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How Depression and Isolation are Leading to Exploitation of Children

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Ivelisse Lopez, MD

Xinjun Zhu, MD


CONTENTS || FEATURES

“In Other Words”

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with RICK

To Screen or Not to Screen? That is no Longer the Question RAMNATH, MD PUBLISHER John Kelly jkelly@orlandomedicalnews.com

FEATURES

——————— AD SALES John Kelly, 407-701-7424

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COVER STORY How Depression & Isolation are Leading to Exploitation of Children

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PHYSICIAN SPOTLIGHT “In Other Words” To Screen or Not to Screen? That is no Longer the Question with Rick Ramnath, MD

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——————— EDITOR PL Jeter editor@orlandomedicalnews.com ——————— CREATIVE DIRECTOR Katy Barrett-Alley kbarrettalley@gmail.com

EOCC MEDICAL CITY The Rest of the Story Edited in Time

——————— CONTRIBUTING WRITERS Basher Atiquzzaman, MD Jan Edwards

Integrating Behavioral Health Services Helps Reduce Rehospitalization Rates

Amy Goodman, CPA Frances M. Grinstead Dorothy Hardee Wendy King

Solo vs. Group Practice

Doug Mintz Gigi Acevedo-Parker

How to Help Healthcare Heroes Deal with Emotional Stress – During and After the Pandemic

Rick Ramnath, MD Jeff Ramos Mary-Catherine Segota, Psy.D.

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Disinfecting Spaces for COVID-19

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The Taxability & Timing of PPP Loan Forgiveness

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Home Office Productivity

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Diagnosis and Management of Typical and Atypical GastroEsophageal Reflux Disease

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ORLANDO, NORTH CENTRAL FLORIDA & VOLUSIA/BREVARD GRAND ROUNDS

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——————— SOCIAL MEDIA DIRECTOR Jennifer Cerna ADVENT UNIVERSITY INTERN Noelle Kelly CIRCULATION jkelly@orlandomedicalnews.com

Orlando Medical News July 2020 is published monthly by K&J Kelly, LLC. ©2020 Orlando Medical News. All Rights Reserved. Reproduction in whole, or in part without written permission is prohibited. Orlando Medical News will assume no responsibility unsolicited materials.

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All editorial submissions and press releases should be emailed to editor@orlandomedicalnews.com Subscription requests or address changes should be emailed to jkelly@orlandomedicalnews.com

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How Depression & Isolation are Leading to Exploitation of Children The pandemic’s emotional toll BY JAN EDWARDS

Given the current environment, many children are at home 24/7, missing their friends, playing sports, experiencing those important interpersonal social interactions and instead are turning to online relationships. In fact, there is even a name for their new ‘online’ friends #IBF, Internet Best Friend.

Our children are ‘bonding’ with people they may never meet in person – which is a perfect breeding ground for predators to circle their prey waiting to step in and be a child’s #IBF. Our children are facing unprecedented challenges today, many experiencing complete isolation which can lead to depression. With the holidays fast approaching, the impact of this isolation can lead to loneliness that may seem never ending. As we know, their prefrontal cortex is not fully developed until their mid-twenties and these new neural patterns can potentially lead to some dangerous side effects, both at home and online. Upsets, unchecked anger, fighting over little things at home or letting their guard down online by over-sharing with a stranger (#IBF), putting them in precarious positions from which it seems next to impossible to remove themselves. “The uncertainty of the circumstances we all find ourselves in is something our minds are not really equipped for,” according to Emiliana Simon-Thomas, science director at the Greater Good Science Center at UC Berkeley. “It ultimately ends up being a chronic stressor, even for people who don’t normally feel that way.”(1) Including children – or said another way, especially children. How many times have you heard how ‘resilient’ our kids are in managing changes but we now see that is not the case. We’ve talked about ACE Scores (Adverse Childhood Experiences) in previous articles and our present time is definitely one for the books. Adverse Childhood Experiences not only present short-term health issues, they carry over into adulthood. Discovering the challenges our families are dealing with and impacting them sooner rather than later, can save lives and needless heartache. The last time I checked, there is no cure or treatment for death. I don’t mean to be flippant, however, that is what we are dealing with here – we must treat depression now, talk about the impact isolation is having on our families and what we can do today to prevent heartache tomorrow. Lovingly asking the tough questions can prevent an untimely death of a child. Don’t believe me? Well here is a startling fact; the suicide rate for children 10-15 years old has risen 299% between 2011 and 2018.(2) I imagine we will see another increase in that number once things settle down and there is less focus on COVID-19, and we can see

the longer-term impact of this crisis. We can count on health professionals continuing to see on the frontlines: increased depression well before parents do, as many of them are experiencing symptoms of depression as well.

What should providers look for? A child being groomed and recruited online, once in too deep, may show signs of depression, masking the guilt and shame they are experiencing, or they may become confrontational, threatening to run away or hurt themselves if things don’t go their way. This type of sudden alterations in behavior is one sure sign something is amiss. The questions we suggested in previous articles are appropriate to learn more about what your patients are dealing with today. It’s a great way to begin an easy interaction with a patient. That’s why you, the frontline professional, are a most important key element in disrupting the cycle of exploitation, which leads to a whole host of mental and physical maladies that will require treatment over their lifetime. This is why the challenges with the current environment are so pressing; children are attached to their phones. Sadly, the rise in attempted and completed suicides by young people has a direct correlation with their access to smartphones. Many health professionals attribute the rise in suicide attempts to the effects of social media and how teens and young adults communicate with their peers. Developmentally, teen years have always been difficult, but that’s been taken to the next level by smartphones, social media and the constant pressure to be online.”(3) They are expected to put on their brave face – always. There is never a break. Always looking perfect, right lighting, right angle, hashtag, etc., etc. It’s exhausting. Put that on top of isolation, separation and loneliness and it’s a recipe for increased online exploitation and addiction. Dr. Ackerman with Nationwide Children’s Hospital in Columbus, Ohio noted that “young brains are less adept at dealing with complex situations,” likewise he believes social media plays an important role in the suicide crisis among the young.(3) I concur with Dr. Ackerman and so does the documentary the “Social Dilemma”. I think we can all agree, we are dealing with some pretty complicated, complex situations right now and our children are feeling it.

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So how can you make a difference with your young patients, and their parents trying to navigate this time in their lives, escape with as few scars as possible with maybe some hope to hang onto? Glad you asked. I will keep sharing this because I believe they are the most powerful tools to use when discovering what your patients are dealing with: asking powerful questions and listening. Dr. Wetter with Cedars-Sinai has some great suggestions of signs to look for and questions to ask if you or a parent are concerned about a depressed child. Key signs to look for are changes in mood or behavior that are different from the norm. Here are some questions to ask your patient or their loved one: • Do they seem to be more withdrawn than usual? • Are they behaving more erratically and impulsively? • Are they more irritable? • Did they typically respond quickly to a text or phone call, but now they are not responding at all? It’s also important to pay attention to the content of what a friend or loved one is talking, texting or posting. Do they avoid talking about future plans? Are they making references of wanting to escape or that they have nothing to live for? These could be cues that someone is feeling hopeless and may even be entertaining serious thoughts of self-harm.(4) Sometimes the very simple act of reaching out can have a positive impact. A simple call, quick text or expression of gratitude can make difference to someone who feels alone. Here are some tips to offer your patients and your staff: • Let them know that you are there for them and they matter to you. • Acknowledge that the holiday season can be difficult and that it’s OK to feel sad vs happy. • Tell them you are grateful they are in your life. • Remind them that even though this might be a difficult or even painful time, things do change. • Offer to go to the doctor with them or spend time in conversation. • Most importantly, let them know that you love and care for them.(4) You may recall the signs of trafficking and a few of the questions to ask from our earlier articles and you can always ask: • Are you feeling pressured to do something you don’t want to? • How are your friends doing? Are you spending time with them online? • Any new video games you’ve been playing?

