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Can’t-Miss Cannabis Conference Surprising ancillary opportunities, seminars dominate third annual AMMPA meeting By PL JETER

Hundreds of healthcare providers and executives will converge at Orlando’s Hilton Orlando Lake Buena Vista Hotel Oct. 4-6 for the American Medical Marijuana Physi-

ON ROUNDS PHYSICIAN SPOTLIGHT Antonio Velardi, MD ... 3 EOCC MEDICAL CITY

How Sweet It Is: First things first … dessert that is! ... 5

ORLANDO NEUROLOGY Brain Tumor… Now what? ... 7

CANNABIS CORNER

What Physicians Need to Know about CBD ... 9

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cians Association’s (AMMPA) third annual conference covering challenges related to the nation’s ever-morphing medical marijuana environment. Orlando-based AMMPA, the nation’s largest physician-advocate medical cannabis

DOCTORS CORNER

Dr. Mark Chaet

association, hosts the threeday event, covering topics ranging from medical marijuana basics to physician areas of opportunity. “We’ll have high-end

featured speakers, both from science and medical marijuana backgrounds internationally,” said AMMPA president Mark Chaet, MD, a pediatric surgeon. “We’re very excited about what we’re bringing to the table.” (CONTINUED ON PAGE 4)

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Why So Much Staff Turnover? By QUINTIN L. GUNN, SR.

Staff Instability, What’s It Really Costing Your Practice? It’s clear to me after working with practice groups for the better part of fifteen years, that the growth and profitability of a practice can never be achieved or maintained if there is instability in the workplace or the workforce. This is especially true when it comes to a fee for service medical practice or group. Staff configuration and alignment is critical. Simply put: To be the best, you have to have the best staff! I have heard many doctors say quite

frequently, “No one is irreplaceable, everyone can be replaced, finding quality replacements is easy” in this job market. Nothing could be further from the truth. The fact is, that it is neither simple nor easy to find or build a great staff in the medical community. As a point of fact, it costs lots of money to replace experienced, qualified, and well-trained staff members, not to mention the brain trust that goes along with their experience. Think about the amount of time and effort your existing practice manager, ancil-

•• •• • •

lary staff, and other members spend training them and showing them all your processes, procedures, protocols, computer systems as well as IT software. It becomes easy to calculate the financial loss. Not to mention HR resources, stationery, and your other intellectual investments for just one new hire alone. The loss of staff has various reasons, but here is a list of the most consistent

(CONTINUED ON PAGE 6)

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PHYSICIANSPOTLIGHT

Finding Opportunities to Save Lives Through Better Quality of Care Antonio Velardi, MD “Nobody wakes up saying, ‘Today, I am going to screw up,’” said Antonio Velardi, MD, Chief Quality Officer for Orlando Health-Health Central Hospital, his voice still carrying hints of his boyhood home in Milan, Italy. All the same, mistakes are inevitable, even in medicine. It is Dr. Velardi’s job to discover when mistakes have happened, to investigate why they happened, and to help figure out what can be done to prevent them from happening again. “The most important thing people should know,” said Velardi, “is that every hospital is doing everything it can to improve, and that each hospital has people whose only job is to ensure the safety of every patient who enters its doors.” For the hospital staff, it is essential they feel comfortable reporting mistakes when they happen. “We must have a culture in which people know they are not going to be punished for reporting mistakes,” said Velardi. “If you are afraid of repercussions, you tend to hide what you did that was wrong. If the organization is focused on improving its policies and procedures instead of punishing people, we have a much more open working environment.” As a simple example, Velardi described the process of transporting a patient from his hospital room to the imaging depart-

ment for an x-ray. A series of checks must be performed every step of the way, with physicians, nurses, transporters, and technicians double checking instructions and procedures. “Moving a patient from Point A to Point B is relatively simple if all we do is to put a patient onto a gurney or into a wheel chair. But quality and safety procedures surround the patient to make sure the right patient is taken to the right place, and the right tests are performed.” While, it sounds like quality control is focusing on mistakes that get made, it also involves finding opportunities to make improvements. Velardi cited the problem of sepsis in hospitals. Sepsis is a condition that arises when an infection someone already has—in the skin, lungs, urinary tract, or somewhere else—triggers a chain reaction throughout the body. If not treated rapidly, sepsis can lead to tissue damage, organ failure, and even death. In 2013, the mortality rate for our patients who developed sepsis was about 25 percent. At Orlando Health-Health Central that rate has been cut in half to 12.5 percent. In large part, that improvement was the result of improved procedures, including early recognition and treatment through the institution of a Rapid Response team. “When the nurse suspects the patient

might by septic, the nurse calls a ‘Sepsis Alert,’” said Dr. Velardi. That alert immediately summons a team of medical professionals to the patient’s bedside to begin aggressive treatment. You get the impression that while cutting the mortality rate for sepsis in half is a significant improvement, Velardi isn’t satisfied. “The results are significant, but they still are not optimal.” Velardi’s interest in medicine started when he was very young. As a boy in postwar Italy, he suffered from asthma, and a local doctor made house calls to treat him. “I remember this doctor coming to our house and making me feel better.” It was the idea that a professional could visit a sick person and do something that could help

them get better that stuck in the young boy’s imagination. It was also the age when spectacular advances in medicine were just beginning. Velardi remembered reading as a teenager about the first heart transplants happening. He was especially inspired by news coverage in Italy of Dr. Denton Cooley, the Texas surgeon who performed the first implantation of an artificial heart into a person in 1969. “I remember reading in the Italian version of People Magazine that he said, ‘No one should die for the mere failure of a pump!’” That sparked an initial interest in cardiothoracic surgery and his eventual admission to the School of Thoracic and Cardiovascular Surgery at the University of Milan. In addition to a love for medicine, Velardi had a love for the United States that had begun with stories told by his mother of Americans liberating southern Italy during World War II. “To me this country is the greatest country in the world.” While at the University of Milan, he (CONTINUED ON PAGE 8)

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Can’t-Miss Cannabis Conference, continued from page 1 AMMPA executive director Savara Hastings said the association’s mission is to “bring physicians from zero to 60.” “There’s so much more they can do,” she pointed out. “We try to at least make them confident in recommendations for various conditions and introduce them to products that have been correctly lab-tested.” First-day events on Friday, Oct. 4, include an overview of medical marijuana pharmacology and understanding the unique endocannabinoid system, which, organizers say, “just may revolutionize the practice of western medicine.” Presentations on specialized challenges surrounding medical marijuana usage – gut health, women’s sexuality, pregnancy and breastfeeding, and geriatric patients – dominate the Friday morning line-up. “We’ve seen a surge of interest in the media about cannabis and women’s health,” said Hastings. “The sexual health lecture should be quite interesting. The presenting physician has completed studies to share with the audience. It’s an exciting topic.” The Anti-Munchies Appetite Buster for Weight Loss and Metabolic Syndrome is the topic of an early afternoon panel discussion on tetrahydrocannabivarin (THCV). Also, on tap: Medical marijuana’s role in treating veterans suffering from post-traumatic stress disorder (PTSD), and general population post-operative pain management and opioids. Florida Agriculture Commissioner Nikki Fried will give the evening’s keynote address. “She heads the medical cannabis com-

mittee and also a hemp committee,” explained Hastings. “Since the laws have changed over the last six months, specifically pertaining to hemp laws, but also medical cannabis laws, she’ll discuss the crossover of the two.” The schedule on Saturday, Oct. 5, focuses on the impact of medical marijuana on African Americans, autism patients, and central nervous system tumors. Business seminars highlight key elements needed to build a successful medical marijuana practice, the how-tos of regulatory compliance, medical director responsibilities, and additional physician opportunities. “Along with presenting fundamental ways physicians can be successful in their offices beyond recommending medical marijuana, we’re also helping them with their business model and other services to better assist their patients and careers,” said Chaet. On Saturday evening, keynote speaker Hinanit Koltai, PhD, will discuss promoting cannabis products to pharmaceutical companies. The conference will wrap around noon on Sunday, Oct. 6, with seminars focusing on “what physicians have learned from recreational marijuana usage in the wild, wild west,” according to the program description; the facts on modes of delivery – vaping, smoking and ingesting; and pediatric guidelines for medical marijuana therapy. Robert Norman, DO, MPH, will share an abstract presentation of medical marijuana use in dermatology.

The 1,250-member AMMPA represents 27 of 34 states – and Canada – that have implemented medical cannabis laws. Five states have CBD oil-only laws; a dozen states have no medical cannabis laws on the books. “At the conference, we’re also going to discuss nationwide expansion of our organization,” said Chaet, noting AMMPA held a successful niche conference, The NFL and Medical Cannabis, that attracted some 200 attendants in Miami. AMMPA’s mission: to serve as a physician advocate to facilitate the outline of practice risks and benefits, educational requirements, compliance issues and to provide a unified voice representing physicians interested in cannabinoid medicine. Online registration is available through Oct. 4 with member rates of $395 and nonmember physician rates of $690. Practice manager registration is $400, while the following medical professionals pay $435: physician assistant, registered nurse, resident, nurse practitioner, physical and occupational therapists. “Right now, only physicians can obtain certification to prescribe medical marijuana, but nurses and supplemental staff are finding the need to become as educated as possible about medical marijuana recommendations as an alternative modality for their patients,” noted Hastings. The deadline for discounted rooms in AMMPA’s room block is Sept. 12. Reference the group code AMM to receive the $175 nightly rate online (https://book.passkey.com/go/ammpa2019) or by phone (800-782-4414).

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How Sweet It Is First things first…dessert that is!

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Joint Chamber Network Mixer Wednesday, Sept 4, 2019 6:00 – 8:00 PM

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EOCC Educational Series “Your Legal Question”

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Thursday, Sept 12, 2019 8:30 – 9:30 AM

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Chefs Gone Wild Just Desserts Thursday, Sept 12, 2019 5:00 – 9:00 PM

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FEATURING ORANGE COUNTY MAYOR JERRY DEMINGS HIS VISION FOR THE FUTURE OF ORLANDO

By DOROTHY HARDEE

Do you often resist the temptation of a luscious dessert because you are counting calories or opting to make healthier choices? I know I did. It is time to blow your mind and rewire your brain. According to the Journal of Experimental Psychology, choosing that decadent dessert first might actually be good for you, allowing you make healthier food choices overall! Researchers tested how the presentation order of food affected food choice, experimenting in a cafeteria and online ordering. One hundred thirty-four university faculty, staff and graduate students participating were offered a choice of four different dessert options over four days, including fresh fruit. Seventy percent of the participants selecting cheesecake went on to make healthier main dish choices and overall consumed about 250 fewer calories than those selecting the fruit option. Martin Reimann, an assistant professor at University of Arizona and co-author of the study, suggested that choosing a healthy option first gives a person license to make a healthier selection later. He later told Bicycling Magazine that “healthy items can signal progress toward a goal and therefore, make individuals more likely to license themselves to choose subsequent less healthy items.” If you felt like you made all the right choices with a healthy meal, then it gives you open season on rewarding yourself with an indulgent dessert, often resulting in consuming more calories.

But if you treat yourself first, you are more likely to make smarter choices for your main meal reducing your calorie intake. Testing the theory, registered dietitian Cynthia Sass was asked to evaluate the accuracy of the study for Eat This, Not That! She said that “adopting this kind of balance or give-and-take kind of system is much healthier and more sustainable than having an all or nothing kind of mindset.” The study suggests that we may naturally gravitate balance unless we are distracted. Sass teaches her clients this as a strategy, so it is a thoughtful action rather than blind grazing. What distracts or derails a natural balance? Sass categorizes key areas of derailment as:

• Emotional eating for comfort or celebrating • Social eating copying what friends are eating • Habit in eating what you always eat when dining out • Environmental which includes advertisements, visual tabletops or servers offering the days specials Overall, Sass agrees with the findings of the study. Researchers at Tel Aviv University surveyed 200 adults on low-calorie diets offering a 600-calorie breakfast with sweets to half the participants and 300 calorie meals to the others. While both groups lost weight, those eating sweets reported fewer craving and less hunger throughout the day as well as sustained weight loss. Another study from the Endocrine Society confirmed similar results.

