’s Steinkamp, “Apologizing is very difficult for some physicians. To some extent, they have been trained that an apology is an admission of wrong-doing and an opening to liability.”

are formal, some informal. Pre-procedural/ BEHAVIOR surgical huddles are a clinical requirement before any type of procedure, and all team members are encouraged to ask questions and make suggestions.” Ed Eckenhoff, founder and president emeritus of the MedStar National Rehabilitation Hospital, maintains that the culture of teamwork is particularly strong in the rehabilitation hospital community: “We incorporate the team approach, where the entire clinical team meets together several times per week to discuss the patients’ successes and needs. They all become quickly up to date with all aspects of patient care and appreciate each other as patient centered team members.” MedStar NRH’s Yochelson adds, “Healthcare in general is moving towards a model that rehabilitation hospitals have embraced since the 1940s. Our patients have unique needs. They require a team approach to care, and that close-knit, interdisciplinary approach is built into our training. In other environments, physicians often talk to nurses, not with nurses. In the rehabilitation setting, that communication is more of a dialog and a two-way street. Nurses learn from physicians and vice-versa.”

Physicians who prescribe pain medication can be held liable for patients’ addictions and for their addi behavior. Although this mid-year 2015 decision by the Supreme Court of West Virginia was likely di providers who knowingly over-prescribed pain medications, the ruling may have an impact on any phy prescribes potentially addictive drugs. The Power of Relationships

Steinkamp suggests focusing on theCenter in West Virginia who were prescribed la The case involved 29 patients from Mountain Medical “power of relationships” rather than on controlled substances for pain caused by accidents or workplace injuries. The patients became addic direct lines of authority. “Physicians can subsequently engaged in criminal activities, as fraud, take steps to humanizesuch themselves, educate theft, forgery, and doctor shopping. The pl vs. dictate, for input, and(e.g., thus increase physicians and three pharmacies for ask negligence prescribing large quantities, allowing for early r influence through ‘soft power.’” resulted in these damages.

Advice for Physicians

Dr. John Wald, Medical Director for Public Affairs at the Mayo Clinic, notes that a team-based approach can lead to direct benefits for physicians. “Approximately 40% of physicians nationally report symptoms of burnout. An internal research group led by both physicians and nurses found that Mayo care groups with a stronger team ethic reported reduced feelings of burnout, and thus greater job satisfaction.”

The ruling brings with it many unanswered questions, for example, what are the implications for pallia specialists, who may prescribe large amounts of controlled substances in good faith? Because the leg the decision are currently unclear, prescribers may want to consider the following: ¥

Prescribe non-opioid therapies whenever possible. Non-pharmacologic adjuncts such as phy be helpful. Strategies that Foster a Culture

¥

When opioids are clinically required, consider prescribing them for as short a time as possible Mr. Steinkamp suggests the use of team The Challenge of Leadership feasible lowest dose.huddles as a way of encouraging team com-

¥

munication. He states, “Physician leaders Dr. Yochelson continues: “These issues Adhere to state and local opioid prescription guidelines. should build these huddles into the daily can be a real challenge to manage as a leader

¥

schedule of medical teams – and then show – nobody really likes, or wants, to deal with Review the patient’s prior medical and pharmacy records. up and engage. Scheduling huddles and them. However, physician leaders have to re-

¥

attending can be more detrimental sist the temptation to sweep these problems Discuss with patientsthen thenot risks of opioid analgesics, including addiction, at the time of prescrib

¥

Follow up with a patient’s other physician and other caregivers.

of Collegiality

than not having a huddle to begin with.” Dr. Defossez points to the Mayo Clinic as an example of a culture that promotes interprofessional teamwork. Dr. Wald agrees: “The Clinic was founded not only by the Mayo brothers, but also by the Sisters of St. Francis, who provided nursing and related care. The culture of mutual respect and partnership between physicians and staff was present from day one, and is still stressed today in every meeting at every level of the organization.” Asked about team huddles, Dr. Wald notes, “These types of interactions are very common throughout the organization; some

Risk Management Assistance

under the rug – they have to be dealt with in a serious manner. Leadership needs to sit down with the physician in question and be very candid; a physician may not have any idea how they come across, and that has to be made clear to them. Hopefully they will have the ability to change, although it may not happen overnight. These conversations may lead to education, coaching, or, if problems continue, discipline.” “At MedStar NRH, we make it clear that regardless of title, all physicians are leaders and role models and are expected to act accordingly.”