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PHYSICIAN || SPOTLIGHT PRESENTED BY

“In Other Words”

To Screen or Not to Screen? That is no Longer the Question

with RICK

This month we shine the spotlight on Dr. Rick Ramnath, a principal at NeuroSkeletal Imaging in Orlando, Merritt Island and Melbourne, who is Board-certified in Diagnostic Radiology by the American Board of Radiology. Before arriving in Central Florida, he was the Chief Resident in Diagnostic Radiology and Chief Fellow in Musculoskeletal Radiology at Harvard Medical School/ Massachusetts General Hospital. He was A.B Cum Laude at Harvard University and earned his MD at Vanderbilt University School of Medicine. In this edition of In Other Words, he discusses for area providers advanced knowledge of low-dose CT scan screening for lung cancer.

In Other Words … Rick Ramnath, MD I distinctly remember, that when I was a child, my mom would tell me, “An apple a day keeps the doctor away,” just before she would pry my reluctant mouth open to receive my daily bolus of fruits and vegetables. In the same vein, the expression “an ounce of prevention is worth more than a pound of cure,” is another one of her frequently used adages. Little did I know that those sage proverbs would forty years later…eh hem…several years later, be applicable to my position as a radiologist advocating for the use of low-dose screening lung cancer CT scans. As of the most recent data, 135,720 people die annually from lung cancer, which surpasses deaths due to breast cancer, prostate cancer, and colon cancer combined! Despite this high death rate, the general public seems to still be under the impression that breast cancer and prostate cancer should be the more feared cancers. It is true that those cancers are far more common, but when combined with survivability, lung cancer should be considered enemy #1. According to the American Lung Association 2020 “State of Lung Cancer” report, the all stages 5-year survival for lung cancer is 22.6 percent, which is a slight improvement over 2019 survival. But let’s not celebrate too quickly. We are still in a dismal situation, especially considering that 47 percent of lung cancers are diagnosed at a late stage equating to a dire 6

RAMNATH, MD

percent 5-year survival. Even more chilling, the American Lung Association report tells us that people of color face worse outcomes than their Caucasian counterparts in terms of early diagnosis and likelihood of receiving potential life-saving surgical treatment. The good news is, and, yes, there is good news, our surgical approaches and techniques have so improved over the decades that the World Journal of Radiology reports a 92 percent 5-year survival in patients diagnosed with Stage 1A1 non-small cell lung cancer. How incredibly encouraging! If only we could diagnose more patients at such an early stage, there would be a drastic improvement in lung cancer survival. The biggest obstacle is, of course, that in early stages lung cancer is asymptomatic. This is where screening comes in. The discussion of screening for lung cancer is certainly not anything new. In fact, the authors in an article published in the Lancet in 1999 stated, “Low-dose CT can greatly improve the likelihood of detection of small non-calcified nodules, and thus of lung cancer at an earlier and potentially more curable stage.” Since then, there has been significant debate in academia as to the cost vs. benefits of low-dose screening CT scans for screening for lung cancer. Meanwhile, there had never

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been a uniformly accepted method of screening with many physicians opting for “occasional” chest x-rays for patients with heavy smoking histories. Most patients would end up having sputum cytology or imaging study only after symptoms arose. Radiologists who interpret chest CTs have always known that CT scans were far superior to chest x-rays for detection of small nodules, but putting meat onto the bone of the screening debate would not happen until the results of a large trial could be completed. Enter the National Cancer Institute’s multi-center National Lung Screening Trial, which enrolled 53,454 patients and randomly assigned patients to either an annual chest x-ray arm or a low-dose CT scan arm. A low-dose CT scan refers to a CT scan with a significantly reduced amount of radiation compared to a routine CT. In fact, the radiation dose is 72 percent lower at 1.5 milli-Sieverts (mSV), just low enough to keep radiation at a minimum, and just high enough to maintain diagnostic accuracy. The results were incredible and finally gave some scientific backing behind the intuition of radiologists. The study showed a 20 percent reduction

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continued RICK RAMNATH, MD

Depression and Isolation ... Then just listen; the bottom line is to create a safe space for them to share what they may be dealing with. The pandemic has revealed an urgent need to address several factors for our children and their parents; screen addiction, isolation, depression and exploitation. There is a need to address the use of digital media and the impact it’s having on our communities. Pretty sure that’s not in your job description, and that’s why we wrote these articles. To give you some of the tools to help families combat these new challenges. We know the environment has made matters worse for victims, because there’s been a global rise of “trafficking in cyberspace” as online, demand has been channeled “through social media, dark web and messaging platforms” which provide easy access to potential victims – our children.(6) Here’s the good news; through these articles we’ve given you powerful access and insight in ways to make a difference for your patients. As you have read, over time, we are touching the tip of the iceberg. There is a solution and it starts with us – one conversation at a time. We can lift the veil of mystery of how our children are being exploited. I invite you to stand with as we empower families to disrupt the cycle. Learn how you can get more involved with Paving the Way Foundation, click here and join the fight.

Resources for Your Patients and Staff for Dealing with Holiday Blues and Depression. Warmline: is a peer-run listening line staffed by people in mental health recovery themselves. https://warmline.org/ Mental Health America: is the nation’s leading community-based nonprofit dedicated to addressing the needs of those living with mental illness and to promoting the overall mental health of all Americans.  https://screening.mhanational.org/depression National Suicide Prevention Lifeline: The National Suicide Prevention Lifeline is a 24/7 toll-free lifeline for individuals experiencing emotional distress or crises. Call 1-800-273-8255 to talk to a trained listener. Nacional De Prevención Del Suicidio: 1-888-628-9454 Lifeline ofrece 24/7, gratuito servicios en español, no es necesario hablar ingles si usted necesita ayuda. Crisis Text Line: Text MHA 741-741 Crisis Text Line provides free, confidential text message support for individuals experiencing emotional distress or crises. It is available 24/7. Text “MHA” to 741-741 for support.

Sources: 1. https://www.capradio.org/articles/2020/11/27/covid19-pandemic-can-exacerbate-stress-depression-duringthe-holidays-especially-for-those-who-are-isolated/ 2. https://www.jpeds.com/article/S00223476(19)30277-X/fulltext 3. https://www.nytimes.com/2019/12/02/well/mind/thecrisis-in-youth-suicide.html 4. https://www.cedars-sinai.org/blog/signs-of-holidaydepression.html 5. https://www.mhanational.org/blog/looking-supportduring-holidays-check-out-these-free-resources

in lung cancer mortality in the CT scan group compared to the chest x-ray group. Shortly thereafter, the United States Preventive Services Task Force evaluated the trial data along with other smaller screening studies and gave a “B” rating to using low-dose screening CT scans for patients with a history of smoking. If your kids are anything like mine, if they got a “B” rating from their teachers, they would lock themselves in their rooms and binge-watch their favorite Netflix shows until they were forcibly extricated. However, a “B” rating from the USPSTF is high enough to compel policy makers to adopt the recommendations as it means it has “a high certainty that the net benefit is moderate” or that it “has a moderate certainty that the net benefit is moderate to substantial.” With that, multiple medical organizations got behind the use of low dose-screening CT scans including the American College of Radiology (naturally), the American Society of Clinical Oncology, the American Association for Thoracic Surgery, the National Cancer Institute, and the American Cancer Society. But most important of all is that the Centers for Medicare and Medicaid Services (CMS) adopted the USPSTF recommendations for all Medicare recipients as long as they met certain criteria. Those “certain criteria” are admittedly sometimes confusing and quite arbitrary but are based on the enrollee criteria used by the National Lung Screening Trial. Specifically, to qualify for a low-dose screening CT scan, a patient must be between the ages of 55 and 77 for Medicare (55-80 for private payers), have a 30 pack-year history of smoking (# of packs/day multiplied by number of years smoked), are current smokers or quit within the last 15 years, and have no symptoms related to lung cancer. Patients are also required to receive smoking cessation literature and a shared decision-making visit with their health care provider. In that shared-decision making visit, the healthcare provider should discuss both the benefits and risks of a low-dose CT scan. The most publicized “risk” is the incidence of false-positive results. These false positives typically arise from non-specific nodules that can lead to either more frequent follow-up scans, PET scans, bronchoscopy, biopsy, or surgery. However, the overall false positive rate is currently close to 12 percent, which is very close to the known false positive rate of another widely used screening study, mammography. The false positive rate has been kept very low because of very strict reporting criteria (Lung-RADS) used by radiologists at ACR-designated lung screening centers. The other risk to discuss is the radiation exposure. Much has been written about the theoretical risk of CT scan radiation-induced cancers and the only true documented correlation comes from two studies looking at CT scans in the pediatric population. If one analyzed those reports, you would find some serious study design flaws that puts some question marks on the actual degree of correlation and certainly calls into question any sort of causation. The evidence is even more scant in the adult population with risk assessments being calculated based on theoretical extrapolations from Hiroshima and Nagasaki survivor data. According to the FDA, the theoretical increased risk of cancer due to a 10 mSV CT scan increases the average cancer risk of 400 in 2000 to 401 in 2000. Considering that a lowdose screening CT radiation dose is only 1.5 mSV, that theoretical risk is even lower. Since the adoption of screening CT scans by CMS and insurance companies, many patients have had cancers detected at early stages and had their lives spared

