Orlando Medical News October 2021 by Orlando Medical News

OCTOBER 2021

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OSHA’s COVID-19 Emergency Temporary Standard:

What Healthcare Employers Need to Know

How do your patients check in? • Mobile Check-in Patients from their Car • Social Distancing 1

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• Text Patients to Come-in

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CONTENTS || FEATURES

PHYSICIAN SPOTLIGHT

Curing Thyroid Nodules Without Surgery: RFA Angela D Mazza, DO

FEATURES 4

COVER OSHA’s COVID-19 Emergency Temporary Standard: What Healthcare Employers Need to Know

PHYSICIAN SPOTLIGHT Curing Thyroid Nodules Without Surgery: RFA Angela D Mazza, DO

EOCC Kicking off the Season of Sharing:

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10 11 12

Vaccine Hesitancy, the Psychology Behind the Confusion Difficult Conversations During a Pandemic Building Design Fighting Covid Telehealth Waivers Are Gone, But Florida Providers

The Future of Healing Technology & Pain Management A Non-Invasive Treatment for Pain Management & Relief

Still Must Mind Virtual Care Risks

Stimulating Mitochondria to produce Adenosine Triphosphate (ATP)

Cannabis and Pulmonary Function Over 20 Years

FDA Approved Laser Treatment with No Significant Risks or Contra Indicators Patented technology

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OSHA’s COVID-19 Emergency Temporary Standard: What Healthcare Employers Need to Know BY MEGAN R. HEIDEN

the facility; and (2) no one with positive screening responses is permitted to enter. This exemption allows many health care providers with office-based practices to apply comprehensive screening protocols in lieu of having to comply with the ETS. The ETS contains a few exclusions specific to different kinds of workplaces. The mere fact that a non-healthcare-provider employee provides first aid assistance in the workplace does not bring that workplace within the jurisdiction of the ETS. Retail pharmacy operations are also exempt. The ETS also provides limited exemptions associated with screening and vaccination requirements:

On June 21, 2021, the Occupational Safety and Health Administration (OSHA) published a set of emergency temporary standards addressing the manner in which healthcare employers must configure their workplaces to protect healthcare workers from occupational exposure to COVID-19. Normally, new OSHA standards undergo a public comment period before implementation. However, when an emergency warrants immediate action, OSHA publishes and begins enforcing the new standards during the public comment period. While OSHA began enforcing all requirements in July, it will formally publish the final rule after the comment period ends several months down the road.

1. "Well-defined" hospital ambulatory care settings are exempt only if (1) all employees are fully vaccinated and (2) people with suspected or confirmed COVID-19 are not permitted to enter. An example of this would be an imaging center that's part of the hospital but not its inpatient unit.

What made OSHA act now, over a year into the pandemic? Shortly after taking office in January, President Biden signed an executive order directing OSHA and several other federal agencies to take steps to protect healthcare workers on the front lines of the pandemic from the risks associated with COVID-19.

2. Home healthcare settings are exempt if (1) all employees are fully vaccinated, (2) all nonemployees are screened prior to entry and (3) people with suspected or confirmed COVID-19 are not present.

Why do healthcare employers need to pay attention?

3. Healthcare support services located separately from the patient care location are also exempt, such as an off-site billing or IT department.

The new emergency temporary standard (ETS) provides set requirements, many of which incorporate CDC guidance. This set of national standards makes it more difficult for covered employers to change workplace practices and make location-specific adjustments as the pandemic evolves. The ETS also creates regulatory consequences for an employer's failure to ensure all employees follow PPE and isolation requirements. In addition, employers covered by the ETS must provide employees with paid leave for time required to undergo vaccination, recover from vaccine side effects, and isolate because of COVID-19 infection or exposure. These provisions will likely be challenged in federal district courts, but, in the meantime, employers must comply. Finally, the ETS contains robust anti-retaliation provisions that could create new avenues of liability for employers.

4. Telehealth services performed outside of a setting where direct patient care occurs are also exempt. Note: A physician conducting a telehealth visit from an empty exam room or their on-site office likely would not be enough to exempt, compared to conducting the visit off site, such as from their home. The ETS refers often to “known” or “suspected” cases of COVID-19. A "known" case occurs when someone has tested positive or been diagnosed by a healthcare provider. The ETS does not define a “suspected” case, but it provides a list of potential symptoms:

• Fever • Chills • Cough

Who is affected?

• Shortness of breath or difficulty breathing

Subject to a number of exceptions, the new standard applies to all settings where any employee provides healthcare services or healthcare support services. This is true regardless of the type of services (COVID-related or not), such as dental work, hospice care, home health and patient transport, among others. Healthcare support services include anything adjacent to patient care like food services, housekeeping, reprocessing, medical waste handling and others. The biggest exemption applies to non-hospital ambulatory health care settings in which (1) every individual is screened for possible COVID-19 infection before entering

• Fatigue • Muscle or body aches • New loss of taste or smell • Sore throat • Congestion or runny nose • Nausea or vomiting • Diarrhea The best practice is to use the above symptoms in the screening and to treat any individual displaying any of

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those symptoms as a "suspected" COVID-19 case.

Examining some "fine print" There are a few noteworthy caveats and clarifications relating to the ETS. Some may raise their eyebrows at provisions requiring "all employees to be fully vaccinated" (i.e., occupational mandatory vaccination policies). For a long time, many believed an employer could not require worker vaccination when the three available vaccines were only approved for emergency use authorization by the FDA. However, the federal Equal Employment Opportunity Commission (EEOC) released guidance clarifying that an employer can require employees to receive one of the the vaccines, but relevant exemptions under the Americans with Disabilities Act (ADA) or religious anti-discrimination laws still apply. The Pfizer vaccine is now fully approved by the FDA, and the federal government is strongly pushing for employer-backed universal vaccination. A landmark court case in Texas set precedent when dozens of hospital employees in Houston sued after resigning or being terminated for refusing to comply with the hospital's mandatory vaccination policy. A federal district court judge ultimately dismissed the case, noting that while employees absolutely have a right to refuse vaccination, they can exercise that right by seeking employment elsewhere. If an employer claims an exemption on grounds that it has a fully vaccinated workforce, it must have written policies on how to determine employees' vaccination status. By law, an employer can require its employees to show proof of vaccination. While the ADA regulates an employer’s ability to ask employees medical questions, recent guidance indicates that simply asking employees whether or not they are vaccinated is not considered an inquiry into their medical conditions. Employers should be careful, however — any follow-up questions beyond the initial vaccination status (such as why the employee is not vaccinated) could implicate the ADA. An employer can also qualify for a fully vaccinated workforce exemption if the employer can accommodate an unvaccinated employee in a manner that totally protects him or her from exposure to COVID-19. For example, the employer could allow the employee to work from home or in a separate, isolated environment. Other unique scenarios include when a healthcare setting is embedded in a non-healthcare setting, such as a medical clinic in a factory or a walk-in clinic located in a retail store like CVS or Walgreens. In those cases, the OSHA standard applies only to the healthcare setting, not the whole factory or the rest of the store. Similarly, where emergency responders or other licensed healthcare providers enter a non-healthcare setting to provide services, the OSHA standard only applies to the healthcare services being provided. For example, EMTs treating an unresponsive person in an office building would need to wear the correct PPE and otherwise comply with the portions of the ETS specific to their persons and their equipment but their presence would not extend the

COVID-19 Infection Prevention and Control Recommendations. Employers are also "encouraged to use telehealth when available and appropriate."

Personal Protective Equipment (PPE) Employers must provide and ensure that employees wear face masks while working and that they change face masks daily; whenever soiled or damaged; or more frequently, if needed. Moreover, employers must provide and ensure the use of respirators and other PPE (including gloves, eye protection, and isolation gowns or protective clothing) for employees exposed to people with suspected or confirmed COVID-19. Respirators and PPE must also be provided during all aerosol-generating procedures. When these procedures are performed on suspected or confirmed COVID-19 patients:

• Limit the number of employees present to only those essential OSHA ETS obligations to that entire workplace. Finally, in "well-defined" areas where there is no reasonable expectation that a person with COVID-19 will be present, certain of the standards do not apply to fully vaccinated employees.

This assessment cannot be performed solely at the executive level. Input from the "boots on the ground" is critical, and employers should be able to show that a reasonable sample of employees participated in the risk assessment. The specifics will look different depending on the size of each organization. After completing the hazard assessment, a covered employer must create the COVID-19 plan to (1) address hazards identified and (2) include policies and procedures to:

How to comply with the new emergency temporary standard Employers covered under the new OSHA standard must develop and implement a COVID-19 plan for their workplace(s). According to the regulations, employers with fewer than 10 employees are technically not required to write down the COVID-19 plan. However, we recommend keeping a written plan regardless of workplace size. If an occupational transmission occurs and an employee reports it, OSHA will survey the workplace and ask the employer for extensive details on the COVID plan. If the plan is not written down anywhere, it will be difficult to provide that in a persuasive way. Employers must also designate COVID safety coordinators to implement and monitor the plan. One suggestion is to select two employees, one from the administrative side and one from the clinical side, for a balanced approach.

• Ensure procedure is performed in an airborne infection isolation room (AIIR), if available • After the procedure, clean and disinfect surfaces and equipment in the room or area Finally, employers may provide respirators in lieu of face masks, and they must permit employees, who so request, to wear their own respirators in lieu of a face mask.