Need more reasons to consider room for dessert? A few bits of chocolate each day could decrease your risk of cardiovascular disease down the line. Chocolate rich in cocoa (unsweetened or dark chocolate) has a high concentration of flavonoids, an antioxidant offering anti-inflammatory and immune system benefits. A Swedish study showed that eating 10 grams of dark chocolate containing 65-70 percent cocoa reduces your chance of stroke by 17 percent. Hungry for more? The East Orlando Chamber of Commerce (EOCC) has just the perfect recipe to tantalize your taste buds. Chefs Gone Wild, Just Desserts is the culinary highlight of the year featuring member restaurants and caterers showcasing their delicious desserts, specialty coffees and dessert wines. It is a fabulous way to feed your sweet tooth and nonstop networking. Secure your tickets early and bring friends for decadent dessert dining you won’t soon forget. It’s just what the doctor ordered. Speaking of doctors, are you an Independent Physician seeking ways to increase exposure, revenue, and attract talent to grow with your practice? Joining the East Orlando Chamber, becoming actively involved in all it has to offer is the perfect way to start. Give us a call at 407-277-5951 or visit our website at eocc.org. Your Business is Our Business. Dorothy Hardee is the administrator of East Orlando Chamber of Commerce. Contact her at DorothyH@eocc.org

Wednesday, September 18, 2019 11:30 AM – 1:15 PM

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Coffee Club Nona at Sam’s Club SMALL GROUP DAY

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Please visit www.EOCC.org for a complete listing of January’s 18+ Events 5

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SEPTEMBER 2019

BETTER Patient Care. BETTER Bottom Line. Behavioral Health Screenings

Delivering highquality preventative healthcare requires physicians to treat the whole patient at both the physical and behavioral levels. Behavioral Health Screenings offer practices a “Front Line” approach to identifying emotional health and substance abuse disorders, which translates into better patient outcomes. Automated • Billable • Revenue Generating A practice, screening just 10 patients per day, can bill an average of $6,000–$10,000 in additional revenue per month!

Chronic Care Management

Chronic Care Management (CCM), released in 2015, is now saving $75 per patient, per month in healthcare costs and hospital readmissions. Practices that offer CCM services to their Medicare patients with two or more chronic conditions benefit from reimbursements that provide a new stream of monthly revenue for each patient enrolled. Just 300 Medicare patients enrolled in CCM can bring in an additional $50,000, or more per year, with no added work on your part!

Small Fiber Neuropathy Biopsies

Are you testing for Small Fiber Neuropathy (SFN)? Physicians striving to improve the quality of their care, lower overall healthcare costs and protect themselves from liability are turning to the “gold standard” for SFN biopsy testing. The ENFD test provides a definitive diagnosis for SFN allowing physicians to prescribe safer and more accurate treatment plans for their patients. Based on current Medicare rates, Physicians testing only one patient per day could increase their monthly revenue by over $5,000!

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Why So Much Staff Turnover?, continued from page 1 reasons you may have heard or seen:

a friendly face who has access to their very personal information and medical records. Seeing familiar faces builds trust, builds confidence and builds reassurance about the kind of care they can expect and will receive at your practice and with your staff.

Factors That Lead to Attrition • Low Wages • Childcare Issues • Lack of Clear Job Descriptions • Micro-Management • Lack of Employee Reviews • Unrealistic Performance Expectations • Failure to say Thank You or Job Well Done • Discriminatory Work Environment • Personality Conflicts • Outdated Equipment or Process and Procedures • Rude/Ill-mannered/Ill-tempered Doctor or Practice Manager • Failure to create work versus home life boundaries Whatever the reason, when a tenured staff person departs that person leaves and takes with them all your teachings, new techniques, and training just to enhance the practice of another doctor, who might possibly be your competitor! Prospects are much more informed and as a result, expect a higher quality of care and professionalism. You can’t create that experience with high turnover. No doctor or practice manager wants to be held hostage by their staff, nor should they be. Our point here is that some team members are indispensable. It is also true that when your patients notice high turnover of staff, they feel less secure and confident about the doctor or the patient care process. Patients look for and need the security that comes from seeing and having a familiar face to speak with about their issues or concerns. It’s part of the continuity of patient care. A familiar face ensures a consistent patient experience at your practice. They want to know what to expect and whom to expect it from. This is extremely important as fee for service practices are on the increase. What will set you or your practice apart when patients are being swayed about making buying decisions is your staff. Just think about it. How would you feel if you saw new faces every time you visited a business establishment? Constant change, lack of familiarity and instability can be very unsettling and detrimental to your practice. Your patients need to know whom they are dealing with on a regular basis –

How Do You Attract and Keep the Best Staff • Offer a Competitive Wage and Benefits Package • Create a Positive and Encouraging Work Environment • Encourage Friendly Competition surrounding positive patient reviews • Promote Continuing Education and Self Development • Avoid, Absolutely Avoid Micromanagement (Time Waster) • Avoid over utilization of salaried employees with excessive hours over 50 • Provide consistent and positive feedback related to their performance • Get their input about changes in process and procedures Doctors and practice managers must recognize, that just as you compete for new patients, you must also be prepared to compete for the best personnel to add to your staff. Even Google, Apple, Facebook, and LinkedIn compete with one another for the best staff. All the more so for the competitive areas of Plastic Surgery, Cosmetic Dentistry, Dermatology, Medical Spas, Anti-Aging, Concierge Medicine or any other fee for service business. It is both the job of the doctor and the practice manager to actively find, recruit, hire, train, and retain the best practice staff for an improved patient experience and to help grow practice profitability consistently. In Order to Get What You Want, You Must Help Others, Get What They Want. What about wage increase requests, given that this is one of the greatest reasons for turnover? It is very important to note that wage increase discussions are not the time for a performance review or appraisal. Any such issues or discussions should have already occurred long before now. Ideally, your discussion is based on the percentage of increase if a prior review was positive. We believe that a practice should al(CONTINUED ON PAGE 8)

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Brain Tumor… Now what? By RAVI GANDHI, MD

There are nearly 700,000 Americans living with brain tumors. There will be another 200,000 people diagnosed with a brain tumor each year. The most common symptoms are: • Headaches, often in the morning • Nausea and vomiting • Changes in your ability to talk, hear, or see • Problems with balance or walking Headaches, often in the morning • Nausea and vomiting • Changes in your ability to talk, hear, or see • Problems with balance or walking • Problems with thinking or memory • Feeling weak or sleepy • Changes in your mood or behavior • Seizure Brain tumors are divided into primary, arising from cells within the skull, or secondary, metastatic tumors that have extended from elsewhere in the body. Approximately, 86,000 of the brain tumors are primary, of which 30 percent are malignant. More than any other cancer, brain tumors can interfere with a patient’s quality of life even at early stages. Despite the morbidity associated with brain tumors and the number of cases,

there have been only four new FDA approved drugs and one new device in the last 30 years. For many of the tumor subtypes, surgery and radiation still remain the first options. Many tumors do not require any treatment other than careful observation. A treatment plan is usually developed by a multidisciplinary tumor team consisting of neuro-oncologists, radiologists, radiation oncologists, and neurosurgeons who specialize in brain tumors. Once an informed decision has been made to proceed with surgery, there are many tools in the neurosurgeons’ armamentarium that facilitate safer, more precise, and

less invasive surgery. These tools such as image guidance and fluorescent help to identify the tumor during surgery. By allowing for precise localization, tumors can be removed through smaller openings and less contact with normal tissue. Fluorescent technology requires a special IV drug to be given and a special microscope during surgery. This helps facilitate differentiation of malignant tumors from normal brain tissue actively. Intraoperative MRI during surgery helps to identify any residual tumor before the patient leaves the operating room. This is important in many tumors in which a

gross total resection can improve survival. For tumors in eloquent locations, neurosurgeons with the appropriate experience can remove tumors with patients awake. This allows for careful mapping of brain function such as language or motor areas. The brain does not have any pain fibers therefore patients tolerate this type of surgery very well. For tumors in deep locations that are not easily accessible, some tumors can be treated with Laser Interstitial Thermal Therapy (LITT). A laser is directed to a defined area within the tumor, using a thin fiber that is guided to the tumor tissue. This fiber is inserted through a small hole in the skull and guided to the tumor using intraoperative MRI and a robotic assisted drive. The laser transmits energy and as a result, heats up the tissue surrounding the tip of the laser fiber. High temperatures can cause rapid, irreversible tissue damage – in this case, to the brain tumor. The endoscope is a tool that allows surgeons to visualize by placing the light and a camera into a small space. This tool allows surgeons to remove complex tumors through access via the nose. This tool gives surgeons the ability to look around corners with exquisite detail often facilitating removal of (CONTINUED ON PAGE 10)

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Why So Much Staff Turnover?, continued from page 6

PHYSICIANSPOTLIGHT

DOCTORS CORNER ||

continued from page 1

ready have a wage increase guideline based on position, annual revenue growth, and employee performance evaluation. Wage increases should always be based on the financial health of your practice and how individual employees contributed directly or indirectly to the practice profitability. The longer the tenure, the better work performance should be, this, in turn, improves workflow, the speed of delivery, and quality of patient care. Other factors relate to product up-sells, the dollar value of sales per transaction, and consultation closure average for leads handled which in turn raise practice profitability.

Antonio Velardi, MD, met an American student, Carol, and an entirely new kind of love began. They married while in Italy, but soon decided to settle in the United States, where Mrs. Velardi could finish her PhD at Stanford University and Dr. Velardi could pursue his studies. He shifted career paths from surgery to internal medicine and became a Fellow in Critical Care Medicine at St. Louis University in St. Louis, Missouri. Velardi’s path eventually brought him and his family to Florida, where he founded what would become one of the largest hospitalist groups in Central Florida. After establishing the first Leapfrog-compliant critical care medicine service at Dr. P. Phillips Hospital in 2007, Velardi joined Orlando Health-Health Central in 2012 where he has held more than a half dozen leadership roles and received the Physician Colleague Award in 2014. “I love what I do. I love this hospital and I love the community,” said Dr. Velardi. “I hope that when I do leave the hospital eventually, that people will remember me as a person who has made a difference.”

When a staff member requests a raise in wages, several factors must be reviewed and taken into consideration. Recap for Raise Request Tenure: How long has the staff member been with your practice? Performance: How have they performed in accordance with their job description? Attendance: The number of days absent from work or tardy beyond ten minutes. Importance: How vital is the service they perform in your practice?

THE

save date Wednesday OctOBER 16 Topic: TBA Speaker:

Cost: What is the cost to find, hire and train someone new? When you have the discussion, it is important to be prepared. You should have all the necessary information and facts at your disposal: • Job description • Attendance record • Figures that indicate the affordability of granting such an increase • How they get along with their peers

• How much daily patient interaction they have The Employee Review Process: The 30-Day Review The new employee is given their orientation, job description, benefits package and work schedule confirmation. Additionally, they are also meeting their peers, getting up to speed with process and procedures as well as seeing if they are a good fit for their new role in the practice. Your observation of them throughout this process is critical. The 90-Day Review This can be used to see if the staff member has met or exceeded their job description. If so, a slight raise may be in order, but bear in mind that it should only be a percentage of what would be given for an annual review. If further improvement is needed, then the next opportunity would be the six-month review. The 6-Month Review The purpose of this review is to ensure that the new employee is staying on track and to bring up any issues on both sides. You can also use this opportunity to offer as an incentive, usually a percentage of the raise due for the year. The Annual Review This is the time to give commendation, say thank you for a job well done and give the remainder of the scheduled wage increase for the year. Apart from as a reward for a job well done, a raise is your way of saying not only thank you but to indicate that you value their service and would like to keep them. So, while on the surface it may seem that your staff is replaceable. The truth is it takes both time and money to replace the knowledge and experience of a tenured staff member. It also slows down future growth

PHYSICIANS & PRACTICE ADMINISTRATOR–MANAGER EVENT

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PRESENTATIONS 7-8:15PM Andrew Cole Introducing the EOCC’s Health Council Larry Jones Independent Physicians Solving the Healthcare Crisis

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plans and sustained growth in other team members because they get saddled with picking up the workload for a missing or new hire trainee. Which reduces productivity gains from their job responsibilities and continuity within the practice. Profitability and sustainability of your practice is a team effort and you are the Team Leader, so be flexible, be their coach, cheer them on when they treat both their internal and external customers well. As a group, you spend more than forty hours per week together. Make it time well spent for one another. Make your practice elite and successful by being the place that most people want to work. It will definitely show in your bottom line and peace of mind. An Annual Practice Review will go a long way to identify problems and issues related to staffing before they reach a critical stage. It will also help to provide and encourage an opendoor policy that focuses on team building, providing weekly practice and staff development sessions, and to help you to create and implement an anonymous suggestion box which allows staff ideas to be considered. No doctor or practice manager is an island unto themselves, you can’t run a practice alone. So, make staff retention a primary focus in your practice. So, who’s to blame, you say? You decide for your own practice? But doesn’t it make good business sense to try and work things out or provide additional training and compensation? And just remember, a staff that feels appreciated will always do more than what’s expected!