6. https://news.un.org/en/story/2020/11/1077402

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from the ravages of lung cancer. The good news: screening is working! The bad news: we are not screening enough! Many have criticized the National Lung Trial and CMS eligibility criteria as too restrictive. That criticism may actually have some serious merit as recently shown by a large trial performed in Belgium and the Netherlands: Nederlands-Leuvens Longkanker Screenings Onderzoek (NELSON for short). This trial enrolled over 15000 patients and compared low dose CT scans to no screening at all. The eligibility criteria were a little more expansive with the earliest age starting at 50 (instead of 55) and the smoking history varying from 15 to 20 pack-years (instead of 30). The European study not only confirmed the positive benefit of screening CT scans, but also showed an even greater reduction in lung cancer mortality: 44 percent reduction! Many attribute this to the expanded eligibility of the patients enrolled and allowed the investigators to catch 69 percent of the cancers in Stage 1. Not wasting any time, the USPSTF got back to work and evaluated the new NELSON trial data along with all previous study data and, on July 7, 2020, released new draft recommendations which would do two major things to the current eligibility criteria: 1) Reduce the earliest eligible age from 55 to 50 and 2) Reduce the smoking history requirement from 30 pack-years to 20. The impact of these two seemingly small changes was not lost on the USPSTF team. The task force believes if CMS adopts these changes, this will double the number of eligible patients and have a direct positive impact especially among women and African Americans. As Dr. Michael Barry of the Task Force elaborates, “New evidence provides proof that there are real benefits to starting to screen at a younger age and among people with a lighter smoking history. We can not only save more lives, we can also help people stay healthy longer.” And Dr. John Wong, also of the Task Force, expands, “Making screening for lung cancer available to people who have smoked less over time will help doctors support the health—and potentially save the lives— of more of their African-American and female patients.” As we await final approval of the Task Force draft recommendations, we as health care providers need to understand that recommendations are only as good as how well they are implemented in our everyday practice. The Journal of the National Cancer Institute in November 2020 tells us we are not doing a very good job of screening our patients, with only 5 percent of all those eligible obtaining a CT scan. The American Lung Association 2020 Report further confirms this with their estimate of 5.7 percent. This rate is woefully lower than the estimated 45 percent colonoscopy screening rate and 65 percent mammography screening rate. As we move forward into 2021, many of us will say good riddance to 2020 and look forward to vaccinations and the eventual (fingers-crossed) containment of the COVID pandemic. But as all-encompassing as the COVID headlines can be, we cannot take our eye off the ball that is the unwavering war lung cancer is waging on our patients. Let’s collectively do our best to get our patients screened. The war against lung cancer for me is more than a professional mandate, it is a personal one. This is a war that was lost by my own mom in 2015 and her brother in 2019. Those words my mom spoke to me as a child refusing his daily fruit and vegetable bolus have a resounding relevance today. Her memory and her words now serve as my motivation to have all of our patients eat the proverbial apple a day.


EOCC || MEDICAL CITY

EAST ORLANDO CHAMBER OF COMMERCE

CALENDAR: Misters & Sisters Great Lunch Adventures – Aurora Restaurant at The Celeste Hotel WEDNESDAY, DEC 2, 2020 | 11:30AM-12:30PM  The Celeste Hotel 4105 N Alafaya Trail, Orlando, FL 32826

Coffee Club East Live & In-Person

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(First Thursday of the month)  “Who Am I?”

THRUSDAY, DEC 3, 2020 | 8:30-9:30AM  Bonefish Grill Lake Underhill Road  12301 Lake Underhill Rd, Orlando, FL 32828  FREE to EOCC Members | $10 for Non-Members

Testimonial Tuesday (Second Tuesday of the month)

TUESDAY, DEC 8, 2020 | 9-11:00AM  East Orlando Chamber office  12301 Lake Underhill Rd, Ste. 245, Orlando, FL 32828 Sponsorships Available (2-3 doz. Donuts)

Member Academy WEDNESDAY, DEC 9, 2020 | 8:30AM-10:30AM Hybrid Event - East Orlando Chamber office  12301 Lake Underhill Rd, Ste. 245, Orlando, FL 32828

EOCC Spark 365 Brain Trust THRUSDAY, DEC 10, 2020 | 8-9:00 AM East Orlando Chamber office  12301 Lake Underhill Rd, Ste. 245, Orlando, FL 32828  Member Exclusive with Limited space

Misters & Sisters Great Lunch Adventures – Bahama Breeze Waterford Lakes  THRUSDAY, DEC 10, 2020 | 11:30AM-12:30PM  Bahama Breeze Waterford Lakes 1200 N Alafaya Trail, Orlando, FL 32828

After Hours at Orlando Lighting Systems TUESDAY, DEC 15, 2020 | 5-7:00PM 10970 Piping Rock Circle, Orlando, FL 32801

Coffee Club Nona Live & InPerson  (Third Thursday of the month) “Networking Poker”  THRUSDAY, DEC 17, 2020 | 8:30-9:30AM  Sam’s Club Lake Nona  11920 Narcoossee Road, Orlando, FL 32832  FREE to EOCC Members | $10 for Non-Members

After Hours at The Celeste Holiday Business After Hours THRUSDAY, DEC 17, 2020 | 4–6:00PM The Celeste Hotel Orlando A Tribute Portfolio Hotel 4105 N Alafaya Trail, Orlando, FL 32826 $10 EOCC Members | $20 Nonmembers  Registration gets 1 Drink Ticket + 1 Ticket for future visit Happy hour pricing and food specials. Registration required.

East Orlando Chamber Office Closed for the Holiday’s

BY DOROTHY HARDEE, CHAMBER ADMINISTRATOR

Tomorrow is the first blank page of a 365-page book. Write a good one…. Brad Paisley  On December 1, 2019, the first known patient experienced symptoms of the mysterious pneumonialike illness known as COVID-19. While there was no epidemiological link established between this case and later instances, Chinese media reported the first case presented November 17. By the end of the month, China alerted the World Health Organization that a growing number of residents of Wuhan, China had become ill. Fast forward 365 days and the CDC reports at the end of November that more than 12 million U.S. cases were reported and 260,000 deaths occurred. The Worldometer’s COVID-19 data was a bit more grim offering a worldwide perspective showing the U.S. leading the number of total reported cases at over 13 million with 270,000-plus deaths. The pandemic has had a significant impact on people’s livelihoods, their health and our food systems. Rewind a century ago, when the United States suffered another economic crisis elevated by a pandemic and other world events. The Spanish flu pandemic struck while World War I continued to rage. Within two years, unemployment went from 1.4 percent to 11.7 percent adding to the unrest and violence rolling across the country. The Palmer Raids took place, prohibition passed outlawing alcohol, women won the right to vote and unrest overseas was what Dr. Harlan Ullman with the Atlantic Council described as a “petri dish for revolution.” Within two years, the Spanish flu ran its course without the aid of vaccines or treatment and thankfully did not recur. In a rather short period, the U.S. recovered from a “world war, two recessions in quick succession, a pandemic and a period of extreme domestic unrest.” It feels like we rang in 2020 and it passed by leaving little distinction between seasons, months or days. As Michael Altshuler said, “The bad news is time flies. The good news is you’re the pilot.” Just around the corner is 2021 with an abundance of change the pandemic inspired. For many of our businesses, the change to remote working has reduced their bottom line and helped them work more efficiently. Manufacturing has made remote work part of a normal business practice, while adapting to customer preferences. We are seeing a transition to product optimization, integrated marketing, sales and service, the evolution of direct and indirect channel strategies and a reinvestment into sales operations.