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• Minimize the risk of transmission of COVID-19 • Effectively communicate and coordinate with other employers who share the same physical location (e.g., an operating room with a nurse employed by a hospital, an anesthesiologist employed by a private practice and a surgeon employed by a separate private practice). • Protect employees whose work involves entering locations not subject to the OSHA regulations (e.g., private homes), including allowing employees to leave those premises if inadequately protected.

Patient screening and management

Workplace-specific hazard assessment

The ETS requires employers with direct patient care settings to:

The first step toward creating the plan is conducting a workplace-specific hazard assessment. It should address questions such as:

TBI Traumatic Brain Injury TBI

Yes, Yes, we treat we treat that. that.

Traumatic Brain Injury ABI Anoxic Brain Injury ABI Anoxic Stroke Brain Injury Stroke Spinal Cord Injury

Spinal Cord Injury Multiple Trauma Multiple Trauma Neurological Disorders Neurological Disorders Complex Orthopedic Complex Orthopedic Joint Replacements Joint Replacements Amputations Amputations

• Limit and monitor points of entry; • Screen and triage all non-employees who enter (including patients, visitors, delivery people, etc.);

• Who is coming in and out of our workplace? • How can employees properly distance themselves from each other and patients?

• Implement applicable patient management strategies in keeping with the CDC's

• Where are the highest risk exposure points? 5

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OSHA’S COVID-19

tests positive, he or she must remain out of work until he or she meets the criteria to return safely. Suspected COVID-positive employees must remain out until (1) meeting return-to-work criteria or (2) receiving a negative PCR test at the employer's expense. An employer may require remote work, if suitable, for these employees.

Other miscellaneous workplace requirements In addition to the above, the new OSHA standards require that employers ensure physical distancing of at least six feet where feasible. Where six feet is not feasible, employees should maintain as far of a distance as possible. Outside of direct patient care areas, if an employee cannot be separated from all others by at least six feet, solid barriers must be installed to block potential face-to-face transmission pathways. Finally, employers must provide at least 60% alcohol-based hand rub and/or readily accessible handwashing stations.

Exposure notification If an employer is notified that a COVID-positive individual entered the workplace, within 24 hours, the employer must notify:

• Any employee who was not wearing a respirator and was in close contact with the COVID-positive employee • All other employees who were not wearing respirators and were in the same area (floor, hospital unit, etc.) as the positive employee

Employee screening, notification and removal from workplace

• Other employers whose employees were not wearing respirators and had close contact with or were within same area of the positive employee during the transmission period

Before each work day and each shift employees must be screened for symptoms of COVID-19 before beginning work. The screening can take the form of self-monitoring or in-person screening. If the employer requires a test, it must not be at the employee's expense. If there is no free community option available, the employer must cover the cost. The employer’s policy must require an employee to notify the employer if he or she:

That said, these requirements do not apply in an environment where potential COVID-19 patients are receiving services as a matter of course (e.g., a COVID-19 ICU or triaging in the emergency room). The notice must not include the positive employee's name, contact information or occupation, but must include the nature of the exposure (close contact vs. present in the workplace) and the date(s) of exposure. Employers should consider preparing a form of notice to maintain consistency. The fact that the employee told others that he or she has COVID-19 does not create any exception that would allow the employer to include additional details in the notification.

• Tests positive for COVID-19 • Is told that his or her healthcare provider suspects a COVID-19 infection • Has new loss of taste or smell without other explanation • Has both fever and new unexplained cough associated with shortness of breath Anyone who tests positive or meets other screening criteria must be isolated immediately. If an employee

Medical removal from the workplace If an employer must notify an employee of their close contact with a known COVID-19 case, the employer must immediately remove that employee from the workplace until either (1) 14 days elapse; or (2) 7 days elapse, if the employee tests negative at least 5 days after exposure. However, an employer is not required to remove an employee based on close contact if the employee remains

asymptomatic and has been fully vaccinated, or if that employee had COVID-19 and recovered within the past 3 months. The employer may require that employee to work remotely or in isolation, if suitable. The OSHA standards also mandate medical removal protection benefits, which is essentially paid sick leave for employees who can't come to work due to COVID-19 infection. If a covered employer can find remote work for the employee in question to perform, the employer must continue paying the employee just the same as if the employee was normally reporting to work in-person. If the employee cannot come to work due to an exposure, but the employee refuses to shorten the isolation period by taking a COVID test, the employer is not required to extend those benefits (unless there exists some reason protected under other laws). Once that employee returns to work, the employer must reinstate him or her completely, as if he or she had never been out in the first place. Employers with more than 10 employees must provide regular benefits and pay up to $1400 per week until the employee meets return-to-work criteria. Employers with more than 500 employees must pay up to $1400 per week, but may reduce that to two-thirds of the employee's regular pay beginning in week 3 with a $200 per day cap. If the excluded employee receives monies from other public or private sources as a result of the employee’s removal from the workplace (like short-term disability insurance benefits, for example), the employer’s wage obligation is reduced by that amount.

Vaccinations and other miscellaneous requirements Under the ETS, employers must support vaccination for employees by providing reasonable time and paid leave for vaccination and work missed due to vaccine side effects. The new standard includes specific, detailed requirements for employee training, employer record-keeping and OSHA reporting requirements.

Anti-retaliation provisions The ETS prohibits employers from retaliating against an employee for (1) taking paid leave under the ETS; or (2) engaging in activity to insist upon the employer’s compliance with the ETS. The ETS requires employers to notify employees of their right to protections under the ETS, and also that the ETS prohibits the employer to discharge, discriminate against, or retaliate against any employee for exercising rights and protections under the ETS. OSHA further reminds employers that they may not discriminate or retaliate against employees because of actions required under the ETS or for filing health and safety complaints with OSHA.

Conclusion The OSHA Emergency Temporary Standard for health care employers creates specific workplace safety obligations, including extensive screening and isolation requirements, at a time when many health care employers are struggling to maintain adequate staffing during a major surge of COVID-19 cases. President Biden recently signed additional executive orders instructing OSHA to issue additional regulations designed to protect workers in other industries. Employers in health care and other industries should continue to watch closely for changes in guidance and enforcement related to occupational safety, mandatory vaccination, disability accommodation, and other related state and federal laws. Meg Heiden is a shareholder at Smith Hulsey & Busey, a full-service business law firm in Jacksonville, Florida, and one of the leading healthcare firms in the state. She focuses her practice on complex healthcare and employment-related matters, and helps clients avoid or respond to litigation arising from their transactional and healthcare regulatory obligations. Contact her at mheiden@smithhulsey.com and learn more at www.smithhulsey.com

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PHYSICIAN || SPOTLIGHT SPONSORED BY

Curing Thyroid Nodules Without Surgery: RFA Angela D Mazza, DO

Angela D. Mazza, DO, FAAMFM, ECNU, CDE is double board-certified in Endocrinology, Diabetes and Metabolism and Internal Medicine.

need for surgery for certain nodules. Thyroid nodules are extremely common. About one in three persons will develop some sort of abnormality within their thyroid in their lifetime. Thyroid nodules are masses within the thyroid that are usually quite harmless and require no intervention other than possibly following with routine thyroid ultrasounds. Thyroid nodules can be cancerous, and, at present, the only option is surgical removal of part or all of the thyroid depending upon the mass size. However, some nodules can continue to grow and cause compressive or cosmetic issues, or some nodules become overactive. This is where radiofrequency ablation (RFA) is an excellent non-surgical option. When it comes to thyroid nodules, patients often ask, regarding surgery, “why can’t the surgeon just go in and take out the nodule only?” leaving the rest of the healthy thyroid tissue intact. Although that thought process makes sense, trying to accomplish this type of operation would likely lead to complications like bleeding throughout and after surgery. This complicated procedure would likely lead to more issues than it is worth. Therefore, removal of the entire lobe of the thyroid or the whole of the thyroid is usually performed. RFA is a minimally invasive technique that has been used for years as a common treatment for small tumors in tissues such as the liver, lung, kidney, and prostate. Its use has also been extended effectively in the treatment

She completed her fellowship in Anti-Aging and Metabolic and Functional Medicine through the American Academy of Anti-Aging Medicine (A4M). She is also certified by the American Association of Clinical Endocrinologists (AACE) in neck ultrasounds and diagnostic biopsies, as well as being certified by the American Association of Diabetes Educators (AADE) in diabetes education. Highly regarded for her individualized approach to patient care, Dr. Mazza empowers each person to achieve their unique goals by providing education, lifestyle management and support. Mazza’s broad medical background includes significant research in both basic and clinical realms of endocrinology. She has served as the principal investigator and sub-investigator on multiple, large-scale diabetes therapy and device trials. This expertise led to numerous publications and national and international conference presentations. Originally from Wilmington, Del., Mazza earned a double-major in chemistry and biology from West Chester University of Pennsylvania, where she graduated Magna cum Laude. She attended medical school at Nova Southeastern University College of Osteopathic Medicine in Fort Lauderdale, where she graduated as a member of Psi Sigma Alpha, the National Osteopathic Scholastic Honor Society. She completed her internship and residency in Internal Medicine at Mercy Catholic Medical Center in Darby, PA before pursuing fellowship training in Endocrinology, Diabetes and Metabolism at Saint Louis University in Saint Louis, MO. Mazza is the founder of Metabolic Center for Wellness in Oviedo, where the goal is to provide integrative endocrinology care for optimal hormonal balance. In our most recent edition of “In Other Words,” Dr. Mazza shares an innovative technique for curing thyroid nodules without the need for surgery.