In light of the West Virginia ruling and the wide-spread national concerns with opioid use, we have tak our members: 1. A key statement was added to the Narcotic Drug Treatment Agreement consent form:

26 pages.indd 26

I confirm that I have not given any false health facts and am not seeking treatment under false agree to release my doctor and his/her staff from any liability caused by or due to my misuse THE NORTH CAROLINA FAMILY PHYSICIAN • Summer 2016 drug(s).

8/3/2016 4:40:03 AM The updated consent is posted on the Medical Mutual website (https://www.medicalmutualgro


r their addiction-related was likely directed at on any physician who

escribed large quantities of ame addicted and ing. The plaintiffs sued four g for early refills), which

About CPEP ns for palliative care CPEP (www.cpepdoc.org) is a 501 ause the legal ramifications of (c)(3) organization that promotes quality patient care and safety by enhancing the competence of physicians and other healthcare professionals in all 50 states from its offices in Denver, Colorado and Raleigh, North Carolina. CPEP offers focused courses on communication in the clinical environment, prescribing controlled drugs, and professional ethics as well as comprehensive clinical competence assessments.

Accelerate Your Medical Career

uch as physical therapy may

as possible and at the

e of prescribing. About the Author

Bill O’Neill, MBA, is Director of Communications and Outreach for CPEP based in Raleigh, NC. Mr. O’Neill has an MBA in marketing and finance from the Wharton School of Business and has spent much of his career in the health care field. At CPEP, he manages the organization’s eastern U.S. operations in Raleigh while focusing on outreach to licensing boards and medical executive committees throughout the United States and Canada.

we have taken steps to help

rm:

under false pretense. I my misuse of narcotic

pages.indd 27 almutualgroup.com/informed-

NCAFP

Resident+Physician Mentoring PROGRAM www.ncafp.com/rpm

8/3/2016 4:40:06 AM


THE NORTH CAROLINA

PRACTICE

ncafp.com/practice-mgt

implementing practice portal technology - Part II in a series

Improving Patient Communications and Engagement with Portal Technology By: S. Mark McNeill, MD Trillium Family Medicine Asheville, North Carolina

I

n last quarter's article, I wrote about automated practice scheduling as one way to extend value to patients and help practices realize the full potential of an electronic patient portal. In this segment, I will discuss enhancing digital patient communications and engagement as another key strategy.

Secure messaging Besides scheduling, a significant amount of phone call volume at most practices involves patients asking about test results, medication refills, and other concerns. Handling these inquiries by phone requires staff and physicians to answer calls in real time, which can be inefficient. To reduce the time spent on the phone for these concerns, we moved most of our communication with patients to secure messaging through the portal. We train and expect patients to use the portal to obtain clinical advice, medication refills, and retrieve test results. We limit phone calls to high-risk issues such as communicating abnormal test results or bad news or to the small number of patients without Internet access. This dramatically reduces phone call volume, and communication tasks are sorted and completed in a fraction of the time. This allows my staff to spend more time taking care of patients who are in the office and better supports my efforts during the workday. As with self-scheduling, we spend part of a patient’s first visit showing how secure messaging works and providing strong physician endorsement. Our goal is to

respond to all patient messages through the portal in two hours or less, and patients appreciate having this level of access and service. All messages go to my inbox first, and it is my responsibility to respond. With a panel of 1,000 patients, I usually receive between five and 15 messages a day. Most are straightforward, clinically safe to handle via messaging, and take no more than one or two minutes. If a patient’s inquiry involves a complex issue and requires more time, or if my response leads to more questions from the patient that cannot be handled easily online, we simply ask the patient to come in for an appointment to discuss further. We also do not hesitate to train patients