Change is imminent! We must enthusiastically embrace it, manage it, and craft it to our advantage … Steve Craft. It is time to make sure you are connecting with clients, get active on social media, refresh your brand, work on your website and make sure your printed materials are fresh and current. Forbes’ Shep Hyken predicts that moving into the New Year businesses need to be prepared as customers will continue to get smarter, more impatient, and desire convenience (which is no longer optional). He adds that a virtual and remote workforce will become business as usual, making it imperative that companies and brands find more ways to automate and digitize the experience.

DEC 21, 2020 – JAN 1, 2021

Please visit EOCC.org for a complete listing of December events

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Integrating Behavioral Health Services Helps Reduce Rehospitalization Rates Better for the patient and better for you BY MARY-CATHERINE SEGOTA, PSY.D.

episode of panic vs. a cardiac event or COPD flare up, bringing them frequently back to the ER. An individual with a long-standing personality disorder may present with difficult interactions with medical staff, including confrontational dialogue, avoiding or denying personal accountability, or outright rejecting medical recommendations or treatment. An individual who becomes hypersensitive to their physiological symptoms may misinterpret sensations of normal healthy functioning and seek additional care or services. An individual who is disconnected from their psychological distress may present repeatedly with vague physical complaints, or shifting symptomology, making it difficult to identify any underlying medical condition, if one is present. An individual whose identity surrounds their illness, as compared to an individual who sees themselves as separate from and coping with an illness that does not define them, will be less likely to integrate behavioral change that will facilitate wellness and will reinforce behaviors that will maintain their ‘sick patient’ identity. It is im-

Reducing hospital readmissions is a national priority seeking to improve health outcomes and enhance care at lower costs. The transition from the hospital to the next care setting can be unsafe, inconsistent, rushed, confusing or ineffective. This point is where patients are the most vulnerable and failures cost most. Have you ever wondered why patients with the same general medical conditions can have vastly different outcomes? Every case is unique, and medical comorbidities complicate the picture, but more often than not, psychological and behavioral issues are overlooked when assessing readmission risk. From 2009 to 2011, about 21.7 percent of patients with psychiatric comorbidity went back to the hospital within 30 days of discharge, compared with 15.5 percent of those without such diagnoses, said Brian Ahmedany, PhD, LMSW, of the Center for Health Policy and Health Services Research at the Henry Ford Health System in Detroit in Psychiatric Services in Advance. One sure-fire way to impact readmission is to address underlying behavioral health factors that your patient is experiencing. Behavioral Health factors that have a negative impact on medical outcomes include:

portant to remember that most people with behavioral health issues have never participated in therapy and have not developed coping skills to manage their symptomology. Additionally, people with behavioral health issues often lack insight into their illness making it worse.

As their clinician, what can you do? • Assess the patient’s understanding of their own medical condition. (Ex. Does the patient understand what it means to have diabetes and what lifestyle modifications are necessary for survival?) • Assess the patient’s appraisal of their medical condition. (“I will always be sick.” “I will only feel better when I am 100 percent pain free.”) • Assess the patient’s need for community resources (food banks, shelter).

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PRE-OP COVID TESTING

• Co-existing chronic psychological diagnoses such as depression, anxiety, and bipolar disorder • Co-existing conditions such as substance abuse disorders or personality disorders • Social isolation or lack of caregiver support • Social Determinates such as economics, housing, and food instability It is more important to know what sort of person has a disease than what sort of disease a person has….Hippocrates Nearly all psychological conditions have physically manifested symptoms, and nearly all medical conditions are impacted by psychological conditions. It is important to understand how these factors interact with each other to ensure the most optimal outcomes.

How do psychological conditions directly affect outcomes? An individual who experiences clinical depression may have difficulty with energy, sleep disturbance, and motivation. This may translate into medication irregularities, missed follow up appointments, and decreased physical activity, which will lead to exacerbation of their medical condition. An individual who experiences panic disorder may find it difficult to differentiate between an

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The Rest of the Story Edited in Time

Integrating Behavioral Health Services ...

The East Orlando Chamber is here to help with unique offerings to help elevate your business’ visibility and connect you with others helping your business thrive. Testimonial Tuesday features our members on a live broadcast allowing them to share personal and professional information with listeners. The Member Academy shows new members how to use the valuable resources provided with hands-on training to jump start their chamber journey. Taking it one step further, the EOCC Spark 365 Brain Trust is an intimate meeting of the minds helping to decode problems, design solutions and offer leads members desire. We will also celebrate a new schedule in 2021, offering a quarterly menu with industry focus including our Chamber Luncheon, Women in Successful Endeavors (WISE), OPTIC – Orlando Professional Technical In-

• Assess the patient’s existing coping skills (adaptive and active vs. passive and avoidant). • Assess caregiver support (and caregiver burnout). • Assess secondary gain and maintaining behavior. (Ex. “If I get better, I lose my disability benefits.” “If I get better my spouse won’t give me the love and attention I get now.”) • Refer to mental health therapists that are trained in working with individuals with chronic medical and pain conditions. Integrating mental and behavioral health treatment addresses those issues that are barriers to a positive treatment outcome. Targets for behavioral health interventions include: • Psychological symptom reduction • Active (vs passive) coping strategies • Adaptive (vs maladaptive) cognitive appraisals • Medication compliance • Improved sleep hygiene • Nutrition/eating compliance • Activity pacing • Adaptive appraisals about health and wellness. • Improved social support • Facilitating optimism In the age of COVID, individuals with underlying psychological diagnoses are experiencing an exacerbation in symptoms due to extended isolation, financial hardship, and losses in multiple domains. While telehealth is an important tool, it does not entirely replace that which is provided by face to face visits. This means it is more important than ever to ensure that patient psychological, behavioral, and social issues are adequately identified either through thorough history taking or utilization of standardized inventories. By incorporating mental and behavioral health services with your patients, you will ensure that the symptoms that cause barriers to wellness behaviors and treatment adherence are identified and addressed, leading to a decrease in rapid rehospitalization rates and an improved outcome for your patients. With a doctorate in clinical psychology and over 20 years of experience in the field, Dr. Segota has conducted university-based behavioral medicine research, acted as a consultant to professionals and organizations, and worked with a diverse number of psychological and medical conditions. By identifying unique needs, the source of distress, and what’s perpetuating the problem, she will help develop the tools to overcome seemingly insurmountable circumstances. She offers an environment where patients will become empowered and achieve maximum personal and professional growth, through therapy, testing, biofeedback, mediation, and coaching. Visit www. CounselingResourceServices.com

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DECEMBER 2020

novation Council, Connect 4 for Property Professionals, our Healthcare Council Collaborative and more. Kick off the year by joining us for our event January 27th from 11:30 AM – 1:00 PM at Bonefish Grill Waterford, as we celebrate our Volunteers of 2020, recognize our Chamber Ambassadors and Install the 2021 East Orlando Chamber Board of Directors. Judge Eric Dubois will lead the ceremony as Karen Jensen (Orlando Health) passes the gavel to incoming Board Chair Martha Santoni (Nemours Children’s Hospital). Pete Folch (Second Wind Finish Strong, Inc) will also join to provide an inspiring message for the New Year. For more information or to register call (407) 2775951 or visit our website at eocc.org.  The East Orlando Chamber of Commerce everywhere East of I-4.


Solo vs. Group Practice What are the Pros and Cons? BY JEFF RAMOS

Some of the disadvantages include:

After spending years working hard to build your practice, a physicians group tells you that you can earn more with less stress if you join their group. What should you do?