of heart disease and varicose veins. RFA involves the introduction of alternating electric current into a tissue by an electrode. Ionic agitation causes ionic friction, which, in turn, results in heat production. This frictional heat that is generated in the vicinity of the electrode causes immediate tissue coagulation; however, more distant tissue is ablated via conductive heat more slowly. In 2002, RFA was first used for the treatment of enlarged benign thyroid nodules in South Korea. Since that time, RFA has been studied internationally and has proven to be a safe and effective therapy for benign thyroid nodules as well as autonomously, or “toxic” thyroid nodules. The great success of RFA around the world led to the approval of RFA in the United States for this purpose by the FDA in late 2018. There are still very few providers in the United States who offer this treatment modality. RFA for thyroid nodules involves directing the energy of the electrode precisely into the thyroid nodule using ultrasound guidance. This allows targeting the nodule at hand and minimizing any injury to healthy thyroid tissue. RFA is performed with local anesthetic to the skin and thyroid capsule without general anesthesia that would be

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If you could offer a treatment option that would help your patient avoid unneeded surgery, would you still recommend surgery as the best course of action? Or, furthermore, would your patient still want to be put through surgery if not necessary? Now, there is a treatment modality for thyroid nodules that is effective and obviates the

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EAST ORLANDO CHAMBER OF COMMERCE

EOCC || MEDICAL CITY

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CALENDAR:

Kicking off the Season of Sharing: The Opportunities are Endless

Coffee Club East OCTOBER 7 | 8:30 – 9:30 AM Bonefish Grill Waterford Lakes. “Doing Business with GOAA” featuring George Morning FREE for EOCC members | $10 Nonmembers | Discounts for UCF, Valencia & Full Sail students

Misters & Sisters Great Lunch Adventures: Panda Express University

BY DOROTHY HARDEE, EAST ORLANDO CHAMBER DIRECTOR OF OPERATIONS

OCTOBER 11 | 12:30 PM

“We make a living by what we get, but we make a life by what we give.”

Panda Express, 11871 University Blvd. Ste. 100, Orlando, FL Food & Beverage is the responsibility of each attendee

Testimonial Tuesday

– Winston Churchill

OCTOBER 12 | 9:00 AM – 12:30 PM

In January 2020 there were more than 580,000 people experiencing homelessness in America. According to the National Alliance to End Homelessness, 70 percent of those were individuals and the rest were people living in families with children. Special attention has been given to this population by policymakers and practitioners, especially for the most vulnerable (children within families and unaccompanied youth under age 25). Sadly COVID-19 contributed to a 2 percent uptick in the numbers marking the fourth straight year of incremental population growth among homeless. In Florida there were nearly 28,000 people homeless on any given night in 2020. For every 10,000 people 12.8 were homeless. In the Tri-county area (Orange, Osceola & Seminole) 2,007 are homeless on a given night, effecting 9.0 out of every 10,000 people in the general population. The Coalition for the Homeless of Central Florida reports the main contributors as:

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Chill Pop Lounge Ribbon Cutting After Hours OCTOBER 14 | 5:00 – 7:00 PM Chill Pop Lounge Avalon Lake Drive | RSVP at EOCC.org

Chamber Luncheon: “Homelessness: It’s Complicated” Panel Discussion OCTOBER 20 | 11:30 AM – 1:00 PM Bonefish Grill Waterford Lakes. Featuring Eric Gray, Martha Are, Frank Wells, Babette Hankey & Will Jefferson $40 for EOCC members | $50 Nonmembers

Coffee Club Nona

• Loss of income, low wages, or unemployment

OCTOBER 21 | 8:30 – 9:30 AM Sam’s Club Lake Nona “Smart About Credit” with Fanny Nater, Nater Law Firm FREE for EOCC members | $10 Nonmembers | Discounts for UCF, Valencia & Full Sail students

• Lack of affordable housing (citing the National Low Income Housing Coalition Report)

EOCC 75th Anniversary Commemorative Golf Tournament

• Aging out of foster care

• Domestic violence (citing NLIHCR) • Substance abuse or mental illness In addition to struggling with shelter, many also suffer a variety of health and psychological issues which only progress in severity as their situation continues including lack of attention. These include poor physical health, nutritional deficiencies, sleep deprivation, mental illness, drug dependency, physician and sexual assault, premature death, increased chance of incarceration and more. How does this impact our community? The Central Florida Commission on Homelessness issued their Economic Impact Report stating, “the average cost per day for a chronically homeless individual living on the streets, including incarceration and hospital stays is $84.93 per day – over $30,000 per year.” For those staying at the Coalition while awaiting housing, the cost is about $26.59 per day or just over $9,700 per year. In addition, our community still has misconceptions about the homeless. The Coalition for the Homeless of Central Florida published an article a decade ago addressing the top ten myths paired with facts. The information was eye opening and sadly continues to plaque our community. As part of their mission and vision for the region, The East Orlando Chamber is working to improve the quality of lives, creating a positive business climate and sense of unity throughout East Orange County. Homelessness is a complicated issue with no quick fix, but something that can be reduced by understanding the facts, resources and modeling best practices from other areas. Eric Gray, Executive Director of the Christian Services Center Central Florida and incoming EOCC Board Chair, will lead a discussion with a panel of experts exploring: why we have a problem; common misconceptions; current state of care for adults and children experiencing

OCTOBER 22, | 7:30 AM Rio Pinar Country Club | $125 Individual | $400 Foursome | $500 Foursome & Hole Sign Check out sponsorship and added opportunities available at eocc.org

CliftonStrengths Workshop with Kim Griffith (Looking Glass) NOVEMBER 2 | 8:30 AM – 12:00 PM Special invitation for Chamber Members to attend a Free CliftonStrengths workshop. A completed CliftonStrengths assessment is required to attend. East Orlando Chamber office

W.I.S.E. Women’s Luncheon: Women in Nonprofit: Focus on the Foundation Sponsored by Orlando Health NOVEMBER 3 | 11:30 AM – 1:00 PM The Celeste Hotel Orlando Featuring Graciela Noriega Jacoby; Lainie Fox-Ackerman; Linda Landman Gonzalez; Meghan Curren; Jodie Hardman & Min Sun Kim $40 for EOCC members | $50 Nonmembers

Visit EOCC.org for a complete listing of October events

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it and how we can end it in our lifetime. Joining Eric will be Martha Are, CEO of Homeless Services Network; Frank Wells, President & Chief Impact Officer with Brightway Community Trust; Babette Hankey, CEO of Aspire Health Partners and Will Jefferson, Community Manager with Valencia College Peace and Justice Institute. Our goal is to raise awareness to the need and how we can each be a catalyst for change through our time, talent, and treasures just in time for the Season of Sharing. Continuing the theme, we will launch November with our W.I.S.E. (Women in Successful Endeavors) featuring Women in Nonprofit: Focus on Foundations, sponsored by Orlando Health, November 3rd at The Celeste Hotel Orlando. Graciela Noriega Jacoby, COO with Heart of Florida United Way will lead the discussion with a dynamic group of women leading nonprofit foundations. Joining her will be Lainie Fox-Ackerman (Orlando Health); Linda Landman Gonzalez (Orlando Magic Youth Foundation); Meghan Curren (AdventHealth); Jodie Hardman (Bank of America Foundation) and Min Sun Kim (Edyth Bush Institute). On November 10th join us for our annual Local Charities Luncheon “Lights, Camera, Action” at the Holiday Inn East UCF, sponsored by Orlando Health and featuring Bar-

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Vaccine Hesitancy, the Psychology Behind the Confusion • A sense of individual vs. collective responsibility

BY MARY-CATHERINE SEGOTA, PSY.D

• Belief that getting vaccinated is giving up a personal right and will lead to greater loss

Today 56.3 percent of adults in Florida have received the full COVID vaccine, and 66 percent have received one dose (OurWorldInData.org).

• Associated political influences • Confirmation bias Confirmation Bias (Wason 1960), an important concept in understanding how people consume information, states that your existing opinion changes how you perceive information. It is an unconscious process that readily occurs when looking for and consuming information. Even if exposed to information that disagrees with your opinion, you might not take it in, misremember it, or find a reason to ignore it. You’ll keep searching until the information you see is what you want to see. Regarding COVID, if you have strong opinions about the virus or the vaccine, and then you go looking for evidence that supports them, you’ll think you see it – even if it means misinterpreting or distorting the information you are consuming. You will also have a more challenging time absorbing evidence that points in the opposite direction. Due to the mechanics of social media, individuals are bombarded with posts that continue to reinforce their belief system. Historical research has identified several common psychological factors in individuals who experience vaccine hesitancy (Murphy et al., 2021). These individuals are more likely to have decreased cognitive reflections, the ability to suppress an incorrect, intuitive answer and come to a more deliberate, correct answer. These individuals also tend to experience reduced altruism, a decrease in the concern for the well-being of others. Additionally, they are more likely to have an internal locus of control, meaning the ability to take action, be effective, influence your own life, and assume responsibility for your behaviors, rather than seeing external variables influencing life. They also tend to endorse an increased amount of conspiracy thinking. It is important to understand the difference between vaccine hesitancy and vaccine opposition to influence change. Realize that thinking based on strong emotions and morals are difficult to change. Those opposed to vaccination are firmly and emotionally grounded in their belief system are less likely to be open to possibilities. Those that are hesitant are apprehensive but have not yet permanently closed themselves off to the idea. You may be able to affect the most change with this population. Reasons that some people are hesitant to obtain the vaccine include:

Currently, more females than males are vaccinated. The age group of 65-74 represents the highest percentage of vaccinated. The average daily death rate is 376.4, and 51,889 individuals have died in Florida due to COVID. Given the spread rate of the disease, the mortality rate, and the length of time since the pandemic began, the vaccination rate is lower than is needed. Vaccine hesitancy (the delay or refusal of vaccines despite the availability, WHO 2015) is not new. Previous research helps identify the critical factors to understand, to better speak with your patients and assist them in their decision-making about vaccination. There is a lot of misinformation spread through social media, websites, and anecdotal tales, which leads to confusion about the COVID vaccine. It is essential to know what the misinformation is to address it when you hear it from your patients. Some examples of highly spread misinformation include:

• Vaccine can cause cancer, infertility, or cause you to sprout a third arm • Vaccination will cause a stronger response to the virus if you do contract it • Vaccination causes the virus to mutate • You can die from the vaccine • Obtaining natural immunity is less dangerous than vaccinating • Vaccines have tracking devices • Vaccines have substances in them that will make you magnetic • Belief that social distancing/isolation protocols is all that is required • Belief in the strength of herd immunity • Feeling the risks of contracting the virus or the risks of the virus itself are exaggerated • Belief that they have already had the disease (not diagnosed) and can’t get it again

• Feeling unsure about the risks and benefits and taking a “wait and see” approach

• Belief in permanent immunity after contracting the disease

• Not feeling they have enough information to make a decision

The average person has difficulty discerning the credibility of information they see and read on the internet. The power of social media and repeated messaging from influencers, politicians, and other people in a perceived position of power significantly affects attitudes toward vaccination. Betsch C et al. (2010) found that exposure to as little as 5–10 minutes of negative and inaccurate information about vaccines increases the risk perception associated with vaccination. Other factors influencing people’s perception of vaccination include:

• Feeling like vaccine will flare up or worsen underlying medical conditions • Feeling like there are risks associated with the vaccine • Fear of potential side effects • Fear of the “unknown” long term effects of the vaccine • Fear of needles or the lack of time to go get vaccinated

• General distrust in the government, scientists, or healthcare professionals

• Worry about the cost of the vaccine

• Distrust in the safety of the vaccine and the process to create the vaccine

Based on this new understanding of the psychological factors and beliefs that are at play, what approach should healthcare providers take to overcome vaccine hesitancy

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best? First, have a conversation, don’t lecture. Provide emotional support and a sense of understanding of their fears, anger, and other negative emotions. Be patient in listening to their concerns. Ask a lot of questions and find out what they would need to know to consider the vaccine. Don’t blame, and try to understand their mistrust. Try sharing your experience; sometimes, relatable events may sway their thinking. Take the emotion out of it - when you feel passionate about their decision, it could increase their defensiveness, particularly when they are leaning opposite your stance. Other techniques include:

• Combat misinformation by providing information from a reputable source • Emphasize safety, but also talk about the known risks – muscle soreness, fatigue, fever, and rare allergic reactions • Align your messaging with a trusted source within their community • Make sure information is in their language of preference • Talk about religion when it is a factor – “God created the knowledge for the scientists to develop the vaccine.” “The Pope has said it is Catholics moral obligation to be vaccinated.” • Offer to help – it may be a logistical issue: How CONTINUED P.13

Difficult Conversations During a Pandemic

CONTINUED ... PHYSICIAN || SPOTLIGHT Angela D Mazza, DO

BY ELIZABETH GALFO, MD

As providers, we continuously communicate with our patients and families.

required for surgery. Thyroid tissue itself does not have nerves. Any procedural discomfort is minimal, and any post-procedure scarring or bleeding is almost negligible. RFA also minimizes any risk of permanent damage to the nerves of the vocal cords or to the parathyroid glands that may accompany thyroid surgery. RFA is extremely effective, and results can be noted quite quickly. Depending on the nodule, most nodules can be decreased in size from 60-90 percent within one year. Clinical studies have demonstrated that benign, non-functioning thyroid nodules showed approximately 50-80 percent by six months and one year follow-up of about 90 percent. As far as overactive thyroid nodules, RFA decreased size about 5070 percent at six months and brought thyroid hormone levels back to normal in most patients. To be considered for RFA, a person must have biopsy-proven benign status. From that point, the thyroid nodule should be creating some sort of issue for the patient – whether it is cosmetically bothersome, causing compressive symptoms, or rapidly growing. Other potential candidates include persons who prefer not to or cannot undergo surgery or who have a toxic nodule. Persons who should not undergo RFA include patients with severe heart disease, patients on anticoagulation that cannot temporarily be held, and patients with a pacemaker and/ or defibrillator. Pregnant patients also should not have RFA. As with any medical procedure, there is the potential for complications. Although complications with RFA are very rare, they may include bruising or soreness, skin burn where the probe was inserted, temporary hoarseness. There is also the possibility of failing to obtain the desired results and requiring additional treatment, and, even more rarely, the possible need for thyroid hormone therapy. As an integrative endocrinologist, one of my goals is to help my patients improve and maintain proper thyroid function. The thyroid is not a disposable gland. It is responsible for thyroid hormones that have receptors on the majority of tissues of our body. It is responsible for metabolism on all levels as well as playing a crucial role in gut regulation, cardiac and pulmonary function, skin and hair integrity, as well as mood effects, just to name a few. Even with the best thyroid hormone replacement, it is incredibly challenging to regain optimal thyroid function post-surgery. I appreciate my surgical colleagues on all levels, but they will also agree they want the best outcomes for their patients and that surgery may not always be the best option. RFA is a step in the progress of thyroid health. RFA has become an invaluable asset to treat thyroid nodules and preserve thyroid function, as well as avoid possible complications associated with thyroid surgery.

We listen to their medical histories, ask them to open wide, say aaahhh, take deep breaths, lie back to palpate the abdomen, and relax to elicit the patellar tendon response. We share the exam findings, summarize test results and recommend a treatment plan. That’s a lot to fit into a 15 minute established patient slot. When everything goes well, we can feel like really effective communicators. As a Hospice and Palliative Medicine physician, I have found that sharing bad or unexpected news and end-oflife discussions with patients and their families is more challenging. It doesn’t usually fit very well into a regular workday, with the phone showing a queue of nurse case managers in their patients’ homes needing orders and multiple text messages demanding urgent responses. While some of our hospice patients have suffered catastrophic illnesses or injuries, the vast majority are at the end of chronic illnesses they have managed for years. If anything, the multitude of incredible medical advances has made end-of-life conversations more complex. Many of our patients with heart disease have repeatedly enjoyed near-miraculous recoveries from the throes of death, thanks to new medications, procedures, and devices. Extraordinary advances in cancer treatments and interventions have transformed what used to be considered terminal illnesses into chronic diseases today. How do we know for sure this most recent relapse isn’t reversible, until every available treatment and intervention has been tried? When do we switch gears and focus on comfort? In the hierarchy of conversation complexity, however, COVID-19 is king. An 80-year-old woman was healthy, caring for her husband with dementia. Their son visited last month and unfortunately tested positive for COVID-19. None of the family members have been vaccinated. Two years ago, this scenario would not have meant much to me or my teammates. Today, it evokes a profound visceral response in every one of us. Because in this scenario, as in so many others today, both parents were hospitalized with pneumonia and hypoxia. Although they survived the acute illness, they were too weak to return home. So they were transferred to a skilled rehabilitation facility for physical therapy in hopes of giving them more time to recover and become stronger. However, over the ensuing weeks, both continued to decline to the point that now, they are bedbound, beginning to develop decubiti, and have almost completely stopped eating, despite all efforts to turn things around. Due to the recent Delta strain surge, their son has not been allowed to visit them in person and is confused by the different reports during phone conversations with various staff members on different shifts. Due to their extremely poor prognosis, their attending physician has consulted the Hospice Team to meet with them to determine hospice eligibility and discuss their goals of care. COVID-19 creates an illness for which there is still a dearth of evidence-based practice, and my world has become a No Hubris Zone. During increasingly common scenarios such as this, donning and doffing for every patient encounter is becoming more automatic. However, it is still a challenge to sound compassionate and supportive through an N95, face shield, and goggles, while sporting the whole PPE ensemble of bouffant, gown, gloves, and shoe covers. I still sometimes struggle to find the right words, deal with the emotional reaction, fraught with temptations to assign blame, frustration at the lack of knowledge, and impotence to make a consistent difference in survival outcomes for these patients dealing with

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the terminal complications of this infectious disease. In the midst of the daily shifting statistics, alert levels, and protocols in what feels like accelerating entropy, one over-arching theme seems to repeatedly emerge during each unique patient and family encounter when discussing serious news – Remember to Be.