about boundaries. If patients are being overly verbose or using the patient portal in an inappropriate manner, then we re-explain our expectations about proper use and the behavior generally changes. Some patients will continue to call instead of messaging. We usually respond to them through the portal and remind them to use the portal for future inquiries. Problems can also occur if patients fail to read their portal messages. But evidence shows that 97 percent of messages sent through a mature patient portal are read by their recipients in a timely manner.4 Compare that with the number of phone calls you make that are never acknowledged, and you will see that secure messaging is an arguably safer way to provide information of low to moderate risk to patients with Internet access. We also encourage portal use by not doing refills by phone. Patients can use the portal to request a refill, which is routed to my medical assistant, or they can contact their pharmacy, which will electronically request the refill. This can be another good starting point for offices trying to increase portal interaction, as well as a good way to dramatically improve office flow. (See “Annual portal activity for 1,000 patients.”) By using the portal for scheduling and secure messaging, we conservatively estimate that we save at least 10,000 phone calls annually.

Patient engagement Many offices ask patients to fill out a history form as part of the paperwork they

Reprinted with permission from the AAFP. Dr. McNeill is a family physician and owner of Trillium Family Medicine in Asheville, N.C. He would like to thank John Bachman, MD, Allen Wenner, MD, and Robert Geist, MD, for their guidance in improving this article, and Sue Stigleman for her research assistance.

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THE NORTH CAROLINA FAMILY PHYSICIAN • Summer 2016

8/3/2016 4:40:09 AM


personal finance

Is Your Financial Plan Efficient? annual portal activity for 1,000 patients Appointment Reminders

5,000

Appointments scheduled online

75%

Average messages sent by patients

2,000

Average messages sent by staff/physician

5,000

Lab results published

1,600

Refill requests online

1,500

complete in the office. Staff then have to collect and enter the data. But what if patients could do this themselves? Most portals make this process easier by creating patient questionnaires that can be completed online by the patient prior to the visit. We use patient interview software called Instant Medical History (IMH), which can interface with numerous EHRs and portals and has been reviewed extensively in the medical literature.5 The software generates a questionnaire personalized for each patient and creates a history comparable in sophistication and accuracy to that produced by third-year medical students. In our practice, the software is embedded in the patient portal and loads the data into the EHR. Every patient with portal access is trained to use IMH, and we remind patients by e-mail 24 hours before their visit to complete the web interview. Those who do not are given the opportunity to complete the interview in the exam room before being seen. Approximately 70 percent of our patients complete the IMH interview before their appointments. IMH improves our office efficiency and patient engagement in several ways. First, it helps patients organize their thoughts and express their concerns prior to being seen. By the time I enter the room, patients are more focused on what they want to talk about. Second, it allows for a more enhanced morning staff meeting, as we can look over the IMH output for patients scheduled that day and provide individualized

care based on what they have told us. Third, documentation is made much easier because the patient’s IMH output populates the subjective elements of the progress note. More than two-thirds of the word count in a patient record is related to the patient history. Having this information already gathered means I do not have to interview the patient and type at the same time. Instead, I can maintain full eye contact with the patient as I review their information during the consultation, which increases patient satisfaction. After the visit, I have less documentation to complete. These features allow me to comfortably meet the needs of my patients with only one medical assistant and negate any need for a medical scribe or transcriptionist. In addition, any time saved is money saved. A word about electronic visits: I do offer online consults, usually for simple acute complaints that can be safely handled without a face-to-face visit, such as urinary tract infections, poison ivy, or colds. Only one insurance carrier in our market will pay for them, so we generally bill patients a $35 fee. We ask our patients to fill out a portal interview regarding their chief complaint, and I respond with my care recommendations within two business hours. Demand is not that high; I provide only one or two a month. Electronic visits may be more helpful in busy offices with access problems, but our patient-centric portal-based workflow increases availability significantly.