• You may have your patients switch care to a colleague

This is the question many private practices are asking themselves. I recently had a conversation with a primary care physician with 30 years’ experience, who shared that the primary reason he was averse to switching his practice management and billing services was a fear of loss of control of his practice. Despite knowing there were many things his business could improve on, the thought of losing autonomy to make critical decisions for his business was daunting. He was told by a large physician’s group that if he were to let them manage his business, he’d have more monthly referrals, not be charged for PM access fees, so long as he filed a minimum number of claims per month, and most importantly, he’d have more time off while the physicians group handled the operations of his business. That sounds great, right? The truth is you don’t need to join a physician’s group to enjoy many of these benefits. Some of the pros of independent practice ownership include:

• Longer wait times for patients

SUSTAINED SUCCESSFUL SUSTAINED OUTCOMES SUCCESSFUL

• Less control of schedule

• Outcome-Focused Neurobehavioral Program

• Office staff is divided among all of the doctors • Partnership deals and overhead allotments can be complicated • Levels of ownership

• Administrative demands are placed on physicians • Productivity demands are placed on physicians, thus impacting compensation The underlying message is that, depending on your longterm growth plans, levels of personal comfort managing a business, and desire to deliver the best possible care for your patients, should all be a factor in deciding whether private ownership or a physician’s group is right for you. The questions you should be asking yourself are simple: What do my patients need, what do I want from my practice today, and what do I want out of it tomorrow? Jeff Ramos is the Owner of Elevate Medical Resources, an Orlando-based company providing back office support, compliance, billing, A/R Management and coding. Jeff can be reached at jeff@elevatemedicalresources. com or 407-217-5635

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TechTip

Insider Tips And Secrets To Get The MOST Out Of Your Computer

The Practice Manager’s Guide To IT Support Services And Fees

Insider Tips And Secrets To GetYou The MOST Out Of Your Computer What Should Expect To Pay

For Support Your SmallAnd Business The Practice Manager’sIT Guide To IT For Support Services Fees

• Ability to hire and fire staff • Setting your own hours

(And How To Get Exactly What You Need Without Unnecessary Extras, Hidden Fees And Bloated Contracts)

• Ability to diversify practice offerings

What You Should Expect To Pay For IT Support For Your Small Business

• Multiple doctors can be partners in a practice • Use of vendor partners such as HR and billing at a manageable cost

Read This Guide And You’ll Discover:

• Drive business performance to meet your unique goals

The 3 most common ways IT services companies charge for their services, and the pros and cons of each approach.

(And How To Get Exactly What You Need Without Unnecessary Extras, Hidden Fees And Contracts) A common billing model that putsBloated ALL THE RISK on

However, for every pro there is a con. When you’re running an independent practice, all the nitty gritty details for the functions of your practice as a business are your sole responsibility. This include things like:

you, the customer, when buying IT services;

Read This Guide And You’ll Discover:you’ll learn what it is and why you need to avoid agreeing to it.

• Responsible for all office expenses

The 3 most common ways IT services companies charge for their services, and the pros and cons of each approach. Exclusions, hidden fees and other

• Always on call and may need to cover for others • Need to manage HR function

“gotcha” IT companies put in A common billing model that puts ALL THE RISKclauses on you, the their contracts that you DON’T want customer, when buying IT services; you’ll learn what it is and why to agree to. you need to avoid agreeing to it.

• Responsible for billing Depending on your long-term goals and preferences, independent practice may not be right for you. There are just as many pros and cons to joining a physicians’ group as there are running an independent practice. Some of the advantages include:

Exclusions, hidden fees and other “gotcha” How clauses IT companies to make sure you know what to. you’re getting to avoid put in their contracts that you DON’T wantexactly to agree

disappointment, frustration and added

• the ability to share office expenses

latergetting on that you How to make sure you know exactly whatcosts you’re to didn’t avoidanticipate. disappointment, frustration and added costs later on that you didn’t anticipate. 21 revealing questions to ask your IT

• affording more expensive state-of-the-art technologies

21 revealing questions to ask your IT support firm BEFORE to your computer network, e-mail and data. giving them access to your computer network, e-mail and data.

support firm BEFORE giving them access

• taking time off with ample coverage from colleagues

Free Copy Of This Practice Guide Today Download Your Free CopyDownload Of ThisYour Practice Manager’s GuideManager’s Today Online At:Online At:

• ability to learn additional skills from your colleagues

www.AtlanticDataTeam.com/itbuyersguide www.AtlanticDataTeam.com/itbuyersguide

• all business functions such as HR and billing managed by group

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How to Help Healthcare Heroes Deal with Emotional Stress – During and After the Pandemic BY GIGI ACEVEDO-PARKER AND WENDY KING

As the coronavirus pandemic continued its spread over the summer, a University of Central Florida health clinic expanded its outreach to the community with mental health counseling. Through pop-ups, a mobile care lab, 60-minute single counseling sessions and no-cost virtual counseling, UCF Restores has aimed to help those bearing the brunt of COVID care relieve the pressure on their mental well-being[1]. While UCF Restores has targeted all essential workers, it is especially looking to support healthcare workers, who are stressed and anxious with the non-stop pressure of the pandemic. Plus, as a group, they are less likely than others to share how they are suffering from depression, insomnia and other symptoms of mental stress. As healthcare employers in the Orlando region assess the damage of the pandemic and remedial steps moving forward, the situation makes their best starting point the emotional health of their own professionals. You might call the pandemic a perfect storm for bringing a worsening issue into sharp focus. Start with healthcare workers’ emotional health during normal times. Doctors, for example, have a higher suicide rate than any other profession at 28 to 40 per 100,000, or 300 suicides per year. It’s also twice the suicide rate of the general population[2]. Symptoms like depression and anxiety tend to go unaddressed, though. Many won’t admit to the need or to having sought care, because of the potential effect on their licensing, 60 percent of surgeons with recent suicidal ideation admitted[3]. The pandemic compounded the crisis as healthcare workers faced personal risk with inadequate protective gear, ineffective treatment options and a defeating death. Being hailed as “healthcare heroes” helped to buoy spirits in the early days. But as the virus has continued to gain ground and battles grew over masks, treatments and more, public attitudes began to shift. A distressing number of people, one study found, believed healthcare workers should be isolated from their communities, families and friends as potential “carriers” of the virus. A third of respondents said they avoided healthcare workers for that reason[4]. It all makes the case. Healthcare employers must act to create support structures that do a better job of bolstering the emotional well-being of their employees. Best in class organizations know its resilience that allows

them to achieve and maintain long-term success. But it can’t happen without employee resilience, a critical component necessary for people to be able to bounce back from periods of stress. An effective strategy to strengthen mental health support systems that improves organizational resiliency must include a framework built on the following components: • Establish key leadership principles. In looking for solutions to relieve stressors and build resilience, it’s important to establish what principles count in the support program. Setting the bar for a proactive stance is one starting point – that means showing a commitment to promoting positive mental health and well-being, not just delivering interventions. Adopting a “whole person and family first” philosophy is another. Now might be the time to repurpose budgets and re-evaluate traditional voluntary benefit offerings for their suitability to today’s needs. • Recognize psychosocial stress reactions. Psychosocial stress is often a result of significant changes in the workers’ environment. Employees under pressure may express feelings of being overwhelmed and a sense of helplessness. Loss of normalcy is another indicator. Some may talk about anxiety-induced sleep irregularities. Managers who are attuned to potential issues (and equipped to offer solutions) are in a better position to improve employee satisfaction and maintain organizational productivity over the long term. Psychosocial stress, along with changes/altercations to the worker’s environment can cause mental distress. • Create a supportive environment. Employers must proactively affirm, through actions and words, their support for employees who are finding it difficult to cope with today’s psychosocial pressures. Barriers to receiving mental health treatment must be systematically dismantled. Policies should be geared toward removing stigma surrounding the professional consequences of seeking treatment. The most effective environments also emphasize the value of compassion. In these extraordinary times, it’s human to feel anxiety or fear, not a sign of weakness or incompetence. • Physical and financial well-being programs count. The well-documented correlation between mental and physical health makes physical well-being programs important to maintain, and even ramp up. Even before the pandemic, financial pressures played