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What Physicians Need to Know about CBD By STACY BIRNBACH

It was an expected, but still a momentous, date. On June 25, 2019 the Florida Governor (Ron DeSantis) approved Florida Senate Bill 1020, which introduced legislation designed to regulate the sale and use of CBD, a marijuana derivative. The bill was remarkable in that it passed with almost unanimous bipartisan support and follows the federal government, which legalized CBD late last year. Now that CBD is legal to grow and use in Florida, more and more physicians are exploring the health benefits of CBD for their patients. Although CBD is derived from the same cannabis plant as marijuana, it does not contain THC, the psychoactive component of cannabis. Pursuant to federal regulations, CBD is legal as long as it does not contain more than 0.3 percent of THC. As a reaction to the new federal CBD regulations, Florida created a legal framework for the new CBD regulations in the state. The new law launched a state CBD program designed to promote the cultivation and distribution of CBD. The law also restricts the sale of CBD to only those businesses that register with the Florida Department of Agriculture and Consumer

drops, vapor cartridges, topical creams, and even chocolate bars. Be aware, however, the amount and quality of CBD varies widely by manufacturer. Can my patients become addicted?

Several studies have concluded that CBD by itself is not addictive. On the other hand, sometimes CBD contains THC, which can be addictive. A patient of mine is suffering from epileptic seizures and is resistant to traditional treatments. Can CBD help?

Services. Farms and businesses who intend to cultivate and produce CBD must provide extensive information about their operation to the department, including details like the exact GPS coordinates of their plants. For physicians, it is important to understand no one can distribute CBD without a certificate of analysis from an independent testing laboratory, confirming each batch does not contain more than a total of 0.3 percent of delta-9-tetrahydrocannabinol concentration on a dry weight basis. The laboratory must also certify each batch is free of unsafe contaminants. Florida is still in it’s cannabis infancy. Misinformation is abundant, and Florida, along with other states, has struggled with

Got CBD?

it’s CBD roll-out. For example, the new federal Farm Bill has put Florida’s new agricultural commissioner, Nikki Fried, in a bind. She ran on a platform featuring making CBD and medical marijuana more widely available, but has faced opposition from a variety of sources. Florida lawmakers are still largely playing legal catch-up. Some common questions physicians have about CBD: What is it? CBD is an acronym for canna-

bidnol, and it is a natural compound found in hemp and marijuana plants.

How is it taken? CBD comes in several forms, including chewable gels, sublingual

The FDA has approved Epidiolex, a CBDbased drug, for treating two rare forms of epilepsy: Dravet sydrome and LennoxGastaut syndrome. Does CBD oil treat pain? The short an-

swer is we simply don’t know yet. Scientists are currently testing CBD as a treatment for arthritis, and there is anecdotal evidence that it can help people with HIV-related nueropathy. Finally, some recent research indicates CBD may provide relief from muscle spasms linked to Multiple Sclerosis.

Can CBD oil help patients with hypertension? At this time, there is no scientific

evidence that CBD can lower a patient’s blood pressure. What about inflammation? Several early (CONTINUED ON PAGE 10)

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ORLANDO NEUROLOGY

Brain Tumor...Now What?, continued from page 7 tumors through very small openings. Other therapies include, implantable chemotherapy or radiation wafers. The diagnoses of any type of brain tumor is certainly life altering.The most important first part is a consultation with a neurosurgeon who works in a team of doctors who are all focused on treating brain tumors. A number of tumors can be observed or treated with radiation.When surgery is necessary, the above advances in technology make the operation safer, more precise, and less invasive surgery improving the chances of a great outcome. Dr. Ravi Gandhi joined Orlando Neurosurgery following a cerebrovascular and skull base neurosurgery fellowship at Goodman Campbell Brain and Spine in Indianapolis, Ind. and a neuroendovascular fellowship at Albany Medical Center in New York. A neurosurgeon with nearly a decade of experience and a wide variety of peer-reviewed articles and oral presentations he has a special interest in the detection and treatment of complex brain and spinal tumors, blood vessel disease of the head and neck, and emergency treatment of neurological trauma and stroke. Visit www.orlandoneurosurgery.com

CANNABIS CORNER

What Physicians Need to Know about CBD, continued from page 9

studies on this treatment indicate CBD may help with inflammation due to Diabetes, Alzheimer’s Disease, Multiple Sclerosis, and Arthritis.

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Can CBD help treat the symptoms of cancer? Several studies have been conducted

with CBD and lab mice, and CBD showed promise by making chemotherapy work better. There is also some evidence that CBD may be effective at killing breast cancer cells.

Is CBD used to treat psychosis like schizophrenia? To date, there has been only

one accredited study on CBD and psychosis but it was unclear how effective CBD was. Can CBD help treat addictions? This

possibility is still being studied. Some early results look promising in helping patients dealing with cocaine, heroin, methamphetamine, and opioid addictions.

What are the side effects? Numerous studies have been conducted on identifying side effects, and so far there is no evidence of anything serious. That being said, there have been reports of fatigue, diarrhea, and changes in appetite when used to treat psychosis and epilepsy. Summary In the end, physicians should keep

in mind CBD is still being evaluated for a wide range of conditions. In the very near future, your practice will likely be dealing with cannabis is some way. Mounting evidence indicates patients will often try CBD without consulting their physician beforehand. Physicians who are open to the treatment possibilities of CBD will likely find an increase in their patient number and satisfaction.

MagMutual.com

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Stacy Birnbach is the Founder and President of CBD for Total Health and provides CBD products imported from the Austrian Organic Farming Zone, which is in a rare location untouched by pesticides. The company has invested in Triple Lab TestedTM products in both the US and Austria, and whose product is listed in the Physician’s Desk Reference.

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Amino Acid Therapy for Addiction By KEVIN BIASI

This modern approach to drug and alcohol dependence and addiction is one of the best kept secrets in the addiction recovery industry. Amino acids have proven to be the most effective method in assisting the body and brain in repairing damages done by drugs (either illegal or prescription), alcohol, marijuana, and nicotine. Ironically, this procedure is being performed by one of the best kept secrets in the industry as well, Serenity Springs Recovery Center in New Smyrna Beach, Florida. As many addicts will tell you, addiction is less about what they are addicted to and more about why they are addicted to it. As more and more research emerges around addiction and treatments for addiction, it is clear that the brain and its functions play a huge role. Without physically changing the way the brain is working, addictions are nearly impossible to overcome. Even if one habit is dropped, another will be picked up just as quickly. This is why many addicts are known to jump from substance to substance, habit to habit. Many addictions are indeed more genetic or psychological than they are physical. Of course, whether or not an addiction is truly a disease or a mental illness is still up for debate and remains to be a highly controversial subject. However, debating what causes addiction or why people become addicts isn’t immediately helpful for individuals

dealing with its effects right now. In order to help individuals with addictions function in daily life, and perhaps even save their life in some cases, effective treatments need to be discovered and made available. The NeuroRecover formulas assist neurological repair of the addicted brain while reducing or eliminating cravings. This can help to manage symptoms and as an ongoing strategy to restore brain normalcy and well-being. It is designed to rapidly assist the addict’s body in restoring neuroreceptor function to normal levels. Once the body’s neuroreceptor functions have been healed, the patient’s cravings, anxiety, and depression are reduced or eliminated, allowing the physician to remediate any underlying conditions that may have led to the original substance abuse. NeuroRecover™ was pioneered by the late Dr. William Hitt with 20 years of intensive research with hundreds of patients. Dr. Humiston was trained by Dr. Hitt and has been treating patients with NeuroRecover™ since 2003. Dr. Humiston wrote the Clinicians’ Manual used to train other physicians on NeuroRecover™ and continues to train other physicians on its use. NeuroRecover™ has been shown on SPECT brain scans performed at the Dr. Daniel Amen Clinics, in images taken before and after treatment, to promptly bring about significant improvement in function in the drug-damaged brain. As the amino acid therapy treatment rapidly reduces cravings

Eliminates Drug Cravings from: • Alcohol Addiction or Alcoholism • Amphetamine (Meth, Adderall) Addiction • Barbiturate (Phenobarbital) Addiction • Bath Salts & Flakka Addiction • Benzodiazepine (Xanax) Addiction • Cocaine & Crack Addiction • Ecstasy & Molly (MDMA) Addiction • Marijuana (THC, CBD, K2) Addiction • Hallucinogen (LSD, Peyote, DMT) Addiction • Methadone Addiction • Methaqualone (Quaalude) Addiction • Nicotine & Tobacco Addiction • Opioid (Heroin, Oxy, Fentanyl) Addiction • Phencyclidine (PCP/Angel Dust) Addiction

and in almost all cases eliminates them, patients can expect the benefits to last – to live without cravings, and to have restored clarity of mind and well-being. In active addiction, a user will have damaged their neuroreceptors to a point where they no longer function properly. Since they become so impaired, the addict has to use drugs in order for his or her neuroreceptors to work. Amino acids can be seen as a “reset” button where those damaged receptors go back to a point before introducing toxins and poisons throughout addiction. Amino acid therapy is given intravenously, bypassing the overworked digestive system,

and are much more effective as a result. NeuroRecover™ is an amino acid therapy administered as a daily intravenous solution for eight hours a day. This prolonged exposure to specific amino acids and NAD bathes the damaged nervous system in an abundance of repair materials. The brain is then able to rapidly employ these natural materials to speed healing and close up the chemical deficiencies that drug, alcohol or marijuana exposure has caused, which minimizes withdrawal and results in lasting healing in almost all cases. The total treatment time varies from five to eight days for those already clean from the substance(s) for three weeks or more, to ten to fifteen days for those who are currently using or who are dependent on a number of substances. The treatment ends when the patient feels no cravings and has restored clarity of mind and enthusiasm to be alive. Protocol NeuroRecover™ is also known as infusion therapy or amino acid therapy, and uses proprietary amino acid based intravenous preparations to assist neurological repair of the addicted brain. Serenity Springs proven infusion therapy program generally lasts 6-8 hours per day for approximately 10 days. It is usually recommended that a client begins the therapy halfway through their stay in treatment. Content sponsored by Serenity Springs Recovery Center. Visit www.serenityspringsrecovery.com

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Cognitive Screenings By RAMI PACKARD DR. ESTÉE DAVIS

and

More Americans than ever are suffering from mental and emotional distress. According to a new study published in the journal Psychiatric Services, 3.4 percent of the U.S. population, or more than 8 million Americans, suffer from serious psychological distress (SPD). Just a few of the major challenges we are facing:

• Deaths - over 50,000 deaths occurred from Opioid related addictions in 2016 • Prescription Pain Killers caused 40 percent of deaths • Mood Disorders - the third most common cause of hospitalization in the U.S. • Mental Illness - increasing while insurance coverage and effective treatment declines • Opioid Addiction - $6 billion is being set aside by the government for treatment And then there’s Alzheimers. Every senior needs cognitive screening according to the Alzheimers Association. Many patients delay seeking answers to cognitive decline according to a survey included in the Alzheimer’s Association’s 2019 Alzheimer’s Disease Facts and Figures report. “We need to increase the confidence and the skill of front-line providers so they can provide more care in this area,” said Joanne Pike, chief program officer at the Alzheimer’s Association. “And we need to destigmatize the process for seniors, encouraging people to talk to their health care providers and families about their concerns,” she said. In the Alzheimer’s Association annual report, they include a call for action to the nation’s primary care physicians. Every senior should receive a brief cognitive assessment at their first Medicare annual wellness visit at age 65 and the exams should be a regular part of their ongoing annual care. Yet a survey by the association found that early cognitive assessments were not the norm during most senior doctor visits. “The survey found a really troubling underuse of cognitive assessments during the annual healthcare checkup,” said Pike. “Despite a strong belief among seniors and physicians that cognitive assessments are important for the early detection of Alzheimer’s, only half of the seniors in the survey were being assessed for cognitive decline. And only 16 percent of seniors received regular followup assessments.” A comparison of those statistics against those of other wellness checkup items give a clear picture of the disparity, Pike said. In each visit, physicians check cholesterol 83 percent of the time, vaccinations 80 percent and blood pressure 91 percent of the time, she said. 12