By Whit Newton, CFP ®, a Northwestern Mutual Financial Advisor based in Raleigh, NC

If you’re a medical professional in your late 30s, 40s or 50s, you’ve probably started dreaming about retirement and started doing some financial planning to get there. But the question I pose to experienced doctors is, “Are you saving efficiently so you can retire with confidence as soon as possible?” Most, though they don’t want to admit it, aren’t sure and that’s not surprising. It takes time to understand the small nuances of financial products. And if there’s one thing I know from growing up in a physician household, it’s that most physicians don’t have extra time. You’re working long hours saving lives, diagnosing patients, keeping board certifications up to date, and sharing experiences with loved ones. I recently helped a busy couple who are both physicians to build a full picture financial plan. They had saved well, but they had failed to consider risks like longevity, health care costs, long-term care and more. Perhaps the biggest item they hadn’t considered was the impact that taxes could have on retirement accounts. Together, we identified a smart balance of investments across pre-tax, taxable and tax-free investments to help keep them in a lower tax bracket in retirement. They were not alone in the sense that many individuals don’t realize that retirement income is just like earned income, it’s all about what you can keep after April 15th. This simple solution helped them to save more efficiently and effectively for retirement.

Article prepared by Whit Newton with the cooperation of Northwestern Mutual. Whit Newton is a Financial Advisor with Northwestern Mutual based in Raleigh, NC. Newton is a licensed insurance agent of NM. Northwestern Mutual is the marketing name for The Northwestern Mutual Life Insurance Company (NM), Milwaukee, WI, and its subsidiaries. Northwestern Mutual Investment Services, LLC (NMIS), (securities) subsidiary of NM, broker-dealer, registered investment adviser, member FINRA and SIPC. Certified Financial Planner Board of Standards Inc. owns the certification marks CFP®, CERTIFIED FINANCIAL PLANNERTM and CFP® (with flame design) in the U.S., which it awards to individuals who successfully complete CFP Board's initial and ongoing certification requirements. Please remember that all investments carry some level of risk including the potential loss of principal invested. They do not typically grow at an even rate of return and may experience negative growth. No investment strategy can guarantee a profit or protect against a loss. THE NORTH CAROLINA FAMILY PHYSICIAN • Summer 2016

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Practice Tracks New Blue Cross PCHM Incentive Program Designed for Independent Primary Care Practices Blue Cross and Blue Shield of North Carolina (BCBSNC) has launched a new program designed to help independent primary care practices transition to PCMHs.   The program offers upfront financial incentives to practices under BCBSNC's standard fee schedule that commit to reaching PCMH-recognition within 15-months.  Practices that successfully complete the PCMH recognition process then become eligible to participate in BCBSNC's Blue Quality Physician Program, a program that also provides enhanced payments.  If you would like to learn more about this program or have other questions, contact BCBSNC at pcmh@bcbsnc. com or call 919-765-1292.

Reimbursable Services

State Fluoride Varnish Program Releases Updated Information in Patient Toolkit

As part of the new

Did you know that early

enrollment screening

childhood tooth decay effects

criteria mandated by

more children than asthma

the Affordable Care

and even obesity? If you

Act, CMS established

are already offering oral

a requirement for all

preventive care to your young

enrolled Medicare

patients, congratulations!

providers to revalidate

If not, did you know that

their enrollment

NC Medicaid and some

information. CMS

private insurers will pay you to provide oral preventive care to young children? Find out more how to participate.

recently completed the first round of revalidations, and

For physicians and practices already offering this care, the program’s oral health toolkit offers updated educational materials for parents, including a �Focus on Fluoride� post-op page that you can print and provide after the procedure. Also new is a link to the series �Healthy Habits for Happy Smiles. All of these great resources are in English and Spanish!  If you have

State Health Plan Now Offering New Diabetes Prevention Program

Medicare Has Resumed Re-Validations

questions or would like more information, please contact: Kelly Close, RDH, MHA, NC Early Childhood Oral Health Collaborative, via email at Kelly. Close@dhhs.nc.gov or by telephone at 919-707-5485

is resuming regular revalidation cycles going forward. CMS sets every provider’s revalidation due date for the end of a month and posts the upcoming six months online at data.cms.

The North Carolina

gov/revalidation.