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a big role in employee stress and anxiety. Employee Assistance Programs (EAPs) should be promoted for their emotional and financial wellness resources like financial counseling services. • About that “family first” focus... Employers who have adopted this sort of holistic thinking should devise a separate support and care strategy to ensure these needs are met and stressors relieved. What resources are available to back up employees with homeschooling and childcare in their communities? What options can help with eldercare? Flexibility on work schedules can provide needed “away” time for mental health days. • Think about the “right” mental health resources. Each organization is different, requiring a serious look at resources and interventions that best fit the need. Brokers and other consultants can help evaluate the options. At the low-risk end of the intensity spectrum are mindfulness practices to reduce stress. Many free apps are available, too. Coaching and coping is for medium-risk needs, delivered through digital or telephone channels, EAPs, stand-alone resources or in wellness or embedded carrier programs. Therapy is for high-risk situations, or those with clinical indications. Referrals can be made to behavioral health professional services provided through digital means, teletherapy or in person. The need for resilience, among our people, our communities, and our institutions, has perhaps never been more urgent than it is today. It’s especially urgent to address among our healthcare professionals, who are dealing with unprecedented and unremitting pressure as the pandemic continues to surge. Finding a way to help them come out from the disruption whole is the least these heroes deserve. Gigi Acevedo-Parker is National Practice Leader – Critical Risk Management, for global insurance brokerage Hub International. She is a nurse executive with more than 30 years as a healthcare clinician, nursing leader, healthcare consultant and educator with a focus on healthcare risk mitigation and patient safety. Gigi has deep experience in many diverse aspects of risk management and compliance, including loss prevention and mitigation, patient safety and quality, claims and litigation management, corporate compliance and privacy. Wendy King is the Director of Health and Performance for Hub International and a leader in the field of healthcare communications and corporate wellness strategy. She manages HUB’s team of health and performance experts, who provide clients the strategic insight, multi-year plans, and provider resources required to create healthy, high performing organizations. [1] https://www.mynews13.com/fl/orlando/coronavirus/2020/08/13/ucfrestores-expands-treatment-to-frontline-workers [2] https://www.webmd.com/mental-health/news/20180508/doctorssuicide-rate-highest-of-any-profession#1 [3] https://pubmed.ncbi.nlm.nih.gov/21242446/ [4] https://www.healthline.com/health-news/no-more-applausehealthcare-workers-now-being-shunned-during-covid-19


Disinfecting Spaces for COVID-19 Know the facts and understand key differences BY FRANCES M. GRINSTEAD

As medical professionals, you’ve likely been inundated recently by advertisements touting products that will disinfect spaces of SARSCoV-2 (COVID-19) and other infectious diseases. While we’ve all had to up our game during this recent pandemic, by either adding products to our repertoire or increasing the use of disinfectants we have on hand, it’s important to make sure that we’re not fixing one problem only to create other problems in the process with our choice of disinfectants. Choosing the best form of disinfection doesn’t have to be difficult, and with the right information and knowledge, you can make an informed decision now that you won’t regret later. Let’s play a game to test that knowledge...

True or False? Whole-Space Disinfection Reaches Everywhere True—And we’ve based our entire company on it. But, it’s important to understand that not all disinfection systems are the same. What you commonly see advertised as “fogging” is actually electrostatic spray. This technology often claims to reach “everywhere” at the same time it advertises a targeted delivery. However, you can’t have it both ways. Either the disinfectant completely fills the space, or it only kills germs on the surfaces where it is aimed. There are times when targeted spraying is ideal due to the difficulty of enclosing a space or due to the fact that the space is so large (like an auditorium) that it makes it difficult to fog. But when possible, engulfing an environment in true vaporous fog is the most effective. Fogging allows vapors to reach every nook and crevice of a space, including all of the room’s contents. For example, CURIS’ hybrid hydrogen peroxide™ (HHP™), a combination of aerosol and vapor hydrogen peroxide, has been validated at 21ft. high and trusted in healthcare environments, such as hospitals, ambulances, and other medical facilities throughout the United States. It has revolutionized disinfection practices and cleaning protocols, changing expectations of germ safety from “attempts to just clean better” to an achievable, measurable kill result of dangerous germs.*

Spraying Means I Don’t Have to Evacuate the Room False—Ok, we’re not talking about a few squirts from a spray bottle here. But anything more than that is cause for serious consideration, e.g., electrostatic sprayers or other volume spray devices. Whether it is bleach,

peroxide, or your favorite name-brand solution, there are strict OSHA limits for what is considered safe for exposure. Just because it smells “clean,” doesn’t mean it is safe. For example, bleach has a limit of 0.5 ppm TWA 8 hrs, which is too much to explain here, but suffice it to say, if you smell it strongly, you probably shouldn’t have patients staying in the room, and it may be unhealthy to breathe in while cleaning with it. The point is, if someone advertises that you can use an industrial sprayer while staff or patients remain in the space, you might want to think again and check the active ingredient for OSHA requirements. Systems that allow for remote, hands-free operation are the safest and can even reduce human error while allowing the operator to remotely monitor, manage, measure, track, and report decontamination efforts.

If the Label Says It Kills the “Germ,” then It’s All Good False—Because you may inadvertently be creating pathogen reservoirs or causing corrosion from the disinfectant you are applying. One of the common ingredients that makes many disinfectants so effective is also the same ingredient that makes them sticky, messy, and corrosive. Ammonium chlorides (Quats/Quacs that are not usually prominently listed as an ingredient but are still there) often help chemical solutions achieve a 99.99 percent kill rate. But if not quickly wiped off, they leave a residue that can build up on a surface, capture grime, retain additional ingredients, such as chlorine dioxide, on the surface that cause corrosion and even unknowingly create a haven for colonies of pathogens to grow. Unfortunately, these adverse effects (rust, corrosion, and sticky messes ruining expensive equipment) have become a known negative side effect as increased frequency of treatments has become necessary during this pandemic.

Killing 99.9 percent is Effective Enough Maybe true, but it depends on your goals—We are firm believers at CURIS® that catching a cold or stomach bug every once in a while can help most people maintain a healthy immune system. However, when dealing with a pandemic or when operating a medical practice where patients may be immunocompromised, there is no room for pathogens left behind. You may or may not have heard of log reduction. This simply refers to how many 9’s after the decimal point a disinfectant can claim. If it kills 99.9 percent of a pathogen like Influenza, then there can be up to 1,000 viable organisms (germs) left behind on just that one spot. If a disinfectant kills 99.9999 percent, then less than 1 (you can never say 0) organisms are left behind. Why does this matter? Sometimes, depending on the pathogen, it only takes 1–10 viable organisms to make you sick. In the case of SARS-CoV-1 (we don’t have the numbers yet for SARS-CoV-2), only 67 organisms (germs) can possibly make someone sick. Knowing that, how many 9s do you need for your disinfectant? The only acceptable number to us is 99.9999 percent.

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UV Light is Fast and Can Disinfect a Room in 10 Minutes False—Disinfection implies a 99.99 percent kill rate, and most industrial UV lights achieve only a 99 percent or 99.9 percent kill in 10 minutes or less. UV light can be a useful tool, but if you’re treating a whole room or object, the time needed to really disinfect is between 30–40 minutes. This means the light will disinfect only where light touches for as long as the light is stationary in that position for 30–40 minutes. Yes, that means if you are using UV light, you need to move the light to a new position every 30–40 minutes, and it may actually take 1–1.5 hours or more to effectively disinfect a patient room with a bed.

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The Taxability & Timing of PPP Loan Forgiveness BY AMY GOODMAN, CPA

Can you imagine a year with more ups, downs, twists and turns than this year?

the due date for filing most S Corporation and Partnership tax returns, which is generally March 15. The result: many businesses may need to file their tax return before a forgiveness decision is reached. If you are in this position, the Treasury and IRS have provided the following instruction: any business which reasonably believes that a PPP loan will be forgiven in the future should treat the expenses related to the loan as not deductible in 2020.   In the case where a PPP loan was expected to be forgiven, and it is not, businesses will be able to deduct those expenses through one of two options: either amending the 2020 tax return to allow the previously disallowed deductions, or possibly deducting them in a subsequent year.

Navigating the everchanging terms of the Paycheck Protection Program (PPP) has certainly contributed to this rollercoaster ride. Alas, we have assembled the following tip and recently issued guidance to assist you in navigating the application process for requesting PPP loan forgiveness.