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“So, while physicians say it’s important to assess all patients age 65 or older, fewer than half are saying that it’s part of their standard protocol,” she said. A good bit of that might be due to “a strong disconnect between seniors and doctors as to who should initiate the conversation,” Pike said. Over 90 percent of seniors thought their doctor would recommend testing, so fewer than 1 in 7 brought the topic up on their own, the survey found. Primary care physicians, on the other hand, say they are waiting for senior patients and their families to report symptoms and ask for an assessment. “We need to increase the confidence and the skills of front-line providers so they can provide more care in this area,” Pike said. “And we need to destigmatize the process for seniors, encouraging people to talk to their health-care providers and families about their concerns.” With no significant treatment and no cure in sight, the association’s report projects that by 2025, the number of Americans 65 and older with Alzheimer’s will “reach 7.1 million – almost a 27 percent increase from the 5.6 million age 65 and older affected in 2019. It’s the “oldest old,” those over 85, who are most at risk for Alzheimer’s, the association says. In 2019, there are just over 2 million Americans 85 and older; in 2031, when the first wave of baby boomers hits that age, the number will rise to 3 million. By midcentury, there will be 7 million of the “oldest old” in the United States accounting for half of all people over 65 with Alzheimer’s. The cost to society will be substantial, the report says. In 2019 alone, it estimates a $290 billion burden from health care, longterm case and hospice combined. Medicare and Medicaid will cover $195 billion of that, with out-of-pocket costs to caregivers reaching $63 billion. Cognitive Assessments or Behavioral Health Assessments no longer have to be long paper forms that are confusing for the patient and difficult to score. There are innovative and customizable solutions that even the insurance companies are starting to acknowledge and reimburse those physicians with higher amounts. These Assessments are for anyone on opioids, at risk of abuse with drugs or alcohol, cognitive decline, PTSD, anxiety disorders, fall risk and so many more. These automated assessments allow physicians to accomplish two important things:

1. Provide improved patient care 2. Add additional revenue streams to the practice and yes … they can be significant! There are a variety of different screenings to choose from based on your practice and patient’s needs. All automated selfscreenings are billable from both commercial and government payers. With the opioid epidemic still hitting

the nation strong and mental illness on the rise; by 2030, depression is expected to be the number one disease burden globally; the government is weighing in. As of February 20, 2018, the government has set aside $6 billion for the treatment for patients who suffer from Opioid addiction. One of the government’s solutions for early detection of cognitive decline: Screenings. If you are currently offering screenings and NOT getting reimbursed as a provider, start getting paid today. If you are offering the screenings AND getting reimbursed, are there some screening opportunities you are missing for your patients?

In some states, these screenings can substitute for a monthly check in for your patient on opioids and they reimburse significantly higher as their worth is shown to exceed a regular checkup. The revenue potential can be upwards of $20/screening with NO fees and very little training or additional time needed for you and your staff. If you were to screen just 5 pts/day and each patient took 2 screenings each, that means your practice could bring in an additional $4,000 per month. Rami Packard is a Regional Developer for RX2Live and assists the growth of medical practices and helps keep their patients well. She also assists with senior and corporate wellness programs. Visit https://livewell.rx2live.com/ or contact her at rpackard@rx2live.com Dr. Estée Davis, PharmD, owns an RX2Live franchise in Melbourne, FL. RX2Live is the only Medical Services Franchise to offer over 18 services for all physician types including specialists and nurse practitioners. She specializes in improving care scores while increasing revenue with NO out of pocket costs to the practice. To learn more about how your practice can benefit from implementing medically necessary procedures into your daily routine, contact or visit edavis.rx2live.com

We Need Your Help! Shepherd’s Hope, the largest free and charitable clinic in Florida, is seeking Orthopedists to provide volunteer care for our patients (one three hour shift per month) at one of our five convenient locations in Central Florida. For volunteer information contact Abby Seelinger, Manager of Volunteer Programs (407) 876-6699, ext. 233 | abby.seelinger@shepherdshope.org or visit www.shepherdshope.org/volunteers.

SHARE YOUR PASSION: Help those in need of hope and healing in our community by joining our clinical and non-clinical volunteers at Shepherd’s Hope.

More volunteer doctors and nurses needed now more than ever to help fill the immense demand for healthcare services to the uninsured and under-insured men, women and children in Central Florida.

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The Downside of Doing Commercial Real Estate Yourself By DOUG PRICE

Are you one of the rare healthcare providers or administrators who understands how much is at stake in commercial real estate negotiations? If so, then you probably know that commercial real estate is the highest negotiable expense for your healthcare practice. Consequently, most healthcare providers fall into the statistic that tells us that 80 percent of healthcare practices still take a ‘do-it-yourself ’ approach to these crucial negotiations and site selection process. In this article, we will break down several reasons why doing commercial real estate without representation will likely cost you a significant amount of time and money. Time The average commercial real estate transaction takes dozens of hours to complete. When you calculate the hours of research, driving the market, communicating with listing agents, touring properties, negotiating letters of intent (LOI’s), negotiating lease contract terms, printing / signing / mailing documents, and the dozens of other miscellaneous tasks you encounter in almost every commercial real estate deal, you can easily spend 30-40 hours or more on a single transaction. That equates to an entire week of work! Given the fact you have a full-time job already, you have two options as to where you will find those hours: 1. During normal business hours (when you could otherwise be generating revenue) or 2. During your valuable time off that would normally be spent with your family, relaxing, taking care of personal errands or making memories with those you love. Neither option is a good one, especially when you consider how much money you could be making per hour if you invested that time into your practice. Since time is a commodity you cannot get back, it’s important it be invested where it can yield you the highest return. Money The average healthcare practice loses tens of thousands of dollars in this ‘do-ityourself ’ approach. In the vast majority of commercial real estate transactions, you will also be working with a listing agent. That agent has a fiduciary responsibility (legal obligation) to the landlord to ensure they get the best possible deal and that their interests are protected and paramount over any other party in the transaction. This is also the person who actually collects a commission on the transaction. The commission amount is set aside before the property is even listed, and it will either be paid to the listing agent only or it will be split between the listing agent and the agent you hire to represent your needs. Often times if there is no buyer / tenant agent, the listing agent gets paid an amount that equals a ‘double commission’. 13

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If you take the ‘do-it-yourself ’ approach, someone else is making the money for doing the job you did yourself. The craziest part is, the person making money is opposing you in the transaction! And, you just helped that person collect twice as much as they would have if you would have hired an expert agent to represent your needs and protect your interests! This could be because you don’t actually understand everyone’s role within a deal. After all, when you called the name on the sign, they told you they wanted to help you get into the space! The problem is that to them, you are just a customer. The landlord is their only client in the deal. That might not sound like a big difference, but it has a HUGE impact on the outcome of the terms that each party receives. They have a legal obligation (called a fiduciary) to ensure the landlord gets the best possible deal within your transaction. They have no such obligation to you, since you are not their client. Without representation that looks out for your best interests, you are almost guaranteed to leave a significant amount of money on the table during negotiations. Experience Some tenants and buyers balk at the idea of hiring an agent to represent them in a commercial real estate transaction through an agency agreement. Those people typically don’t understand that agency is a term created by governmental bodies to protect the consumer (you). If you don’t have an agent involved to exclusively represent you in your transaction, then there is no real estate expert who has a fiduciary responsibility to protect your interests. The vast majority of landlords have an agent and other experts they regularly consult with that work diligently to ensure the landlord receives the best deal possible. Think about that for a moment… The landlord, who has done hundreds of real estate transactions and whose entire livelihood is based on real estate, hires an agent so they can leverage that agent’s experience. Why would a healthcare buyer or tenant who will only transact a few times over the course of their career try to do it alone? Knowledge This is the most important part of representation. We live in a world where “knowledge” is at our fingertips. The problem is, the knowledge that is available is often a cheap knockoff of the real thing. Have you ever had a patient confidently give you their diagnosis of what is happening to them because they looked it up on WebMD? When you explain to them their actual diagnosis, they say, “Are you sure?” They are trying to compare your thousands of hours of experience with their 15 minutes of Googling symptoms. There is a monumental difference in your experience versus theirs. Be careful getting too frustrated, though, because many doctors and practice administrators do the same thing

when it comes to commercial real estate. Those doctors and administrators will hop on a commercial real estate website for 15 minutes, and now they are suddenly a commercial real estate expert. What they fail to acknowledge is that anyone can find properties or call or email a listing agent to get a property brochure. The part where expert guidance is needed is found during the negotiations (and there is definitely more to a negotiation than simply the lease rate or purchase price). This concept is also important in deciding how you select your agent. Many doctors fail to realize the complexities of commercial real estate and imprudently hire a residential real estate friend or patient. That is similar to having a tooth ache and going to the veterinarian for help. Sure, they may have some dental experience (on felines), but it’s hardly the same thing. Ok, I need an agent. How do I go about picking the right one? Here is a quick guide to ensure you are covered. Good: Having a commercial real estate agent represent you in your real estate transaction. Better: Having a commercial real estate agent who only represents buyers and tenants represent you in your real estate transaction.

(This prevents any potential conflict of interest and also ensures you will see every potential property available to you.) Best: Having a commercial real estate agent who only represents healthcare buyers and tenants represent you in your real estate transaction. (This not only ensures you of their unwavering loyalty to you against any possible landlord, but it also ensures you have someone who understands your real estate needs and how to structure a deal that best suits your unique situation as a healthcare provider.) When it comes to ‘do-it-yourself ’ real estate negotiations, you don’t save any money. Instead, you stand to lose a fortune. Hiring an agent will at a minimum save you a substantial amount of time. Hiring the right agent can ensure you get into the best possible situation and has the potential to save you tens to hundreds of thousands of dollars in your next transaction. Doug Price is an agent with CARR Healthcare, the nation’s leading provider of commercial real estate services for healthcare tenants and buyers. Every year, thousands of healthcare practices trust CARR to achieve the most favorable terms on their lease and purchase negotiations. CARR’s team of experts assist with start-ups, lease renewals, expansions, relocations, additional offices, purchases, and practice transitions. Healthcare practices choose CARR to save them a substantial amount of time and money; while ensuring their interests are always first. Contact Doug at Doug.Price@carr.us

Does your lease expire in the next 24 months? If so, allow our team of expert negotiators to save you a substantial amount of time and money.

DOUG PRICE Agent | Florida 407.717.0716 doug.price@carr.us

CARR.US

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Recent Advances in Florida’s Telehealth Law By BRIAN C. EVANDER, Esq.