1. Be intentional: dedicate this moment to shut out distraction and focus on this patient/family before me, right now. 2. Be curious: encourage them to express what they understand. 3. Be empathic: seek to better understand their fears, desires, and needs. 4. Be respectful: ask permission to share what I understand. 5. Be clear: deliver serious news in a brief sentence, in their language. 6. Be silent: giving them a chance to process this information that may have massive implications for their lives. 7. Be observant: watch for and acknowledge their goals and emotional response. 8. Be an advocate: come alongside, to be there with them in this situation. 9. Be proactive: sum everything up and begin to look at next steps. 10. Be committed: let them know I will walk with them through the storm ahead. These are some of the medical lessons I am re-learning during this COVID-19 Pandemic. If there is any silver lining surrounding this pitch-black cloud, it consists of an opportunity for growth that may help me to also become a better wife, mother, sister, friend, and teammate. So to this year’s list of task-oriented professional goals, I am adding two that focus on simply Being:

• Be Present. • Be Kind. Elizabeth Galfo, MD, FACP, FAAHPM, HMDC, hospice and palliative care medicine physician at St. Francis Reflections Lifestage Care, is a graduate of University of California in Davis, California and earned her medical degree from Oral Roberts School of Medicine in Tulsa, Oklahoma by receiving a full fouryear Air Force Scholarship and ranked third in her class. She completed her internal medicine residency at Oral Roberts School of Medicine at City of Faith Hospital located in Tulsa, Oklahoma. In addition, Dr. Galfo has memberships in the following; American College of Physicians, American Academy of Hospice and Palliative Medicine, National Hospice and Palliative Organization, Alpha Omega Alpha Society and Phi Kappa Phi Society. Visit reflectionslsc.org

Building Design Fighting Covid BY KEITH THOMAS

Is SARS-CoV-2 Virus in your air now? What can you do? Are you “stressed out” physically and mentally trying to determine your next move in navigating this ‘new normal’ of Covid transmission to protect your health? This Covid-19 pathogen enemy is NOT an isolated attack of Isis or Taliban, but WORSE! Vaccines, masks and social distancing protocols are not providing ‘bullet-proof’ protection to date. The Covid-19 virus is “unseen” in the air we breathe, and it’s surrounding us on all sides so we don’t know when or where we could be attacked. It is indiscriminate, affecting young and old people, rich and poor, all races and religions, including urban and suburban residents.

What do we know about the Virus and possible means of controlling it? The CDC published the following on their website: The principal mode by which people are infected with SARS-CoV-2 (the virus that causes COVID-19) is through exposure to respiratory fluids carrying infectious virus. Once infectious droplets and particles are exhaled, they move outward from the source. The risk for infection decreases with increasing distance from the source (6+ feet) and increasing time after exhalation. Per published reports, factors that increase the risk of SARS-CoV-2 infection under these circumstances include:

• Enclosed spaces with inadequate ventilation or air handling within which the • concentration of exhaled respiratory fluids, especially very fine droplets and aerosol particles, can build-up in the air space. • Increased exhalation of respiratory fluids if the infectious person is engaged in physical exertion or raises their voice (e.g., exercising, shouting, singing). • Prolonged exposure to these conditions, typically more than 15 minutes.

ings in the fight of infectious disease we can minimize damage to our health and be more productive. Covid is an environmental health issue that needs more than vaccines, PPE and social distancing to reduce its harm. An integrated approach is needed more than ever to treat this menace of disease that is not only creating a physical health pandemic, but has caused social, mental and emotional damage to our families and culture. The CDC and American Institute of Architects (AIA) published a graphic in 2020 about Covid transmission effectiveness. With all the emphasis in our world about using PPE, the CDC and AIA recognize that this is the least effective means of controlling transmission. A more effective solution is engaging buildings with “engineering controls and physical design barriers.” The most effective means of controlling transmission is ‘social distancing’, which is not fully practical or sustainable. We need human interaction to maintain our mental and emotional stability.

predominant message from many leaders is focused on vaccines and PPE. Perhaps we need to step back and engage other tools (engineered air) in the fight. Transforming our interiors from “pathogen polluted” to “healthy and safe” are possible.

Why are we not engaging our buildings in the fight?

Keith W. Thomas AIA, LEED AP, CEEE, Fitwel Amb. is the CEO of inpura, a healthy building consulting firm specializing in measuring and purifying indoor air quality in the Southeast U.S. His 35+ years of architectural practice and healthy living initiatives offer his clients a global perspective to solving environmental design and health issues in commercial and residential buildings. Visit https://www.inpuradesign.com/ Reach out to him at keitht@ inpuradesign.com

Healthier Air equals a Healthier You! Architects and engineers are working diligently to resolve Covid issues in their designs and engineering cleaner air through the use of ionization and UV technologies. Engage qualified professionals that offer solutions in your fight for clean air and reduce the opportunity of the virus in your air. Let’s engage all the resources available similar to what happens in a military campaign. A multi-faceted and comprehensive approach is more likely to offer a better chance of defeating an enemy. We can do this together and possibly reduce the spread of the Covid virus and live healthier and happier lives.

Prominent engineering and design professionals have testing from 3rd party entities for inactivation of the Covid virus available, yet the

The virus droplets typically fall due to gravity after exhaling, but it can attach to other particles and be carried further than 6 feet in a room. It would be reasonable to conclude that if we can reduce the number of airborne particles and dust pollution inside with good ventilation, filtration and purification of the air, the virus would not have additional means to travel further. This is supported by leading experts in building and health sciences including the AIA, ASHRAE and the CDC.

What’s the solution for us?

October 20 | 3PM-5PM

There are no quick fixes or easily achieved solutions to fix the problem. But, what if we could measure the air and manage the pathogens or particles that are in our interior environments? There are digital tools to measure toxins and particles that the Covid virus attaches to and is carried throughout interiors. A doctor uses an MRI to see and discover the internal workings of our bodies and offers insights on how to effectively treat compromised situations. “If you can measure it, you can manage it” says Peter Drucker, the 20th century business guru. There are tools for measuring pollutants and pathogens. In addition, new technologies are available to mitigate the viruses and bacteria that are damaging us. UV lights, bi-polar ionization and advanced filtration and ventilation can be used to control the spread of diseases. Joseph Allen, Director for Harvard’s T.H. Chan School of Public Health, says that if we can engage our build-

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Telehealth Waivers Are Gone, But Florida Providers Still Must Mind Virtual Care Risks BY JONATHAN ROMERO

Like healthcare providers across the country, Florida’s medical community found the state’s telehealth emergency waivers to be a Godsend for allowing services to be delivered virtually and organizations to stay afloat financially during the pandemic. Their unexpected expiration took place in late June without a “glide path” to manage the impact. The timing wasn’t ideal as the Delta variant of the coronavirus has surged. The state now has twice as many people hospitalized than earlier surges, a crush that has patients being stacked in hospital hallways. Practitioners not on the front lines of the crisis who learned to rely on virtual health services are, for now, putting their faith in the Florida Medical Association’s lobbying to reinstate the waivers and make them permanent. But the medical community would do well to understand and take steps to guard against telehealth’s downsides that may earlier have been glossed over. On a national basis, adoption of virtual health solutions has accelerated with the pandemic: 75 percent of providers expect it to account for at least 40 percent of their business in the future. But for all the benefits, it’s also given the community worrisome new risks that have

also escalated with deployment: Growing incidents of cyberattacks with another digital opening, and the greater risk of misdiagnosis and professional liability.

Ransomware and other cyber attacks skyrocket For a period during the summer the clinicians of UF Health Leesburg Hospital and UF Health The Villages Hospital were using pens and paper to document all patient care following a “cybersecurity event” in late May. Access to all system platforms was suspended for nearly a month. While UF Health wouldn’t confirm it, one published report said called the breach a ransomware attack with a $5 million ransom demanded. Ransomware has been the leading form of cybercrime, which has shot up 470 percent since the pandemic. No surprise, as digital health records command over $1,000 per record on the black market, versus a paltry $5.40 each for payment cards. Not only are healthcare systems and practices vulnerable as technology deployment expands, but their vendors are, too, opening another door. In fact, 75 percent of 2020’s breaches stemmed from vendors. Further, as virtual health deployment exploded, the security testing and protective measures may not have been up to snuff – especially with mobile apps. It’s all cause to proceed with caution. Risk mitigation measures are critical. So is the right insurance protection in the right amounts. Putting best risk deterrent practices will not only protect providers but are an important indicator to insurers of how seriously cyber security is taken. They also influence premiums. Among the measures:

CONTINUED ... EOCC || MEDICAL CITY Kicking off the Season of Sharing: The Opportunities are Endless bara Poma, Founder of onePULSE Foundation. Five local charities will also be highlighted offering guests an opportunity to support them fulfilling the need displayed on our “Giving Tree”. It is a meaningful way to start the Season of Sharing and supporting the good work of our highlighted nonprofit organizations. Reserve your seats early. Looking for more ways to highlight your business? The East Orlando Chamber has a plethora of opportunities to get you noticed, connecting you with your next clients and partners, keeping your business healthy. Enjoy the great outdoors with our 75th Annual Commemorative Golf Tournament, October 22nd at Rio Pinar Country Club. Play as an individual, with your foursome or become one of our Foursomes with Hole Sign teams. Check in is at 7:00 AM with a shotgun start at 8:00 AM. Additional opportunities include Chance drawings, power packs and more. Awards lunch and silent auction follow the tournament in the Club House. A portion of the proceeds benefit the East Orlando Chamber Foundation. For the health of your business reach out to the East Orlando Chamber for a menu of unique offerings elevating your businesses visibility and connect you with others helping your business thrive. We are the first in the state offering traditional Health Insurance plans, as well as supplemental products including dental, vision, critical illness, accidental and more. 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.

• Regular staff education and training, especially on recognizing and avoiding cyber schemes. • Basic protections like firewalls and antivirus software – and regular system backups. • Advanced security measures like dual authentication, encryption and virtual private networks. • Routine, third-party network audits, and requesting confirmation of consistent audits of vendors, as well. 12

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An experienced broker will be invaluable in security cyber insurance; the risk needs to be quantified and the coverage amount must be sufficient against the escalating number of breaches. Given the current hard insurance market, provider groups should budget for premiums 20 percent to 30 percent ahead of 2020 levels.