Background As a reminder, earlier this year, the CARES Act provided for the issuance of PPP loans as a means of helping businesses maintain certain expenses, particularly payroll, during the COVID-19 shutdown. The Act intended for these loans to be forgiven if certain requirements were met. Generally speaking, the forgiveness of a loan results in taxable income to the loan recipient. The CARES Act explicitly provided that businesses should not be taxed on the proceeds of a forgiven PPP loan.  Many have wondered whether the loan would indeed escape taxation upon forgiveness. We now know the answer.

By what date do I need to file my forgiveness application? There is no defined deadline for borrowers to submit the forgiveness application. The SBA explains that borrowers may submit a loan forgiveness application any time before the maturity date of the loan, which is either two or five years from the loan’s origination, depending on the borrower’s agreement. But the SBA also reminds borrowers that loan payments are deferred until 10 months after the last day of each borrower’s loan forgiveness covered period. This means that most likely you would want to submit well in advance of that date. Most banks have opened their portals for applications. It may be advisable to get your application filed sooner than later with the hope that you receive a decision before filing your business tax return. Extending your business tax return on March 15 will also help if a decision has not received from the SBA, however, as always, any tax due for 2020 will still be due by April 15 when you file or extend your individual income tax return. Finally, some are still hopeful that the tax impact as currently outlined will be “fixed” in future stimulus legislation. Having said that, it will be most prudent to start planning for additional income taxes owed on the 2020 tax return assuming no changes are made.

Will I Be Taxed on the PPP Loan Proceeds? Although the CARES Act stated that forgiven loans would not be taxable, the CARES Act did not address whether expenses paid using forgiven PPP loans would be deductible for income tax purposes. The IRS released guidance over the summer, and again in November, stating that expenses paid using PPP loan proceeds that are forgiven cannot be deducted for income tax purposes.

What if the SBA has not issued a determination on my forgiveness application by the time I file my 2020 Business Tax Return? The SBA has provided certain requirements with respect to the turnaround time of the forgiveness application by lenders. Lenders have 60 days after receipt of the forgiveness application to issue a decision to the SBA. The SBA then has 90 days after receiving the decision from the lender to review the application and remit the forgiveness amount to the lender. The outlined turnaround time means that it could take 5 months from application filing to determination of forgiveness. Consider this timeline in contrast with

Resources for more information: Revenue Procedure 2020-51 Revenue Ruling 2020-27 https://www.sba.gov/document/support-frequentlyasked-questions-ppp-loan-forgiveness Amy Goodman is a CPA and Partner at Peter J. Freuler & Associates, CPAs. Freuler & Associates is a central Florida accounting firm devoted to assisting practitioners and practices in the healthcare industry maximize their business’ income, while minimizing the tax impact. For more information contact amy@pjfcpa.com or visit www.pjfcpa.com.

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Disinfecting Spaces for COVID-19 So, what’s so great about true whole-space disinfection fogging? Simply put and most importantly, fogging is the most effective disinfection, as it reaches everywhere air touches. It kills germs in every nook, cranny, and crevice that wiping or spraying often miss. With a high-level, EPA-registered sporicidal disinfectant fog, you can feel confident that you are using the most effective disinfection system available, and with the right systems and protocols, you can change expectations of germ safety from just “cleaning better” to achievable, measurable kills of dangerous germs. The best whole-space fogging leaves no harmful residues. It engulfs a space with powerful disinfectants like hydrogen peroxide that decompose to harmless water and oxygen. Ideal whole-space disinfection systems keep surfaces “wet” enough to kill germs without soaking or damaging surfaces. True whole-space fogging is also faster. If you factor in the time it takes to properly spray every surface, let the disinfectant stay wet as directed (dwell time), and then wipe it off, your staff will spend equal or more time than fogging takes. And lastly, ideal whole-space fogging is safer to use. With remote operation, neither staff nor patients are exposed at any time to dangerous chemicals. So the bottom line is that, while there are various solutions and systems available that claim to fight infectious diseases in spaces and on surfaces, it’s important to remember that there may be hidden truths, misleading information, and unfortunate side effects. Understanding the differences is key to achieving the highest rates of effectiveness, safety and overall ease of use. Frances M. Grinstead, CEO, CURIS System, has been working in bio-decontamination for over a decade and has been at the forefront of innovation in high-level disinfection in high traffic facilities. As the first to develop a truly portable decontamination device and the first to establish a bio-decontamination service for the purpose of outbreak control, she has created a market that others now emulate, all in an effort to improve innovation and understanding of infection prevention and control. She develops and implements fact-based programs to minimize risks, helping prevent the spread of infectious disease. Visit www.curissystem.com


Home Office Productivity Keep working from home fresh and exhilarating BY DOUG MINTZ

With so many employees now working from home indefinitely, many are finding it harder to concentrate at the same level of intensity when they first started the practice.

Create a to-do list at the beginning of each day. Try to prioritize it as best you can and stick to it! Check off the tasks as you complete them. Try to separate personal and business tasks. Assign a specific block of time for personal tasks so they do not intertwine with your work mindset throughout the day.

Initially workers were excited about working from home and were team-motivated because of the necessity to maintain workplace continuity. According to a survey of 1,100 workers by the Society for Human Resource Management, 22 percent of workers had difficulty concentrating last April of 2020. But now, over six months later, the excitement has worn off and home distractions have increased dramatically. This is the result of COVID-19 stress, the presidential election, and a non-stop negative news cycle. If these challenges sound familiar, here are some pointers to be more productive.

Schedule several breaks throughout the day. Read something non-work related, take a walk, or listen to your favorite music to mentally decompress.

Take a lunch break, whether you eat or not. Eating something, even a light snack, will help recharge your brain cells. Drink plenty of water. Stay hydrated to prevent physical and mental fatigue.

Silence all alarms on your computer and phone.

Be sure your office furniture is ergonomically correct to keep you productive and physically healthy. It could be as simple as having a quality task chair. It might involve better positioning of your computer keyboard and monitor. Some individuals may want a sitstand desking setup. Healthy ergonomics is different for everyone. Make adjustments that are right for you. Follow most of the tips above and you will be more productive with your work tasks and minimize your home office burnout. Doug Mintz has been in the office furniture industry for over 20 years. After working three years for a family-owned dealership, Mintz ventured out on his own in 2001 and founded CPOF Inc – Cubicles Plus Office Furnishings. CPOF quickly differentiated themselves in the marketplace by providing project management services and other value-added benefits for clients in the mid-market; services that were normally offered only by larger contract furniture dealers ($10 Million +). His focus is primarily on the patient’s waiting room experience, as well as the ergonomic health and wellbeing of clinic employees. Visit www.cubiclesplus.com or email Doug@CubiclesPlusOF.com

If Wi-Fi is not part of your job necessities, disable it while you are working. This will create a quieter and less distracting environment for you to concentrate on the real work. Determine and schedule a specific time of day to check emails and perform your internet tasks (if applicable).

Set boundaries at your home with your family. Be clear that you are working and cannot be disturbed. Create an office that provides privacy. Close the door! Make family members aware. Let them know that even though you are home, you’re not home, unless there is a real emergency.

Create a less distracting acoustic environment for better concentration. Portable sound masking generators (defined-frequency white noise) can be purchased. Another aid is noise cancelling headphones. For some, simply having a radio or television on at low volume may create the same desired effect. These acoustic options are proven to be effective and are used in the workplace by thousands of companies of all sizes; you may have experienced a sound masking environment in your workplace and not been aware of it.

Keep a to-do list or Post-Its close by. This will help you stay focused on the tasks at hand. If something pops into your head that you need to eventually address (work related or personal) put it on the list. Or write it on a Post-It note and hang it nearby but out of sight. You can also use different colored notes for personal and business tasks.