As we close in on the last quarter of 2019, the telehealth industry has never been larger, and Florida is no exception. On April 29, 2019, Florida’s legislature passed HB 23, a bill intended to provide additional guidance to health care providers regarding the delivery of telehealth services to Florida patients. HB 23 was then approved by Governor DeSantis on June 25, 2019, enacted as § 456.47, Florida Statutes, and made effective on July 1, 2019. § 456.47, Florida Statutes, fulfills several important functions that health care providers in Florida have desired for some time, including more specifically-defined telehealth practice standards, as well as a registration process for health care providers from outside of Florida to use telehealth to deliver health care services to Florida patients. § 456.47 defines telehealth practice standards and, in some cases, expands the permitted scope of telehealth in Florida. Under Subsection (2)(b) of § 456.47, telehealth providers are permitted to perform patient evaluations using telehealth. Moreover, if the telehealth provider conducts a patient evaluation sufficient to diagnose and treat the patient, that provider is not required to research the patient’s medical history or conduct a physical examination of the patient before using telehealth to provide health care services to the patient. Under Subsection (2)(a) of § 456.47, a telehealth services provider does have a duty to practice in a manner consistent with her or his scope of practice and the prevailing professional standard of practice for a health care professional who provides in-person health care services to patients in Florida. Further, pursuant to Subsection (2)(c) of § 456.47, telehealth providers may not use telehealth to prescribe a controlled substance except under one of four particular circumstances. Specifically, only if the controlled substance is prescribed using telehealth:

ment at hospitals. That said, prescribers using telehealth should ensure they remain mindful of not only the above state laws, but also federal laws addressing the remote prescribing of controlled substances (such as under the Ryan Haight Act). It is ultimately each provider’s responsibility to ensure that their telehealth and prescribing practices are compliant with both state and federal laws as applicable. Subsection (4) of § 456.47 sets forth the process of registering as an out-of-state telehealth provider for purposes of providing health care services using telehealth to patients in Florida. In essence, out-of-state health care providers can use telehealth to

deliver health care services to Florida patients even without a Florida license if the provider registers with the Florida Department of Health or applicable board, meets certain eligibility requirements, and pays a fee. More specifically, the provider must: (1) Complete an application as prescribed by the Florida Department of Health or applicable board; (2) Maintain an active, unencumbered license issued by another state that is substantially similar to the corresponding Florida license; (3) Not have been the subject of disciplinary action relating to her or his license for the previous 5 years; (4) Designate a registered agent in Florida for service of process; and (5) Demonstrate

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2. For inpatient treatment at a hospital licensed under Chapter 395, Florida Statutes; 3. For the treatment of a patient receiving hospice services as defined in § 400.601, Florida Statutes; or 4. For the treatment of a resident of a nursing home facility as defined under § 400.021, Florida Statutes. The above represents a notable expansion of the use of telehealth in controlled substance prescribing in Florida. Prior to the passage of HB 23 and subsequent creation of § 456.47 on July 1 of this year, prescribing of controlled substances using telehealth was restricted to the treatment of psychiatric disorders and inpatient treat15

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Brian C. Evander, Esquire is a partner at Lowe & Evander, P.A., and regularly represents providers, physicians and other licensed health care professionals, and facilities in a wide variety of health care law matters. For more information regarding those health care law and such matters please visit our website www.lowehealthlaw.com or call our office at (407) 332-6353.

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1. For the treatment of a psychiatric disorder;

that he or she maintains professional liability coverage which specifically includes coverage for telehealth services to patients in Florida (in amounts equal to or greater than what is required for a Florida-licensed practitioner). Depending on the specific license, additional requirements may apply. On the other hand, Subsection (6) of §456.47 may provide a potential exemption to the above registration requirements under limited circumstances, such as in the case of telehealth services provided in response to an emergency medical condition or in consultation with a Florida-licensed health care professional who has ultimate authority over the diagnosis and care of the patient. While this article touches on multiple aspects of telehealth law in Florida, it is by no means a comprehensive review of all relevant statutes, rules, and laws governing telehealth services in Florida and is not intended to be (and should not be construed as) legal advice. Telehealth is an evolving and - quite frankly complicated field. Meeting the ever-changing telehealth requirements and complying with applicable state laws (such as § 456.47) and federal laws will continue to require careful assessment and analysis by knowledgeable health care counsel. We are proud to offer such legal services, as Florida health law continues to advance and develop.

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Importance of Clinical, Academic and Community Partnerships By MARGARET BRENNAN

To provide the best care for a community and its residents, you cannot do things alone, or by yourself. You need to establish and grow trusted relationships with your peers and partners to maximize the positive impact you can have on a population. Community Health Centers, Inc. has been blessed with several outstanding partnerships since our founding in 1972. These relationships include academic partners such as Florida State University, Valencia College, University of Florida and the University of Central Florida, as well as close partnerships and alignment with health systems such as AdventHealth and Orlando Health, among others. These valuable relationships contribute to our success as a Federally Qualified Health Center (FQHC) in many ways. From financial support to expand necessary services and facilities, to providing a training pipeline for the next generation of medical or dental providers, pharmacists, nurses, medical staff and dental assistants, we are grateful to those that share in our mission. By having a strong community focus, a non-profit organization such as ours is able to develop a strong community reputation. By building trust with our patients, we are able to truly become partners in not only their care, but also their life. We seek to care for the whole person, and this includes assisting with nutrition and emotional health as well as physical wellness.

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For example, we have developed innovative partnerships with local foodbanks to develop prescription health programs, that have a significant impact on managing conditions such as diabetes for our patients. We also work very closely with our local WIC and Healthy Start programs, as well as the Farmworker Association of Florida, to provide care to those that might not otherwise have access to quality options. Our community partnerships also benefit us in staffing our facilities and health centers. As a region that is currently facing shortages in the workforce, it is important to

develop programs that will help attract students to the medical field and help bridge the gaps that currently exist in filling our entrylevel positions. We are proud to serve culturally diverse communities and our workforce reflects that. There have been numerous instances where our patients eventually move on to become our employees. It is an amazing feeling to see a patient who trusts you with their care, want to give back and serve other patients in a similar way. Our centers are staffed with friends and neighbors caring for other friends and neigh-

bors. This is ultimately what partnerships are about and demonstrates the positive impact and influence a Federally Qualified Health Center can have within a neighborhood. I invite you to learn more about our many partnerships, and the value that they bring to our patients and our community. For more information, or to view available career opportunities, please visit www.chcfl.org/ about/chc/ Margaret Brennan is President/CEO of Community Health Centers, Inc.

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Florida- One of the Fastest Growing Medical Marijuana Programs in the USA By MICHAEL C. PATTERSON

The U.S. currently has 34 states in which medical cannabis is legal. Since cannabis is still considered illegal by the federal government, each state must create their own rules when it comes to legalizing and implementing a medical cannabis program. This leads to the effect of each state becoming their own “country” when it comes to cannabis law and regulation. Some states have law allowing the medical cannabis market to grow quickly (which could be bad), and some have more balanced law to grow slowly and build over time (which is more ideal). Marijuana Business Daily recently performed analysis of the fastest growing state markets in the United States. They found Oklahoma is highest in daily patient growth, followed by Florida, Ohio, and Illinois. The historical average for patients who qualify for Medical Marijuana (MMJ) is 2-4 percent of the state’s total population. Oklahoma’s Medical Marijuana program growth is 641 patients per day (currently total number of patients are 4.1 percent of population). This growth is unbelievably

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high in such a short amount of time (OK legalized through Constitutional Amendment in 2018). The state requires a physician recommendation for MMJ but has ZERO qualifying medical conditions. Furthermore, there are no limits on the number of licensed MMJ cultivators, processors, and dispensaries. As of July 2019, Oklahoma has over 150,000 total MMJ patients and over 6,500 licensed businesses! This unprecedented rapid growth of MMJ patients and stores has led to problems such as robberies of MMJ dispensaries and internal employee theft, black market sales

of product, and decreased tax revenue by the OK Tax Commission due to dealing with an all cash MMJ businesses. Furthermore, certain marijuana businesses are starting to fail due to the low “bar” set by the constitutional amendment which states the only requirement to open a marijuana business is passing a background check and paying $3,500 (there is no requirement for previous business experience of any kind). In regard to banking marijuana businesses, few banks in Oklahoma publicly advertise the ability to bank marijuana companies, which can create a tremendous public safety problem with so much cash being moved around society. Florida’s growth has been just as impressive as Oklahoma but has taken many more years to become steady. Florida is increasing the number of MMJ patients by 609 each day (over 222,000 per year). The big difference in Florida’s system is limited marijuana business licenses (only 22 as of August 2019), and slower roll-out of dispensaries (approximately 130 across Florida as of August 2019). However, Florida allows

statewide home delivery which increases access for people with limited mobility. This limit on the number of licensed entities has caused prices to remain high, but there have been ZERO public safety issues within the state related to MMJ (no robberies, theft of dispensaries or processors, no major compliance issues with licensed entities). Florida’ percentage of population who currently have an MMJ doctor recommendation is 1.6 percent. This is low but will continue to grow exponentially to over 4 percent of the state population (over 880,000 residents) by 2021. With the state of Florida gradually continuing to increase licensed entities, it will allow the state to continue steady, consistent growth of the MMJ program, decrease prices of medicine, and keep public safety of the program strong. Growth of a statewide MMJ system is good, but strong, consistent, safe growth is better. The Florida MMJ system is not perfect, by any means, but it is one of the safest MMJ systems in the country due to its current regulatory structure. 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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Medication-Assisted Treatment: A Bright Spot in a Dark Opioid Crisis By COLETTA DORADO

The phrases “opioid epidemic” and “opioid crisis” are rarely missing from today’s news. Over the last two decades, addiction to opioids—prescription drugs, heroin, and the powerful synthetic opioid fentanyl— has steadily increased in the U.S. In 2017, 72,000 people died in the U.S. to overdoses, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). Of those 72,000, more than 47,000 were opioid related, according to a 2018 Centers for Disease Control and Prevention (CDC) study. There are over 23,000 treatment centers in the U.S. treating substance use and co-occurring illnesses. With the death toll rapidly rising, and the economic cost, estimated at over $600 billion dollars a year, spiraling up yearly, the Centers for Medicare and Medicaid Services are supporting new treatment methods to improve staggeringly low clinical outcomes. One of the most promising such treatment methods has been medication-assisted treatment. What is MAT? Medication-assisted treatment, or MAT, involves treating those who have addictions by administering a drug that resembles the addictive substance in some way, but is safer and easier to control. MAT aims to treat addiction by addressing the following issues: • Cravings. Those who are addicted to opioids experience intense cravings when they do not use them regularly. This makes it difficult for them to quit, even if they “taper off” by gradually using less of the drugs. • Withdrawal Symptoms. When those who are addicted to opioids stop using them, they can often feel seriously ill. These symptoms occur because their body adjusted to the drug, and now cannot cope with not having it. • Dangerous Health Effects. In some cases, withdrawal symptoms can be deadly. Even when they’re not, they have a severe negative effect on the patient’s health. Medication-assisted treatment curtails both cravings and withdrawal symptoms, so patients won’t be in danger when they stop using opioids and will have a time to stabilize while in recovery. When combined with scheduled therapy, such treatment significantly increases the odds that a patient will successfully overcome their opioid addiction for the long haul. Medication-assisted treatment for opioids comes in many different forms. The most common medications are: buprenorphine (Suboxone®, Subutex®), which has a “ceiling effect” and is thus considered one of the safest treatment options; naltrexone (Vivitrol®), which is taken by pill or injection and is also effective for treating alcohol depen-

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dence; and methadone, which is intended for patients who are addicted to opioids in high doses. Benefits and Concerns Some seasoned addiction treatment professionals understandably have qualms about medication-assisted treatment. Some common concerns include: • Isn’t this just replacing one addiction with another? • What about abstinence-based care? • If a person is regularly using another opioid substance, like buprenorphine or methadone, to reduce withdrawal symptoms, have they really been cured of the addiction? There are elements of truth in all of these. The argument of “replacing one addiction with another” has been levied against maintenance treatment for opioids predating the invention of buprenorphine, when methadone was the only option on the market. There is no simple fix to addiction. Induction, stabilization and maintenance are key. A physician can’t treat a dead person. Ultimately the benefits of MAT must be weighed against the supposed cost. By using safer and easier-to-control withdrawal management drugs, rather than illicit substances like heroin, the risk of dying due to overdose drops dramatically. Additionally, these substances do not get those with opioid use disorders high. Rather they simply alleviate the symptoms of withdrawal, assisting Opioid Use Disorder (OUD) sufferers in their path to recovery. Studies have shown that treatment programs using MAT report fewer relapses than programs that do not. Additionally, it’s cheaper: the U.S. Surgeon General reported in 2018 that SUD sufferers receiving buprenorphine in conjunction with counseling accumulated healthcare costs of $13,578, compared to $31,055 for SUD sufferers receiving little or no treatment. MAT’s Destigmatization at the National Level Despite detractors, medication-assisted treatment has become increasingly destigmatized in recent years. In November 2017, sixteen major healthcare payers released a statement in support of MAT, including the line: “Just like with any other chronic disease, medication is appropriate for treating some addictions. It should be destigmatized and easily accessible.” In October 2018, the federal government followed suit. The landmark Opioid Crisis Response Act, comprising 70 bills aimed at addressing the opioid epidemic, included several provisions related to MAT. The act loosened restrictions on MAT and also created grant programs to go toward Medicare and Medicaid coverage of MAT. Addiction treatment continues to shift

to further accommodate medication-based addiction treatment methods. At the time of this article, SAMHSA reports 1,688 Opioid Treatment Programs (OTP)—MAT programs accredited as OTPs by the Joint Commission. SAMHSA also reports 3,786 Office-Based Opioid Treatment programs, where buprenorphine is administered in an outpatient setting. These numbers increase every month. Physicians are recognizing the opportunity in MAT, an opportunity to increase the patient population that they serve, create a complementary business model and

deliver a much-needed service in any community. Stay tuned next month for another editorial covering rules and regulations, and the logistics of opening a MAT program. Coletta Dorado is the Founder and CEO of AZZLY®, Inc. With more than 30 years business workflow process experience, Dorado, since 2009, has dedicated herself and her team to improve clinical and business in healthcare. Their latest version of software is specific to the addiction treatment and behavioral healthcare sector. AZZLY Rize™ is an all-in-one clinical and billing solution designed to eliminate duplicate order entry and reduce human error to improve patient outcomes. Contact hello@azzly.com or visit azzly.com to learn more.