Heightened risk of misdiagnosis A recently released University of North Florida poll of healthcare providers found most were not fully equipped to manage virtual health consults. While over a third of respondents utilized these services during COVID’s spread, over 40 percent acknowledged that they had no formal training in providing them. This poses a professional liability issue that has gotten more serious with the pressure of the pandemic. The risks with virtual health start with simple oversights – like failing to ask the right questions to uncover conditions. Further, it isn’t always the best way to observe the presentation of many conditions. Take heart disease, often marked by fluid retention that may not be visible in a video consult. Or a skin growth that’s not recognized as a melanoma due to a camera malfunction where a faulty image is projected. Providers need to understand when virtual consults are ideal and when they may be less so. They also should focus on informed consent in educating their patients. Not only do they need to know when virtual health is just what the doctor ordered, but also when it may be a lessthan-ideal risk. It’s also important for providers to work with their brokers to clarify how the provision of virtual care services needs to be reflected in their professional liability insurance policies. They should also make sure that their telehealth system vendors have sufficient Errors & Omissions (E&O) coverage, as any misdiagnoses due to system malfunctions are a vendor issue. Jonathan Romero is a commercial advisor with global insurance brokerage Hub International. He holds the Property & Casualty insurance license (220) and Life & Health insurance license (2-15) through the State of Florida. Jonathan earned his Bachelor of Science Degree in Finance and Economics from Florida Southern College. Jonathan’s industry focuses include medical and white-collar professional risks, advising on professional, malpractice and management liability exposures and coverages. He also provides comprehensive property, casualty and benefits consulting to those clients, both for smaller, private clientele and for the large, public groups. Jonathan works with the State of Florida’s medical association and the local medical society in Leon County and the surrounding areas. Visit hubinternational.com

Cannabis and Pulmonary Function Over 20 Years

CONTINUED ... Vaccine Hesitancy, the Psychology Behind the Confusion do I get it? How can I get there? How do I pay for it? • Help them see vaccination as a right or privilege that they would not want to be taken away

BY MICHAEL C. PATTERSON

A recent study published in the JAMA NETWORK asked the age-old question; Is there an association between marijuana exposure and pulmonary function over 20 years? The study can be found via the link below: Association Between Marijuana Exposure and Pulmonary Function Over 20 Years | Adolescent Medicine | JAMA | JAMA Network What they discovered was that “occasional and low cumulative marijuana use was NOT associated with adverse effects on pulmonary function.” In other words, cannabis smoke – unlike tobacco smoke – doesn’t have such a drastic impact on lung function despite having some of the same chemical profile in smoke. The study performed was called CARDIA, which is a longitudinal study designed to measure risk factors for coronary artery disease in a cohort of black and white women and men (n = 5115) aged 18 through 30 years and healthy at enrollment in 1985. Participants were sampled from 4 US communities without selection for smoking behaviors and comprise a broad cross-section of typical tobacco and marijuana use patterns. Each study center (Oakland, Chicago, Minneapolis, and Birmingham), participants underwent a baseline examination and 6 follow-up examinations, with 69 percent retention at year 20. Pulmonary function testing was performed at years 0, 2, 5, 10, and 20. For this investigation, we included all visits for which pulmonary function, smoking behavior, secondhand smoke exposure, height, and waist circumference were available. Current intensity of tobacco use (cigarettes smoked per day) was assessed at each examination. These data, along with baseline examination data on past years of smoking, were used to estimate cumulative lifetime exposure to cigarettes in terms of pack-years, with 1 pack-year of exposure equivalent to 7300 cigarettes (1 year × 365 days/y × 1 pack/d × 20 cigarettes/pack). Misclassification of smoking exposure by self-report, measured by comparisons with serum cotinine levels, is uncommon.19 Current intensity of marijuana use (episodes in the last 30 days) was also assessed at each examination. Using baseline examination data on past lifetime exposure to marijuana, current intensity of marijuana use, and another question designed to assess number of joints or filled pipe bowls smoked per episode we calculated total lifetime exposure to marijuana joints in joint-years, with 1 joint-year of exposure equivalent to 365 joints or filled pipe bowls smoked (1 year × 365 days/y × 1 joint/d), as described previously.20 The 5115 CARDIA participants recruited in 19851986 contributed 20 777 total visits that included pulmonary function testing. Of these, 959 visits were excluded for lack of complete information on smoking behavior, 114 for lack of height or waist measurements, and 1 for an unknown visit date, leaving 19 703 visits (95 percent) with complete data from 5016 participants (98 percent). Participants contributed 3.9 visits/participant on average; attrition was more common in tobacco smokers but not associated with marijuana use. FEV and FVC varied across participants, increased slightly with age through the late

20s, and declined slowly thereafter. More than half of participants (54 percent; mean age at baseline, 25 years) reported current marijuana smoking, tobacco smoking, or both at 1 or more examinations. Smoking patterns differed by race and sex, with black women most likely to smoke tobacco only, white men most likely to smoke marijuana only, and black men most likely to smoke both. Tobacco smokers tended to have lower education and income and to be slightly shorter and less active, whereas marijuana smokers tended to be taller and more active. The median intensity of tobacco use in tobacco smokers was substantially higher (8-9 cigarettes/d) than the median intensity of marijuana use in marijuana smokers (2-3 episodes in the last 30 days). Although marijuana and tobacco exposures were strongly correlated, our sample included 91 participants with no tobacco exposure and more than 10 joint-years of marijuana exposure (contributing 153 observations of pulmonary function), 40 (56 observations) of whom had more than 20 joint-years of exposure. The findings suggest that occasional use of marijuana for these or other purposes may not be associated with adverse consequences on pulmonary function. It is more difficult to estimate the potential effects of regular heavy use, because this pattern of use is relatively rare in our study sample; however, our findings do suggest an accelerated decline in pulmonary function with heavy use and a resulting need for caution and moderation when marijuana use is considered.

Analysis While this study is good news, smoking cannabis for medical purposes is not the most efficient way to consume medicine. A lot of cannabinoid effects are lost when cannabis is burned to be smoked. A similar, but better way to consume cannabis is via vaporizer or vape pen. The cannabis not being burned but heated into a vapor, which maintains all of the cannabinoids in order to be available for absorption into the body. Furthermore, more accurate dosing of cannabis can be found via edibles or tinctures, which allow a patient to have a measured amount of cannabinoids (THC, CBD, THCA, CBG, CBN, etc.) to build confidence and certainty in the reaction of cannabis medicine on the body. Michael C. Patterson, founder and CEO of U.S. Cannabis Pharmaceutical Research & Development of Melbourne, is a consultant for the development of the medical marijuana industry nationwide and in Florida. He serves as a consultant to Gerson Lehrman Group, New York and helps educate GLG partners on specific investment strategies and public policy regarding Medical Marijuana in the U.S. and Internationally. He can be reached at mpatterson@uscprd.com

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Community versus individual factors do influence decision-making for many individuals. When discussing options, focus on individual personal agency and individual benefits, but alternatively frame vaccination as a step toward a meaningful goal for the society as a whole and create a sense of being part of a community in the battle against the virus. Attempt to increase a sense of altruism by eliciting someone specific in their life who would be kept safe by vaccination (a close elder or child). Focus on the future and “getting life back.” Realize that it may be a process – not one conversation, but a series of conversations that brings the patient closer to the decision of vaccination. Regardless of a patient’s individual decision regarding vaccination, it is important to continually reinforce the established precautions to prevent the spread of COVID. With a doctorate in clinical psychology and over 20 years of experience in the field, Dr. Mary-Catherine 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. Visit www.CounselingResourceServices.com

ORLANDO || GRAND ROUNDS Walgreens and VillageMD Expand to Florida with Plans to Open 10 Full-Service Primary Care Clinics in Orlando This Year

program aims to reduce the number of ER visits, hospitalizations, and other impacts of mental health crises. In the past two years, over 300 children were hospitalized at AdventHealth for Children following a suicide attempt or other self-harm event. Recruitment is underway with providers expected to be in place in early 2022. Dr. Phillips Charities has been a supporter of AdventHealth for decades. Since November 1956, Dr. Phillips Charities has provided over 60 contributions to AdventHealth totaling over $10 million, including this five-year, $6 million commitment. Dr. Phillips Charities’ mission has always been to help people help themselves, which this program aims to accomplish. “Our most vulnerable young people, who may be as young as 10 years old, are suffering from undiagnosed and mistreated behavioral and mental health issues. Early intervention and treatment is very important to prevent negative long-term consequences,” said Dr. Rajan Wadhawan, senior executive officer of AdventHealth for Children. “We’ve come a long way in caring for our children’s physical health, but their mental health can have just as great of an impact on their futures. Through this program, we’ll soon have even more resources to ensure a brighter future for the children in our community.” There continues to be a severe national shortage of child and adolescent psychiatrists, according to the American Academy of Child and Adolescent Psychiatry. Nearly one in five U.S. children have a mental, emotional, or behavioral disorder each year. Only about 20% of children with mental, emotional, or behavioral disorders receive care from a specialized mental health care provider.