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Diagnosis and Management of Typical and Atypical GastroEsophageal Reflux Disease BY BASHER ATIQUZZAMAN, MD

Twenty percent of the United States population has a medical illness called GERD, short for Gastroesophageal Reflux Disease. Though it is a common disease among many of the population, it can lead to serious complications over time. GERD occurs when stomach acid flows from the stomach to the esophagus, due to the relaxed sphincter that is between the esophagus and the stomach. This flowing of acid is called acid reflux, and allows for irritation of the esophagus lining. This irritation causes acid indigestion or “heartburn.” GERD is a one-time occurrence of acid reflux/heartburn, but GERD is longer lasting and more serious. Though there is not one cause of GERD, there are risk factors. Obesity, smoking, connective tissue disorders, hiatal hernia, certain foods, and certain medications are large factors in GERD. GERD may cause complications, such as esophagitis, esophageal stricture, or respiratory problems. Some of the most common complications occur because of chronic inflammation of the esophagus. Esophageal stricture occurs with the narrowing of the esophagus, which leads to difficulty in swallowing. An esophageal ulcer can form due to stomach acid wearing away the esophageal tissue. Barrett’s esophagus is the damage in the lower esophagus that increases risk of esophageal cancer.

To confirm that a patient has GERD, there are many tests for diagnoses: upper endoscopy with biopsy, esophageal manometry, x-ray, pH probe test. In an endoscopy, the doctor inserts a tube (with a camera and light) down the throat to examine the esophagus and stomach. An endoscopy can detect inflammation and a biopsy can test for Barrett’s esophagus. With an x-ray, the patient drinks a liquid that fills the lining of the esophageal tissue that allows for a silhouette in the x-ray. The manometry measures the esophageal muscle contraction rhythm and the force exerted by esophageal muscles. In the pH probe test, a monitor is used to identify when the stomach acid regurgitates and how long it occurs for. GERD can be treated over the counter, with prescription medications or surgical procedures. The prescription medicines are h2 receptor blockers (Pepcid, Zantac) and proton pump inhibitors (Nexium, Prilosec). Some of the surgical procedures are Robotic Valvuloplasty, fundoplication and LINX devices. Fundoplication is

done when the surgeon puts the top part of the stomach around the esophageal sphincter. Tthis allows for the tightening of the esophageal muscle and less acid reflux. The LINX device allows for magnetic beads to be inserted around the area in which the esophagus and stomach join together. The magnetic attraction between these beads allow for the tightening of the junction of the esophagus and stomach. GERD related to hiatal hernia can be treated with Robotic Valvuloplasty, a minimally invasive procedure. Basher Atiquzzaman, MD, is the Director of the Heartburn Center at Digestive and Liver Center of Florida, providing personalized management of (GERD), its complications and related disorders. Leaders in academic research on endoscopic therapies and novel treatments for GERD we provide our patients access to the latest and most advanced endoscopic and surgical options, including those currently only available through clinical trials. Visit www.dlcfl.com

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Community Health Centers Receives National Recognition for Third Consecutive Year continue to focus on joyful, purpose-filled team members while delivering quality and compassionate primary healthcare services to Central Florida’s diverse communities.,” states Debra Andree, MD, President/CEO of Community Health Centers, Inc. The Best and Brightest Companies to Work For in the Nation Winners will be honored during the virtual Illuminate Business Summit week in the spring 2021. “It is truly an honor to be chosen as a Best and Brightest winner, for the third consecutive year. This award is nationally recognized and includes employers from across the nation and all industries. We value each of our team members and strive to provide quality programs to support them, so they can focus on our mission,” said Cheryl Viadero, Vice President/Chief Human Resources Officer/Chief Compliance Officer, Community Health Centers, Inc.

Central Florida-based Community Health Centers, Inc. was, recently, announced as a Fall 2020 Best and the Brightest Company to Work For® by National Association for Business Resources (NABR), for the third consecutive year. The 2020 national winning companies were assessed by an independent research firm which reviewed a number of key measures relative to other nationally recognized winners. The Best and Brightest Companies to Work for Winners are not ranked. The Best and Brightest Program honored 151 national winning organizations from across the country out of 1,100 nominations. “On behalf of our team members, leadership team, and the Community Health Centers Board of Directors, we are pleased to accept the award for The Best and Brightest Companies to Work For®. This national competition identifies and honors companies that deliver exceptional human resource practices and an impressive commitment to their team members. We will

Orlando Health South Lake Hospital Names New Hospital President

Tracy Wynne Joins CURIS System Tracy Wynne has joined CURIS System with more than 20 years of experience in the healthcare field.  As director of business development for CURIS, Tracy works with hospitals, long term care, assisted living, and wound care facilities to ensure access to the world’s most advanced hospital-grade disinfection effective against pathogens such as SARS-CoV-2 (COVID-19)  and C. diff.  She is a native Floridian, a member of APIC and volunteers her time with charities such as New Hope for Kids and the National Kidney Foundation of Florida.

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Orlando Health has named Lance Sewell as the new president of Orlando Health South Lake Hospital, promoting him from his role as chief financial officer at Orlando Health South Lake. Sewell joined the hospital in 2006 as director of finance before being promoted to chief financial officer in 2007. During this role, Sewell headed a number of initiatives which include leading the recruitment of primary care physicians as well as specialists to fulfill the needs of the community. Heavily involved in the South Lake and Central Florida communities, Sewell has served with the South Lake Rotary and Leadership Lake County. He is a member of the Healthcare Financial Management Association and the American College of Healthcare Executives. In addition to his professional associations, he has also served as past board chair for the Community Foundation of South Lake, past board chair of the South Lake Chamber of Commerce and a board member for New Beginning of Central Florida. Sewell’s new role at Orlando Health South Lake became effective December 1, 2020.

Ocala Regional Medical Center Named One of The Nation’s 50 Top Cardiovascular Hospitals Ocala Regional Medical Center was recently named as one of the nation’s top performing hospitals by Fortune and IBM® Watson Health®. The annual Fortune/ IBM 50 Top Cardiovascular Hospitals study spotlights leading short-term, acute care, non-federal US hospitals that treat a broad spectrum of cardiology patients. “This achievement is a demonstration of the patient-focused approach adopted by our multi-disciplinary team in the care of patients and families in need of heart surgery,” says Omeni Osian, MD, Cardiothoracic Surgery Medical Director, Ocala Health. Paul Urban, MD, FACC, Medical Director Cardiac Catheterization Laboratory and Chest Pain Center at Ocala Health says, “This award demonstrates our continued commitment to providing the highest quality care for patients with heart attack, heart failure and coronary stenting procedures.”

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Parrish Medical Center Offers the World’s Smallest Pacemaker that can Treat Atrioventricular (AV) Block Parrish Medical Center is one of the first hospitals in the state of Florida to offer Micra™ AV, the world’s smallest pacemaker with atrioventricular (AV) synchrony. This new device, indicated for the treatment of patients with AV block, extends the most advanced pacing technology – at one-tenth the size of a traditional pacemaker – to more patients than ever before. The first procedure was performed by Interventional Cardiologist Rene Celis, MD, on December 19, 2019 and since then 14 have been performed at Parrish Medical Center. Historically, patients with AV block have been treated with traditional dual-chamber pacemakers which are implanted in the upper chest, under the skin below the collar bone, and connected to the heart using thin wires called “leads.” Micra™ AV

for older patients where a short recovery time is essential,” said Dr. Celis. Comparable in size to a large vitamin pill, physicians at Parrish Medical Center have elected to use Medtronic’s Micra AV based on its ability to deliver therapy via a minimally invasive approach. During the implant procedure, the device is inserted through a catheter and implanted directly into the heart with small tines. Because Micra AV does not require leads or a surgical "pocket" under the skin, potential sources of complications related to leads and pockets are eliminated - as are any visible signs of the device. For more information visit parrishhealthcare. com/MicraAV

has several internal atrial sensing algorithms which detect cardiac movement, allowing the device to adjust pacing in the ventricle to coordinate with the atrium, providing “AV synchronous” pacing therapy to patients with AV block. “At Parrish Medical Center we are extremely proud to be the first in Brevard County to offer the latest fully self-contained pacemaker. This minimally invasive technology is a game changer. With nearly the same capabilities as a traditional pacemaker, we are able to offer an alternative that is cosmetically invisible to the patient post-implementation and implanted within 15-30 minutes. The Micra™ AV pacemaker has reduced the rate of complications by approximately 60%, decreasing infection rates and proving to be most ideal

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DECEMBER 2020