State Health Plan for

NCAFP members who

Teachers and State Employees is now offering a new covered benefit that supports members who are at risk for diabetes: The  Diabetes Prevention Program (DPP).  DPP is a

Newborn Screening —

State Public Health Lab Reinstates Cystic Fibrosis DNA Testing

CDC-recognized, evidence-based, comprehensive

wish to determine their revalidation date should refer to that page. Members should also note that new assignments were

lifestyle program proven to delay or avert the

The NC State Health Lab has established an agreement with the Wisconsin

released on July 1st,

development of diabetes in at-risk patients. As

State Lab to help it reinstate cystic fibrosis (CF) DNA testing as another

2016 and that any

a partner in preventing diabetes, please refer

means to identifying babies with the highest risk for CF. North Carolina’s

date listed as ‘TBD’

those who are at risk to participate in DPP by

existing CF screening algorithm that starts with evaluation of IRT remains

means your validation

visiting www.diabetesfreenc.com. You will

unchanged. As of this June 3rd, specimens with IRT values greater than the

date is at least six

receive notification when your patients, who

95th percentile will be reported as having an elevated IRT and an interpreta-

months away.

are State Health Plan members, participate in

tion will be included to assist providers in determining the urgency of sweat

DPP, so you can further support their journey to

chloride testing. In these cases, a portion of the specimen will be sent to

better health. Patients can receive these services

Wisconsin to conduct CFTR mutational analysis as well.

for a $25 co-pay versus normal costs of approximately $400 to participate in DPP educational

Physicians and practices with questions about this enhanced process

programs. Visit www.diabetesfreenc.com to

should contact Ann Grush at 919-807-8881.

learn more.

THE CLASSIFIEDS

Family Medicine Practice Opportunity in Wilmington Board certified family practice physician in established practice with M.D. and two Physician Assistants in Wilmington hopes to retire sometime in 2017. We are seeking another board certified physician to take over the practice which is an outpatient practice open Monday-Friday 8-5. Telephone call only rotated among three providers. Solstas lab drawing station, practice owned XRAY and EKG on site. If interested, call 910-793-8738 evenings/ weekends.

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Introducing NCAFP FMCareers! The NCAFP is proud to announce our new online career center -- NCAFP FMCareers! Access this targeted and qualified pool of opportunities and talent by looking for or advertising your jobs online. • Easily SEARCH and POST jobs • ACCESS highly-qualified, professional opportunities and candidates • TOOLs to deliver the best opportunities and candidates

Access now at jobs.ncafp.com

If you are a job seeker, post your resume anonymously. Create job alerts. And do it all in less time than it takes to search through job postings on the mass job boards.

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8/3/2016 4:40:22 AM


North Carolina Academy of Family Physicians, Inc. 1303 Annapolis Dr.ive Raleigh, North Carolina 27608

heart Health Now

Non-Profit Org. US Postage

PAID

Pontiac, Illinois Permit No. 592

Heart Health NOW Recruiting Primary Care Practices for Innovative Program The University of North Carolina at Chapel Hill and a cooperative team of health care and quality improvement experts are working to improve heart health of millions of Americans, and they are recruiting primary care practices to help make it a reality! Heart Health Now! Advancing Heart Health in NC Primary Care will use a variety of interventions to help small and medium-sized primary care practices build their capacity to use the ABCS of cardiovascular disease prevention. In North Carolina, the latest data show an annual cardiovascular death rate of 263 per 100,000, explaining almost one-third of deaths in the state, more than any other cause. The program is engaging 250-300 small, independent primary care practices and providing quality improvement services typically not available to them because of their size. Practice sites qualify for Heart Health Now if they have 10 or fewer FTE primary care providers at the site, have an EHR, and take care of at least a few Medicaid patients. Both the state AHEC System and CCNC are involved in this project. To learn more about Heart Health NOW or if your practice would like to participate, please contact: Eastern NC: Jill Boesel at jboesel@n3cn.org; Western NC: Kerry Kribbs at kkribbs@ n3cn.org; or Central NC: Robin Wagner at rwagner@n3cn.org

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8/3/2016 4:40:27 AM

Profile for NCAFP

Summer 2016  

Summer 2016  

Profile for ncafp1