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Terminating Patient Relationships By JULIE BRIGHTWELL, JD, RN and RICHARD CAHILL, JD,

Just as it is an acceptable and reasonable practice to screen incoming patients, it is acceptable and reasonable to know when to end patient relationships that are no longer therapeutic. It is critical, however, that the physician end the patient relationship in a manner that will not lead to claims of discrimination or abandonment. The criteria for terminating a physicianpatient relationship are numerous and varied. Although the list is not exhaustive, it is appropriate and acceptable to terminate a relationship under the following circumstances:

• Treatment nonadherence—The patient does not or will not follow the treatment plan. • Follow-up nonadherence—The patient repeatedly cancels follow-up visits or is a no-show. • Office policy nonadherence—The patient fails to follow office policies, such as those for payment, prescription refills, or appointments. For example, the patient uses weekend on-call physicians or multiple healthcare practitioners to obtain refill prescriptions when office policy specifies how to obtain refills between visits. • Verbal abuse—The patient or a family member is rude and uses improper language with office personnel or other patients, visitors, or vendors; exhibits violent behavior; makes threats of physical harm; or uses anger to jeopardize the safety and well-being of anyone present in the office. • Nonpayment—The patient owes a backlog of bills and has declined to work with the office to establish a payment plan.

Exceptions and Special Circumstances A few situations, however, may require additional steps or a delay or even prohibit patient dismissal. Examples of these circumstances include the following: • If the patient is in an acute phase of treatment, delay ending the relationship until the acute phase has passed. For example, if the patient is in the immediate postoperative stage or is in the process of a medical workup for a diagnosis, it is not advisable to end the relationship. • If the practitioner is the only source of medical or dental care within a reasonable driving distance, he or she may need to continue care until other arrangements can be made. • When the practitioner is the only source of specialized medical or dental care, he or she is obliged to continue care until the patient can be safely transferred to another practitioner who is able to provide treatment and follow-up. • If the patient is a member of a prepaid

health plan, the patient cannot be discharged until the practitioner has communicated with the third-party payer to request that the patient be transferred to another practitioner or otherwise complies with the terms of the payer-provider agreement. • A patient may not be dismissed or discriminated against based on limited English proficiency or because he or she falls within a protected category under federal or state legislation. Examples of civil rights laws include the Americans with Disabilities Act (ADA), the Civil Rights Act, and the Emergency Medical Treatment and Labor Act (EMTALA). • If a patient is pregnant, the physician can safely end the relationship during the first trimester if the pregnancy is uncomplicated and there is adequate time for the patient to find another practitioner. During the second trimester, a relationship should be ended only when it is an uncomplicated pregnancy and the patient is transferred to another obstetrical practitioner prior to (CONTINUED ON PAGE 20)

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Terminating Patient Relationships, continued from page 19 the cessation of services. During the third trimester, a relationship should end only under extreme circumstances (such as illness of the practitioner, etc.). • Physician or dental groups with more than one practitioner may want to consider dismissing a patient from the entire practice. This will avoid the possibility that the patient might be treated during an on-call situation by the practitioner who ended the relationship. • The presence of a patient’s disability cannot be the reason(s) for terminating the relationship unless the patient requires care or treatment for the particular disability that is outside the expertise of the practitioner. Transferring care to a specialist who provides the particular care is a better approach. Steps for Withdrawing Care When the situation with the patient is such that terminating the relationship is appropriate and acceptable and none of the restrictions mentioned above are present, termination of the patient relationship should be completed formally. Put the patient on written notice that he or she must find another healthcare practitioner. The written notice should be mailed to the patient by both regular mail and certified mail with a return receipt requested. (Both types of mailing are required in some states.) Keep copies of all the materials in the patient’s medical record: the letter, the original certified mail receipt (showing the letter was sent), and the original certified mail return receipt (even if the patient refuses to sign for the certified letter). Elements of the Written Notice The written notice terminating the relationship should include the following information: • Reason for termination—Although a specific reason for termination is not required, it is acceptable to use the catchall phrase “inability to achieve or maintain rapport” or to state that “the therapeutic practitioner-patient relationship no longer exists.” • Effective date—The effective date of termination should provide the patient with a reasonable amount of time to establish a relationship with another practitioner. Although 30 days from the date of the letter is usually considered adequate, follow your state regulations. The relationship may be terminated immediately under the following circumstances: • The patient has terminated the relationship. (Acknowledge this in writing with a letter from the practice.) • The patient or a family member has threatened the practitioner or staff with violence or has exhibited threatening behavior. • Interim care provisions—Offer interim emergency care. Refer true emergency situations to an emergency department or instruct the patient to call 911 as necessary. • Continued care provisions—Offer referral suggestions for continued care through medical or dental societies, nearby hospital medical staffs, or community resources. Do not recommend another healthcare practitioner by name. • Request for medical or dental record copies—In your written notice, offer to provide a copy of the medical or dental record to the new practitioner by enclosing an 20

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authorization document (to be returned to the office with the patient’s signature). One exception is a psychiatric record, which may be offered as a summary in lieu of a full copy of the medical record. • Patient responsibility—Include a reminder that the patient is responsible for all followup and continued medical or dental care. • Medication refills—Explain that medications will be provided only up to the effective date of termination. Case Examples The following scenarios illustrate some of the issues involved in terminating a patient relationship. Case One A patient has been in your practice for about 10 years, has faithfully made regular visits, but has not been compliant with your medical regime for taking hypertension medications. You have repeatedly explained the risks of nonadherence, and you have rescued the patient on many occasions with emergent medications, usually in the local emergency department over a weekend. You are convinced that the patient understands but stubbornly refuses to comply. Should This Patient Relationship Be Terminated? With any nonadherent patient, it is essential to document your recommendations, the patient’s continued nonadherence, your efforts to help the patient understand the risks of nonadherence, and his or her failure to follow the treatment plan and advice. Terminate the relationship if the patient and physician agree that the patient would achieve better compliance with another practitioner. The written notice terminating this relationship should be explicit

in stating the reason you are no longer willing to provide care—that the patient’s outcome is predestined to be unfavorable because of his or her nonadherence with recommended treatment plans. Suggest that the patient would benefit from a relationship with another physician, and state that continued medical care is an absolute requirement. Case Two A new patient has made an appointment with your office for a full and complete physical examination. Before the appointment, the patient experienced an unusually long wait in your office as a result of your need to address an urgent situation with an infant. Your office personnel explained the delay to those in the waiting room, and this new patient reacted by becoming loud and abusive, insulting the registration person, and shouting that his time is as valuable as that of the doctor. Options for the Practitioner In the privacy of an office or an examination area, address your concerns about his behavior by indicating that the practice maintains a zero-tolerance policy for loud, threatening, or abusive behavior, and state that this type of reaction will not be tolerated in the future. After you have completed his physical examination, suggest that he seek medical care elsewhere if he is reluctant to observe office decorum. If the patient indicates a refusal to comply, consider preparing and sending a termination letter. If the patient fails to keep subsequent appointments or has notified your office that he will be seeking care with another physician, document the conversation and send the patient a letter reiterating his decision to seek care elsewhere.

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The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome.

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How Technology is Helping with Healthcare Costs

By JOSEPH C. FILICE, MBA

Business owners continuously struggle to keep up with the costs of healthcare in today’s market. Once again healthcare costs are expected to rise in 2020 making this struggle for business owners and employees even more of a battle. With this continuous struggle, employers have looked to technology for assistance and they have found the answer in telehealth. Telehealth has shown to offer affordable easy access care to employees and their families while also saving money for both the employer and the employees. Telehealth is the hottest trend in the healthcare industry and is expected to continue through 2020. Telehealth allows an employee access to a U.S. board certified physician 24/7 and covers an average of 70

percent of all doctor visits including cold & flu symptoms, allergies, sinus problems, sore throats, pink eye, respiratory infections, skin problems, UTI, ear infection, bronchitis, asthma, joint aches, fever, nausea, vomiting and much more. For an employee or their dependent to seek care, they simply go online, on the app or call for an appointment. Within minutes a U.S. board certified doctor contacts them by phone and/or secure video to assist with their non-emergency medical situations. After the consultation, the doctor then can call in a prescription to the local pharmacy of choice. The entire process of seeing a doctor for non-emergency situations and being prescribed the necessary and appropriate prescriptions has been reduced to approximately 20 minutes and you didn’t have to leave your home, job or school and you did not have to sit in a crowded doctor’s office waiting room across town and take hours out of your day. Not only has Telehealth made healthcare more accessible, it has made healthcare more accessible while saving valuable funds

for both the employer and the employees. Traditional major medical plans are hundreds of dollars in monthly premium alone not including possible deductibles and copays. Telehealth is a fraction of the cost and comes in at approximately $20 a month for the entire family. This allows the employee and their dependents to seek care for their non-emergency situations if they do not have major medical insurance, but it also allows them to save money off their medical plans, avoiding deductibles and co-pays that might apply to their medical plan if they do have major medical insurance The value of offering Telehealth does not stop at the employees and their dependents, but also helps the employer. If the employer cannot afford to offer major medical insurance but does want to be able to offer something to their employees, telehealth has been the overwhelmingly popular answer. For those groups over 50 or already offering major medical insurance, telehealth helps your group’s claims experience by directing the non-emergency medical situ-

ations in the appropriate direction versus unnecessary and costly urgent care or ER visits. The ease of access also allows employees to seek care more easily and often leading to less time off, and an overall healthier and more productive workforce. Telehealth is one of the hottest trends in the healthcare industry and is forecast to continue to grow in 2020. Telehealth provides employees and their dependents easy 24/7 affordable access to non-emergency medical needs at a fraction of the traditional price of healthcare. Telemedicine saves both the employer and employees valuable money while supporting a healthier and more productive workforce. Contact your employee benefits broker today to learn more about offering telehealth to your employees. Joseph C. Filice, MBA, is the owner of Avalon Insurance Services, LLC, located in Avalon Park Florida. Filice has been in the insurance industry for more than 13 years and is a proud member of the National Association of Health Underwriters (NAHU). Visit www.avaloninsuranceservices.com Contact him at jfilice@avaloninsuranceservices.com

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September 2019

Federal Judge Orders Summary Judgment Finding in Favor of Parrish Medical Center In a decision with potential implications for hospitals nationwide, a Federal Judge has ordered a summary judgment finding in favor of Parrish Medical Center (PMC) in a lawsuit brought against PMC by seven oncology physicians whose credentials were not renewed after they failed to provide, or cause to be provided, PMC with patient-centered data. The Court’s published opinion, released August 22, clarifies that hospital bylaws may “…allow issues outside the realm of clinical competence to be considered when evaluating a staff member’s reappointment application,” citing its February 24 order denying the physicians’ motion for preliminary injunctive relief. “This ruling has implications nationally in favor of hospitals seeking data from physi-

cians applicable to their quality of care initiatives for the benefit of patients,” said Joe Zumpano, who along with law partner Leon Patricios of Zumpano Patricios, handled the matter. “This is one of the largest instances of physician privileges’ non-renewal of which we are aware. “PMC CEO Dr. George Mikitarian and the Parrish Medical Center Board of Directors should be credited for the successful efforts regarding the matter,” Zumpano said. In his order, U.S. District Court Judge Roy B. Dalton noted, with respect to the case brought by the seven physicians affiliated with Health First - and who had privileges at PMC - “…at bottom, this dispute revolves around the thinly veiled effort of Health First to flex