Walgreens Boots Alliance and VillageMD have announced the opening of three new Village Medical at Walgreens locations in the Orlando area with plans to open seven additional locations by end of this year. Through the Walgreens and VillageMD integrated care model, patients are able to receive convenient and coordinated pharmacy services alongside cost-effective and comprehensive primary care. “Together, Walgreens and VillageMD are committed to expanding access to healthcare in America through coordinated primary care and pharmacy services in our stores and virtually,” said Jamie Vortherms, vice president of healthcare services, Walgreens. “These 10 new clinics in Orlando are the first of many we hope to bring to Florida to provide residents high-quality care in the communities where they live, shop and work.” More than 13 million Floridians have at least one chronic condition, many of whom require multiple daily medications. VillageMD primary care physicians and Walgreens pharmacists work together to provide care for chronic conditions such as diabetes, asthma and high blood pressure, as well as everyday illnesses and injuries. Patients may benefit from a seamless experience that saves them time and money and helps them take medication as prescribed by their primary care providers. These Village Medical at Walgreens locations in Florida will create approximately 400 jobs within the community, including 200 STEM (Science, Technology, Engineering, and Mathematics) high-paying, professional positions.2 VillageMD, through its subsidiary Village Medical, is a leading, national provider of value-based primary care services. VillageMD partners with physicians to provide the tools, technology, operations, staffing support and industry relationships to deliver high-quality clinical care and better patient outcomes, while reducing the total cost of care. The Village Medical brand provides primary care for patients at traditional free-standing clinics, Village Medical at Walgreens clinics, at home and via virtual visits. VillageMD and Village Medical have grown to 12 markets and are responsible for more than 1.6 million patients. VillageMD is also the largest participating sponsor of CMS’ new Direct Contracting program and estimates it serves more than 56,000 patients. To learn more, please visit www.villageMD.com.

Orlando Health Announces Promotion of COO to Hospital President Orlando Health has announced that Brian Wetzel has been named president of Orlando Health Horizon West Hospital and vice president, Orlando Health. Wetzel has served as the hospital’s chief operating officer since its opening in January 2020. In his new role he will lead all aspects of hospital operations with responsibility for achieving organizational goals, monitoring quality care, and meeting financial plans. Wetzel has achieved considerable success during his 25-year career at Orlando Health, beginning at Orlando Health St. Cloud Hospital and spending more than a decade at Orlando Health Dr. P. Phillips Hospital. He was responsible for operational planning and expansion activities, including the construction of the additional bed tower during his tenure at Orlando Health Dr. P. Phillips. In 2011, Wetzel moved to Orlando Health’s downtown Orlando campus to take the lead on the occupation project of the Orlando Health Heart & Vascular Institute. A year later, he moved to the Orlando Health Cancer Institute, where he was responsible for growth strategy development for the oncology service line. In 2013, Brian was named administrative project lead for the $320 million Orlando Health ORMC renovation and redesign project, while continuing as administrator for ancillary services and facility planning. In 2016, he became assistant vice president and chief operations officer for the oncology service line, and in 2020, Brian took on the leadership of the Orlando Health Horizon West Hospital project completion and opening. Wetzel earned a Bachelor of Science in Human Resources Management from Florida Southern College and a Master of Science in Health Services Administration from the University of St. Francis. Wetzel began his new role on September 1.

Dr. Phillips Charities and AdventHealth Partner to Improve Mental and Behavioral Health Care for Kids Dr. Phillips Charities, a Central Florida philanthropic organization, recently awarded a $6 million grant to support AdventHealth for Children in the creation of the Center for Advancement and Support of Youth (CASY), the first-of-its-kind comprehensive pediatric and young adult mental and behavioral health program in Central Florida. Through a holistic and patient-centered approach, CASY will improve and expand access to mental health care, fill gaps in the care continuum, increase early diagnosis and intervention of mental and behavioral health concerns, and help patients and families navigate the complex mental and behavioral health care system. The program will help close the gap between the need for mental health resources for children and the services available. When fully implemented, CASY will provide up to 10,000 child and adolescent psychiatrist visits and 5,500 psychologist visits every year. By increasing the resources available for pediatric patients in Central Florida, the

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Golfers to Tee Off to Prevent Child Abuse On Fri., Oct. 22, golfers will tee off in the “Fore Our Kids” tournament to raise money for Embrace Families. The event will support critical services that provide assistance to strengthen families and prevent child abuse. Last year, Embrace Families delivered services to over 9,800 young people in Central Florida. Some are in foster care; all are victims of, survivors of, or at risk of abuse or neglect. Funds raised from this event will be used to ensure safety, provide permanency and maintain the well-being of children in Central Florida. Participants can compete either individually or as part of a team of four. Golfers must register online at www. foreourkids.com. Space is limited; registration closes on Friday, Oct. 15, if spots are available.

After evacuating from Hurricane Ida, Louisiana woman delivers baby at AdventHealth Winter Park Preparing for a new baby is stressful. So is planning for the approach of a dangerous storm. Lindsay Friedmann recently had to do both – at the same time. Friedmann, who lives in New Orleans, was 39 weeks pregnant as Hurricane Ida churned toward the Gulf Coast. She and her husband Josh elected to ride out the storm at home so she could deliver at the same hospital where she’d given birth to their first two children. They made it safely through the storm, but their plans quickly changed in the aftermath. “The power company declared a catastrophic failure, and that’s when we knew we were out of here,” Friedmann said. “The house was fine, so we did a little bit of cleanup, and then we cleared out.” Fortunately for the Friedmanns, one of their closest friends in New Orleans is Carly Plotkin, whose parents live in Winter Park. And Carly’s father is Dr. Jay Plotkin, a longtime OB/GYN at AdventHealth Winter Park. Dr. Plotkin set Lindsay up with a local OB/GYN and pediatrician, and got her registered at the hospital just in case she went into labor. The Friedmanns, their two daughters, 5-year-old CJ and 1-year-old Millie, and their three dogs got into town on Aug. 31. Four days later, Lindsay delivered at The Baby Place at AdventHealth Winter Park. William Friedmann was born at 4:46 a.m. Sept. 4, weighing 8 pounds, 4 ounces, and measuring 20.5 inches. “There was such a sense of relief that we were going to be taken care of, and there’s an eternal sense of gratitude,” Friedmann said. “Everyone was really wonderful, so friendly and supportive.” The Winter Park team was quick to step in and assist the family. "We treat everyone like family here at AdventHealth Winter Park, and that's exactly what Dr. Plotkin and our team did when they provided a safe space for this family during a time of chaos and uncertainty," said AdventHealth Winter Park CEO Justin Birmele. “I’m so glad we were able to come together and help this family in their time of need.”

VOLUSIA/BREVARD || GRAND ROUNDS Parrish Medical Group Welcomes Orthopedic Physician David Schafer, MD Parrish Medical Group welcomes David Schafer, MD to the North Brevard community. Dr. Schafer is a board-certified orthopedic physician now offering a wide variety of orthopedic care at two convenient locations: Parrish Healthcare Center 250 Harrison Street, Titusville, FL 32780 and Parrish Healthcare Center 5005 Port St. John Parkway, Cocoa, FL 32927. Dr. Schafer completed his medical studies at Northwestern University in Chicago, Illinois. Following his studies, Dr. Schafer completed a fellowship at the prestigious Kerlan-Jobe Orthopedic Clinic in Los Angles. Most recently, Dr. Schafer held the position of Medical Director at Grand Avenue Surgical Center/Surgicare of Chicago. He is a member of the American Orthopedic Society for Sports Medicine, the Arthroscopy Association of North America and the American Academy of Orthopedic Surgeons. Having conducted a wide amount of research in his area of expertise and publishing in many academic journals, Dr. Schafer is passionate about the orthopedic field.

In Memory of James Moore, MD We are saddened to share that long-time VCMS member James Moore, MD, has passed. Dr. Moore specialized in Psychiatry/Behavioral Health with Florida Health Care Plans and was a member of the Halifax Health Medical Staff. Memorial donations may be made to Sophie’s Circle, non-profit dog rescue and pet pantry, 312 Julia St., New Smyrna Beach, FL 32168 or St. George’s Coptic Orthodox Church, 300 N. Halifax Ave., Daytona Beach, FL 32118.

St. Francis Reflections Lifestage Care Adds Two New Physicians St. Francis Reflections Lifestage Care is pleased to announce two new physicians have joined the nonprofit’s medical team. Doctors Ryan and Diane L. Danly started in late August to meet the increase in demand for hospice and palliative care services. They round out a team of eight board-certified or board-eligible Hospice and Palliative Medicine physicians. “As a long-standing, community-centric organization, we take incredible consideration when deciding who will care for our patients,” said Cami Leech Florio, Chief Strategic Officer. “We are confident we have found great partners in Dr. and Dr. Danly, who exude compassion, knowledge, and excellence. Their hiring comes at a time when our community continues to see an increase in demand for services.” The announcement comes on the heels of another recent business announcement that St. Francis is partnering with Melbourne Regional Medical Center to open a new 10-bed in-patient hospice care center. The centrally-located unit is slated to open in January 2022 to provide care for the short-term management of complex symptoms and periods of respite for families. It will be staffed entirely by St. Francis medical providers. Dr. Ryan received his bachelor’s degree from Carleton University in Ottawa, Canada and his medical degree from Nova Southeastern University School of Osteopathic Medicine. He completed his residency in internal medicine at Jackson Memorial Hospital in Miami, where he also completed a Hospice and Palliative Medicine fellowship. Dr. is board-certified in Internal Medicine and Hospice and Palliative Medicine. He maintains professional associations with the American Medical Association and the American College of Physicians. In his free time, Dr. enjoys golfing, traveling the world, and spending time with his family, including his wife, a physician associate. Dr. Diane Danly received her bachelor’s degree from the Whitworth College in Spokane, Washington and her medical degree from the University of Washington School of Medicine. She completed her residency in family med-