Volusia-Brevard Medical News to Come Onboard Orlando Medical News is happy to announce the expansion of our healthcare coverage with the addition of the Volusia-Brevard Medical News special section of our publication. We invite all physicians and healthcare professionals to become involved by sending us your press releases and contributed editorials on topics of interest to others in the healthcare community and by signing up for free delivery of our digital publication. We primarily cover topics on the business of healthcare, clinical developments and regulatory updates. A favorite is our monthly provider spotlight, focusing on an outstanding person doing their part to keep the population of the two counties healthy. We advocate for the healthcare community from the largest to the smallest pro22

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viders, whether independent or full-service health systems. We invite your comments and ideas on who and what would be great stories to share. Please feel free to email our editorial department anytime at editor@orlandomedicalnews.com. Of course we’d like you to explore the many avenues we offer for sharing that all important message your organization has to tell by utilizing our print, digital, podcasting and video – platforms and hosting special events for networking and education by contacting John Kelly, publisher of Orlando Medical News at JohnKelly@OrlandoMedicalNews.com or by calling (407)-701-7424. We look forward to serving and hearing from you!

its muscle in the long running, heavily litigated, ‘scorched earth’ turf war for Brevard County’s health care business.” The seven physicians “…have been employed as foot soldiers in the intractable hostilities,” the Judge said. “Whether Health First has any concern for the reputation of their employee physicians, or the unfettered delivery of health care services to Brevard County citizens, or simply disregards this as unfortunate but necessary collateral damage is unclear. No sacrifice is too great when it’s not yours,” Judge Dalton wrote. “The patient-centered data PMC sought from the seven physicians was essential for the hospital’s quality improvement

initiatives,” said Chris McAlpine, PMC senior vice president. “Information timely provided is important in any environment, and particularly in health care,” Zumpano said. “Hospital quality initiatives matter, and no one should be exempt from doing their part to contribute the appropriate supporting data,” Zumpano said. “We live in an age where patient-centered data and hospital quality initiatives are inextricably tied to patient well-being. That Parrish Medical Center’s Board, CEO and managed care officers, stood firm for that principle - despite the fierce opposition faced from other interests - is both inspiring and comforting to our community.” The summary judgment was granted

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September 2019

Federal Judge Orders Summary Judgment, continued from page 20 in PMC’s favor on all claims brought by the physicians - for violation of procedural due process, breach of Bylaws, and violation of substantive due process. In ruling for PMC on the procedural due process claim, the Court held that through the hearing process provided by PMC, followed by plaintiffs exhausting the appeal process, the seven physicians received, “the full panoply of due process protections,” citing the 11th Circuit Court of Appeals standard on such legal issues. The physicians alleged that in the case of their privileges non-renewal, hospital bylaws had been breached. However, the Court found that PMC was entitled to invoke statutory immunity, given that PMC’s bylaws allow consideration of issues outside of clinical competence

when evaluating physician reappointment. The Court also found that Dr. Mikitarian’s representations to the PMC Board, that PMC had requested the data, were truthful and supported. Wrote the judge, “…all Plaintiffs admitted in their depositions that they had been informed and/or asked about Health First providing PMC data for accreditation purposes before the December Board Meeting.” The Court further ruled that Dr. Mikitarian’s statements that PMC’s accreditation was in jeopardy (due to the missing data) were also accurate. PMC asserted that the patient-centered data was necessary for the re-accreditation process with the Commission on Cancer (CoC): “…PMC fought tooth and nail to gain re-accreditation and succeeded despite

this missing data. PMC worked with the CoC’s surveyor to brainstorm and create workarounds to get at this missing data from another angle, via records it could obtain,” the opinion stated. The Court further complimented PMC for its tenacity and perseverance in obtaining its re-accreditation despite the lack of the patient-centered data. “Plaintiffs’ evidence shows that PMC didn’t take no for an answer and still endeavored to obtain accreditation. But PMC’s success does not mean the refusal to provide data didn’t undermine and obstruct this process,” the Judge wrote. Finally, the Court ruled in PMC’s favor in that the hospital satisfied substantive due process principles in its decision to not renew

GrandRounds Jess Parrish Medical Foundation to Host Annual Gala “Treasure Island” Benefiting the Children’s Center Extraordinary plans are underway for Jess Parrish Medical Foundation’s (JPMF) annual benefit gala, Treasure Island, which takes place on Saturday, Oct. 12, from 5-10 pm at Cruise Terminal One, Port Canaveral. GrayRobinson, P.A., and William and Laura Boyles are presenting sponsors for the event. More than 400 guests are expected to attend the swashbuckling evening of romantic elegance. Guests will enjoy signature cocktails, a tropical island inspired dinner and treasure hunting at the silent auction. One thousand pieces of gold will be at stake in the Hooks ‘n Tails costume contest. Guests are encouraged to wear elegant pirate and mermaid inspired attire - $500 prize for the best mermaid and $500 for the best pirate will be awarded. Event proceeds will benefit The Children’s Center to fund current and future needs and help bring the center into its 20th year of providing access to services, guidance and support for children and their families. “GrayRobinson, P.A. and William and Laura Boyles are honored to once again partner with Jess Parrish Medical Foundation as presenting sponsor of this year’s benefit gala,” said William A. Boyles, shareholder at GrayRobinson, P.A. “As presenting sponsor, it is gratifying to know that our investment is providing access to high-quality care that develops Strong Families for Life® and will continue to provide future generations of our children with a safe place to learn, grow

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and reach their full potential.” Holly Carver and Laura Anne Pray are co-chairs for the event. Gala committee members include, Judy Allender, Winnie Brewer, Kelley Broome, Mary Coleman, Lauren Coyne, Carlos Diaz, Lori Duester, Voncile Franklin, Betty Greene, Samantha Guyre, Nadine Itani, Jessie Kirk, Elizabeth Kump, Melissa Lugo, Christina Morrison, Susan Morse and Dr. Tanya Taival. “We are overjoyed by the tremendous support we have received for Treasure Island, and are thrilled to have so many organizations and community partners joining us to make a difference in the health of our community,” said Judy Allender, event underwriting chair. The growing list of this year’s event partners include: • Shores of Plenty-level sponsors: Injury Centers of Brevard, OMNI Healthcare, Susan Morse and Daniel Levy/UBS Financial Services and Zumpano Patricios; • X Marks the Spot-level sponsors: Allender & Allender P.A./Port Commissioner Jerry and Judy Allender, Coastal Ambulance Services and Bob and Jessie Kirk/ Kirk Management LLC; • Pirate’s Cove-level sponsors: The Broome Law Firm, P.A./ Chris and Kelly Broome, HealthFund Solutions, LLC, Hopkins Pharmacy, Julius Miller Scholarship Fund, Person Doyle

Mohre & Pastis LLP and Barbara and Terry Terhune. • M e r m ai d L a go on -l evel sponsors: Bermello Ajamil & Partners, Inc., Steve and Winnie Brewer, Ashley Byrne, Jamie and Melissa Lugo, Turmy Lum and Oscar Sieveking, Howard and Sandra Rinker, Catherine Spencer, VITAS Healthcare and Fred and Misty Wilson. • Captain’s Hideout sponsors: Dr. and Mrs. Anthony Allotta, Boggs Gases, Davies, Houser & Secrest, CPA, P.A., Greg and Lori Gullikson, Dr. Patricia C. Manning, Chris and Lisa McAlpine and Miller & Hurt Wealth Advisors. • In-kind event sponsors include Stina Bee Marketing. • In-kind media sponsors include Brevard Business News, Florida Today and SpaceCoast Living. Other generous sponsors will be recognized at the gala. Individual gala tickets are available at $125 and sponsorship opportunities are offered starting at $500. For more information about sponsorship packages, to donate tax-deductible auction items or to purchase general admission and chance-drawing tickets, please contact Jess Parrish Medical Foundation at 321-269-4066 or visit www.parrishmedfoundation. com/gala. Space is limited.

the physicians’ privileges. The Court found that PMC’s grounds for denial of the renewal of privileges were “reasonably related to the operation of the hospital,” “fairly administered,” “geared by a rationale compatible with hospital responsibility,” and relevant to the seven physicians’ applications for the renewal of the privileges. “I want to congratulate George Mikitarian, Chris McAlpine, Joe Zumpano and Leon Patricios for this great outcome,” said Herman Cole, PMC board chairman. The federal district court order can be read here The Law360 article on this case can be read here

From Brain Disorders to Brain Health: Preventing Cognitive Decline and Dementia The Volusia County Medical Society is extremely pleased to bring back, by popular demand, Dr. Demetrius Maraganore, as our featured speaker for the October 24th General Membership meeting, at 6:30 PM. If you missed him this past April, you won’t want to miss this presentation! More information will be coming your way!

Family Medicine Physician Joins AdventHealth’s Employed Physician Group Family medicine physician Dr. Jodi Wilder has joined the AdventHealth Medical Group. As an AdventHealth Medical Group physician, Wilder joins AdventHealth’s employed group of physicians with more than 300 providers, including 160 primary care doctors and specialists in Volusia, Flagler and Lake counties. Wilder cares for patients who are newborns and older. She performs minor dermatology procedures, physicals, and well woman and well child exams. In addition to focusing on preventative medicine, she also manages acute and chronic conditions. Wilder is board certified in family medicine by American Board of Family Medicine. She earned her medical degree from Lincoln Memorial University’s DeBusk College of Osteopathic Medicine in Harrogate, Tennessee. In addition, she completed her residency at St. Elizabeth Family Medicine in Edgewood, Kentucky. Her practice accepts new patients and most insurance plans. Her office is located inside the AdventHealth New Smyrna Beach Medical Plaza. orlandomedicalnews

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GrandRounds continued... AdventHealth Donates Equipment as Part of Partnership with Volusia County Schools

Pictured from left to right: Pine Ridge High School athletic director John New and athletic trainer Tori Haire with Erik Nason sports medicine outreach coordinator for AdventHealth.

AdventHealth has donated over $8,000 of equipment to help prevent and treat heatrelated illnesses for Volusia County student athletes, including cold water immersion tubs, ice containers, thermometers, and “grab and go” emergency medical bags with all the equipment necessary for managing exertional heat illness. This donation also included wet-bulb globe temperature (WBGT) thermometers which measures the heat stress in direct sunlight and takes into account: temperature, humidity, wind speed, sun angle and cloud cover. This differs from the heat index, which is calculated for shady areas and considers only temperature and humidity. The WBGT thermometers are key prevention tools for exertional heat illness as they help identify weather conditions that are unsafe for student athletes to practice or compete in, or that a practice should be altered to ensure the safety of the student athletes. Exertional heat illness is a serious medical condition that happens when the body is

unable to cool down and overheats. It can be triggered by physical exertion, like playing sports, particularly in the hot and humid conditions that are common in Florida. When the body’s core temperature reaches 104 degrees Fahrenheit, it can become a life-threatening emergency that can cause long-term damage to the brain, liver, kidneys and other organs, as well as death. In Florida, exertional heat illness is one of the top three causes for catastrophic injury/death of football players in high school and college. When treated promptly and correctly, exertional heat illness is a catastrophic injury that is 100% survivable. This donation is part of AdventHealth’s $2 million partnership with Volusia County Schools. As part of the historic agreement, AdventHealth is committed to streamline and coordinate care for the 5,000 student athletes at Volusia County Schools. Last year, the hospital system focused on improving concussion protocols. 

Foundation Donates Nearly $40,000 to Hospital

On Aug. 13, the AdventHealth New Smyrna Beach Foundation presented a check for nearly $40,000 to the 109-bed hospital.

AdventHealth New Smyrna Beach Foundation presented a check for $38,755.55 to the 109-bed hospital. These funds will be used to purchase additional equipment for AdventHealth New Smyrna Beach’s emergency department and cardiac rehab, as well as staff training. This donation will also help the hospital purchase furniture, including recliners for the emer-

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gency department, a replacement bed in the intensive care unit, and more wheelchairs. These funds were raised through various philanthropic efforts, including a gift from the Edgewater Aerie #4242 Fraternal Order of Eagles, a gift in loving memory of Mark Roadarmel, and proceeds from the AdventHealth New Smyrna Beach Foundation’s 2018 Charity Ball.