Jess Parrish Medical Foundation to Host Annual Gala “A Whole New World” Benefiting Parrish Healthcare’s Cancer Care Programs and Services Planning is underway for Jess Parrish Medical Foundation’s (JPMF) annual benefit gala, A Whole New World, which is scheduled for Saturday, Jan. 15, 2022, from 5:3010:00 pm at Space Coast Convention Center, Cocoa, FL. GrayRobinson, P.A., and William A. and Laura M. Boyles are presenting sponsors for the event. Sultans, wise genies and Ali Baba will come to life in the elegant Arabian Night themed evening alive with Mediterranean inspired cuisine, enchanting music, dancing and magic lamps. A Whole New World is sure to be an evening you won’t forget. Guests will enjoy dinner in the Casbah inspired ballroom, cocktails at the Oasis Sand Bar, souvenir photos and the opportunity to take home a new favorite libation when they take a chance at the wine pull. Elegant Aladdin inspired attire is suggested; black tie optional. Event proceeds will champion the advancement of Parrish Healthcare’s Cancer Care program – the area’s only program that is nationally accredited by the Commission on Cancer. “It is our honor and privilege to partner with Jess Parrish Medical Foundation for the tenth year as presenting sponsor of the Foundation’s annual benefit gala,” said William A. Boyles, shareholder at GrayRobinson, P.A. “We are committed to continuing the Foundation’s mission of providing healing experiences to families throughout Brevard County and supporting Parrish Healthcare’s vital Cancer Care programs and services.” Individual gala tickets are available at $125 and sponsorship opportunities are offered starting at $500. For more information about sponsorship packages or to purchase general admission and chance-drawing tickets, please contact Jess Parrish Medical Foundation at 321269-4066 or visit parrishmedfoundation.com/gala. Space is limited.

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icine at Providence Family Medicine, and she completed a Hospice and Palliative Medicine fellowship at St. Louis University Hospital, VA Hospitals. She is board-certified in Family Medicine, and Hospice and Palliative Medicine. Additionally, she is certified as a Hospice Medical Director. Dr. Danly is a Fellow of the Academy of Family Physicians and the American Academy of Hospice and Palliative Medicine. In her free time, Dr. Danly enjoys being active, walking on the beach, swimming, biking, and spending time with her dogs and family, including her husband of nearly 30 years and her two daughters.

Parrish Healthcare Partners with the Titusville Police Department and DEA for National Take Back Event On Saturday, October 23, 2021 from 10a.m. – 2p.m. Parrish Medical Center is partnering with the Titusville Police Department (TPD) and the Drug Enforcement Administration (DEA) to serve as a collection point for the National Prescription Drug Take Back event. During this national take back event community members are able to surrender expired, unwanted or unused prescription controlled substances and other medications to law enforcement officers for destruction. “The Titusville Police Department is grateful for our community partnerships with the DEA and Parrish Medical Center” said Special Investigations Section Sergeant Troy Barbour. “The upcoming Pill Take Back event provides an extraordinary opportunity for citizens to responsibly dispose of unwanted medications and prescription drugs, no questions asked, ultimately keeping these drugs off the streets and making our community safer” added Barbour. This semiannual event provides not only the opportunity for law enforcement, prevention, treatment and business communities to collaborate and establish a safe collection site for all community members but also allows for law enforcement to educate the general public about the potential for abuse of medications. “The DEA Takeback Day gives us the opportunity twice a year to make our community a safer place for our families. Parrish Medical Center’s participation in this effort underscores our commitment to the support of the wonderful place we all call home!” said Parrish Medical Center Director of Pharmacy Eric Renker. For more information on the DEA Take Back event and its national impact, please visit DEATakeBack.com.

NORTH CENTRAL FLORIDA || GRAND ROUNDS

AdventHealth Ocala Achieves National Distinction of Excellence for HeartCARE by the American College of Cardiology tHealth system to achieve all five accreditations and the HeartCARE Center™ National Distinction of Excellence. The hospital achieved the status based on world-class cardiovascular care through comprehensive process improvement, and a commitment to professional excellence and community engagement. AdventHealth Ocala has also earned a distinguished three-star rating from the Society of Thoracic Surgeons (STS) for its patient care and outcomes in isolated coronary artery bypass grafting (CABG) procedures. The three-star rating, which denotes the highest category of quality, places the hospital among the elite for heart bypass surgery in the United States and Canada. The STS star rating system is one of the most sophisticated and highly regarded overall measures of quality in health care, rating the benchmarked outcomes of cardiothoracic surgery programs across the United States and Canada.

AdventHealth Ocala has achieved the American College of Cardiology’s (ACC) HeartCARE Center™ National Distinction of Excellence, the organization’s highest honor for cardiovascular care. The HeartCARE Center™ distinction is designed to shine a light on the elite group of hospitals in the United States that go above and beyond to ensure each patient that needs care has access to consistent, highest-quality cardiovascular care. “AdventHealth Ocala made a commitment to raising the bar on clinical excellence in Marion County and this distinction is a reflection of us honoring our word to this community,” said Joe Johnson, President and Chief Executive Officer for AdventHealth Ocala. “We want to be the first choice for heart care and this recognition shows we are home to prestigious care that you won’t be able to find anywhere else.” AdventHealth Ocala is the first hospital in the Adven-

AdventHealth Ocala Expands Emergency Care into Belleview Community Leaders at AdventHealth cut the ribbon on a new 13,000 square foot, 24-hour emergency room (ER) located at 6006 SE Abshier Blvd in Belleview, Florida. The 12-bed facility is a full-service ER and has the ability to transfer patients requiring an extended stay to AdventHealth Ocala for care if needed. The ER will officially open for care on Tuesday, October 12 at 9 am. “As our community grows, it’s imperative that we continue to grow and expand our services. We are excited about bringing our connected network of care to families in Belleview and The Villages,” said Joe Johnson, President and CEO of AdventHealth Ocala. “With this new ER, we can provide our brand of whole person care to more families, fulfilling our promise to elevate care for everyone in the Greater Marion County community and beyond.” The $18 million facility offers a wide array of services from board-certified emergency medicine physicians and nurses who specialize in emergency care for adults and children. Some of the services will include state of the art, on-site diagnostic imaging including x-ray, ultrasound, CT scans and onsite laboratory services to provide patients with real-time results – leading to more accurate and convenient diagnosis and treatment. “AdventHealth Belleview ER will be home to some of the best doctors and nurses in emergency care,” said Dr. Michael Torres, Chief Medical Officer of AdventHealth Ocala. “Whether you’re having chest pain or a critical injury, we have the experts ready and waiting to care for you when you need us most.” The new emergency room is expected to provide more than 100 jobs in Marion County. This will be AdventHealth’s second offsite emergency room in Marion County. The hospital system also operates AdventHealth TimberRidge ER in Ocala.

Orlando Health Announces Major Plans for Expansion in Lake County Orlando Health South Lake Hospital will soon start construction to expand its campus to provide South Lake County with greater access to high-quality healthcare. Plans include an expansion and renovations to the Orlando Health South Lake Center for Women’s Health and the construction of a new 95-bed patient tower. The first phase of construction will begin with the realignment of Don Wickham Drive to intersect with Legends Way and include the addition of a stoplight to improve traffic flow. “This is an exciting time for our hospital,” said Lance Sewell, president of Orlando Health South Lake Hospital. “Lake County is steadily and rapidly growing, and we’re excited to continue growing with it. By expanding our facilities, we’ll be able to increase the types of services we offer while providing the quality care that Orlando Health is known for to even more people in the communities we serve.” The expansion of Orlando Health South Lake is made possible in part by a $50 million grant from The Live Well Foundation of South Lake, an organization created to address healthcare needs in the community. The foundation meets these needs by partnering with local nonprofits to provide grants for healthcare-driven initiatives and has been in partnership with Orlando Health since its founding in 2019.

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“We’re honored to partner with Orlando Health South Lake Hospital to increase its impact in our community,” said Kasey Kesselring, Ed.D., chairman, Live Well Foundation of South Lake Board of Directors. “As South Lake County continues to develop and grow, so will the need for access to preventative and emergency healthcare services. This expansion means that more individuals and families will not only receive the best healthcare possible, but also a better quality of life through improved health and wellness.” Renovations for the hospital’s Women’s Center will be completed in early 2022 and include the addition of new beds for postpartum and labor and delivery as well as expanded women’s services. The completed tower will allow for an expanded intensive care unit and will create more than 150 new full-time hospital positions. The expansion will generate more than 500 construction jobs and is anticipated to be completed in late fall 2023. Orlando Health, headquartered in Orlando, Florida, is a not-for-profit healthcare organization with $7.6 billion of assets under management that serves the southeastern United States. Founded more than 100 years ago, the healthcare system is recognized around the world for its pediatric and adult Level One Trauma program. It is the home of the nation’s largest neonatal intensive care unit under one roof, the only system in the southeast to offer open fetal surgery to repair the most severe forms of spina bifida, the site of an Olympic athlete training facility and operator of one of the largest and highest performing clinically integrated networks in the region. Orlando Health is a statutory teaching system that pioneers life-changing medical research. The 3,200-bed system includes 15 wholly-owned hospitals and emergency departments; rehabilitation services, cancer and heart institutes, imaging and laboratory services, wound care centers, physician offices for adults and pediatrics, skilled nursing facilities, an in-patient behavioral health facility, home healthcare services in partnership with LHC Group, and urgent care centers in partnership with CareSpot Urgent Care.

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