Tim Tebow Foundation Opens a Children’s Playroom at AdventHealth Daytona Beach In partnership with the Tim Tebow Foundation, AdventHealth Daytona Beach opened a children’s playroom. “We are honored and incredibly proud to bring a Timmy’s Playroom with Tim Tebow to the Daytona Beach community,” said Ed Noseworthy, AdventHealth Daytona Beach CEO. “With our mission to extend the healing ministry of Christ, and Tim’s mission to bring faith, hope and love to those needing a brighter day in their darkest hour of need – you couldn’t ask for a better pairing of two organizations driven by perfectly aligned missions.” Located on the Daytona Beach hospital’s fourth floor – the same floor for women’s health services, pediatric care, birth care, and the neonatal intensive care unit (NICU) – Timmy’s Playroom serves as an oasis for children who are either patients or are visiting others in the hospital. “Between children receiving care in our inpatient unit, and children visiting mom with a new baby in our NICU and BirthCare Center, as well as our pediatrician offices here on the fourth floor, we do have a lot of kids coming to the hospital,” said Noseworthy. “We know that, to kids, a hospital can be a scary or intimidating place, but with all of the interactive games and activities in this playroom, we hope this will be a place filled with laughter and can help children feel better – regardless of whether they are visiting someone in the hospital or are a patient themselves.” Timmy’s Playroom encourages children to play. The fun, football décor is reminiscent of Tebow’s days as a star football player at the University of Florida and in the National Football League. It has customized turf floors, wall wraps, custom lockers and more. A verse from the Bible (Philippians 4:13) reminds children, their families and visitors of what is possible: “I can do all things through Him who strengthens me.” Within the system of nearly 50 hospitals in almost a dozen states, this is the first and only AdventHealth hospital to open a Timmy’s Playroom.  Timmy’s Playrooms have opened at

hospitals in Tampa, Jacksonville, Gainesville, Tennessee, Texas, Louisiana and the Philippines, but this one at AdventHealth Daytona Beach is the most technologically advanced playroom yet, featuring interactive play that’s gender-neutral and accommodates children with special needs. “We are thrilled to open our newest Timmy’s Playroom at AdventHealth Daytona Beach to be able to share faith, hope and love with pediatric patients and their families,” said Steve Biondo, president of the Tim Tebow Foundation. “It is an honor to partner with the AdventHealth Daytona Beach Foundation to bring this room to life so that children receiving treatment and children visiting patients can have a place of respite to find strength, encouragement and community... and a chance to just be kids for a while.” The vision for Timmy’s Playroom began when Tebow was a student and football quarterback at the University of Florida and visited hospitalized children at UF Health Shands Hospital. That is what led him to create Timmy’s Playrooms, one of several outreach programs of the Tim Tebow Foundation, which he formed to serve the needs of children who cannot fight for themselves.  The cost of designing, building and maintaining Timmy’s Playroom is funded through generous donations to the AdventHealth Daytona Beach Foundation and by the Tim Tebow Foundation. Donor support is critical in funding necessary wheelchairs, wagons and in-room gaming systems for the children.  Gale Lemerand, an early contributor to the project, is excited to see the new children’s area and the families whose burdens will be lifted for a time while in the hospital.   “We are hoping many will join our team by contributing to kids’ health here in the Daytona Beach area, and so proud to have the Tim Tebow Foundation as a partner too!” Lemerand said.  To support this initiative, call Call 386-231-5102 or visit https://donation. adventhealth.com/Daytona-beach. 

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September 2019

DOH-Marion Identifies Case of Hepatitis A in Food Service Worker, Encourages Vaccination OCALA, Fla.—The Florida Department of Health in Marion County (DOHMarion) continues to deal with a surge in Hepatitis A cases, similar to what is being seen in the rest of the country. One significant case, announced August 6, was the discovery of a food service worker employed until August 1, at Charlie Horse Restaurant and Lounge who may have been infectious. As of August 30, six additional cases have been reported in the county. This brings the total number of cases in the county to 117 since January 1, 2019, however none of the new cases has been linked to an infected food service worker. “Fewer than 4 percent of our Hepatitis A cases involved individuals who work in food service,” said Christy Jergens, APR, public information officer with the Florida Department of Health in Marion County. Marion County is sixth in the state for the number of Hepatitis A cases that have been reported. “The most important thing residents can do to help stop the spread of Hepatitis A is to get vaccinated for the virus and to wash their hands with soap and warm water after they use the bathroom and before they eat or drink anything. They should also avoid sharing personal items, food, drinks or drugs. It’s crucial to note, residents should not rely on hand sanitizer to clean their hands; alcoholbased hand sanitizer does not kill the Hepatitis A virus,” stressed Jergens. The department is offering free Hepatitis A vaccinations Monday-Friday during normal business hours (8 a.m. to 4:30 p.m.) at the department’s Ocala location or at Mobile Health Unit stops throughout the county. “The Department of Health recommends that people who are at-risk (use injection or non-injection drugs, experiencing homelessness, were recently incarcerated or are in close contact with someone who has Hepatitis A) get vaccinated to prevent the spread of the illness. “People who are vulnerable to the ef26

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fects of Hepatitis A should also get vaccinated. This includes individuals with underlying liver disease and people over age 60 with complex medical conditions, such as diabetes or heart disease, as they are at risk for serious complications if they contract Hepatitis A,” said Jergens. The free vaccination program has been offered for over a month and Jergens said there has been good response. “We have vaccinated more than 5,060 individuals, and local medical professionals have also vaccinated additional individuals in the community,” she said. The hepatitis A vaccination is a 2-shot series, with the second shot given 6 months after the first shot. The vaccine is highly effective in preventing Hepatitis A. Receiving the first shot in the series provides 95 percent protection from the Hepatitis A virus. Both shots are needed for long-term protection. “The nature of the Hepatitis A virus is challenging. People are infectious with it for up to two weeks before they show any symptoms, and the virus is hardy, persisting on surfaces for a month or more. People without symptoms can also spread the illness,” reported Jergens. The Department has communicated regularly with hospitals, ERs, urgent cares, primary care providers, specialists, pharmacies, surgical centers and labs since the surge of infections began said Jergens, who also reported the outbreak is beginning to subside. “We’ve seen a decrease in the number of new cases we see each week. We believe these successes are the result of our heavy vaccination efforts to help prevent at-risk individuals from getting sick with the virus,” Jergens said. The Hepatitis A vaccine may provide protection against the disease if given within two weeks after exposure. If you previously have received the

hepatitis A vaccine or have had a past history of a Hepatitis A infection, you are considered immune to the virus and do not need to take additional action. Those with specific questions about exposure to Hepatitis A at Charlie Horse Restaurant and Lounge can call 352-644-2633 to reach the DOH-Marion Epidemiology staff. DOH-Marion is encouraging all healthcare providers, including hospital emergency departments, to stay on high alert and immediately report cases of Hepatitis A to DOH-Marion, as well as identify those who would benefit from vaccination. Contact your county’s health department for Hepatitis A vaccinations if you live outside Marion County. Vaccination is the best way to prevent Hepatitis A. People who should be vacci-

nated for Hepatitis A include: • All children at the age of 12 months • People who are experiencing homelessness • Users of recreational drugs, whether injected or not • Men who have sexual encounters with other men • People with direct contact with others who have Hepatitis A • Travelers to countries where Hepatitis A is common • People with chronic/long-term liver disease, including Hepatitis B or Hepatitis C • People with clotting-factor disorders • Family and caregivers of adoptees from

countries where hepatitis A is common

Go to http://Marion.FloridaHealth.gov or call 352-629-0137 for more information.

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September 2019

GrandRounds Cornerstone Hospice’s Paula Loats to Educate Oncology Social Workers about Hospice Care Tavares, Fla. – Cornerstone Hospice and Palliative Care’s Clinical Liaison Educator Paula Loats, RN, BS, MBA, CCDS will present “The Hospice Discussion” at the Society of Florida Oncology Social Workers 36th Annual Conference, in St. Augustine. Loats’ presentation is scheduled for Friday, September 27, at 11 a.m.

Loats began her nursing career more than 32 years ago and has practiced in many specialties. As Cornerstone Hospice’s clinical liaison educator, Loats educates Central Florida medical organizations about the need for appropriate patient care at the end of life.

Summerfield-area Residents Asked for Feedback in Community Survey OCALA, Fla.—The Florida Department of Health in Marion County is asking Summerfield-area residents to take a survey to share their thoughts on daily life in the community. Dubbed an Environmental Health Assessment, the survey asks residents to voice their opinions on what can be improved within the community to build a healthier Summerfield. Residents can complete the brief survey by visiting https:// is.gd/29E8o4. All responses need to be received by Oct. 31.

Once the survey is complete and results are compiled, a community group will determine how to move forward with improvement projects based on short, intermediate, and long-term goals. Examples of possible projects from the Environmental Health Assessment Survey include park development, sidewalks, and community gardens. For questions about the Environmental Health Assessment, contact Tammie Durden at 352-299-0089 or tammie.durden@ flhealth.gov.

Villages Rehab & Nursing Center Earns National Award for Excellence in Quality Care

Ocala Health Opens Full-Service Emergency Department on Maricamp Road Ocala, FL. – Residents of Marion County have additional access to emergent care as Ocala Health opens its new Maricamp ER, a freestanding ER located on Maricamp Road adjacent to First Baptist Church. The $13 million project employs approximately 30 full-time healthcare professionals. The 24/7, full service freestanding emergency department features 12 emergency room beds and is capable of caring for all ages, including pediatrics. The 10,820-square-foot freestanding ER is expected to serve more than 11,500 patients in its first year. “The Maricamp ER facility represents our latest step to expand health care into the community,” said Chad Christianson, CEO, Ocala Health. “While continuing to expand our Ocala Regional and West Marion campuses, we saw an opportunity to bring emergency care closer to our southeast Ocala residents. We believe this freestanding emergency room will provide our patients a more convenient, higher level experience for emergent care. We will continue to ex-

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pand healthcare services where needed for our growing community.” The announcement comes during the addition of multiple access points and expansions across Ocala Health. Ocala Regional Medical Center is currently expanding and renovating its emergency department along with a recent announcement of a $31M expansion in which 34 beds will be added to the facility. Plans were also announced in May of a $27M expansion at West Marion Community Hospital in which a second cath lab will be added along with a dedicated 10-bed, pre-post cath lab recovery unit as well as two large operating suites, bringing the total to 10 operating suites. This will be Ocala Health’s second freestanding emergency department. Ocala Health opened its first freestanding emergency department in Summerfield (Summerfield ER) in October 2016. Ocala Health will be breaking ground on a third freestanding emergency department in Wildwood next month.

Lady Lake, FL – Villages Rehab & Nursing Center’s focus on patient-directed care has earned the post-acute rehabilitation facility a 2019 Gold – Excellence in Quality Award from the American Health Care Association and National Center for Assisted Living (AHCA/NCAL). Gold – Excellence in Quality Award winners are recognized as some of the best in the profession after demonstrating application of rigorous quality improvement standards that achieve superior results in leadership, strategic planning, customer and workforce focus, and operations and knowledge management. The 120-bed Villages Rehab & Nursing Center, which was completed in 2013, is one of only five in the nation to receive the award and it is also only the third rehabilitation facility in Florida to have ever achieved this recognition. Villages Rehab & Nursing Center has 235 employees who are empowered to be leaders and are encouraged to take initiative to ensure each patient receives quality care. Brazill cites exceptional performance measurements which contributed the ACHA/NCAL award, including: · A 96% customer satisfaction rate as determined by an independent survey company that polled Villages Rehab & Nursing Center patients. · Centers for Medicare & Medicaid Services (CMS) quality measures ranks Villages Rehab among the top 10% in the nation for number of patients discharged to the community post discharge. · A recent employee survey revealed 95% of Villages Rehab employees feel inspired by the mission and purpose of the company and 93% like the culture. The Villages Rehab & Nursing Center previously received the 2017 Bronze—Excellence in Quality Award and the 2018 Silver—Excellence in Quality Award. Both honors were received after first-time applications. Based on the core values and criteria of the nationally recognized Baldrige Performance Excellence Program, the AHCA/NCAL National Quality Award Program challenges member providers to achieve performance excellence through three progressive levels—Bronze, Silver, and Gold. The Gold – Excellence in Quality Award is the most renowned of the program. At this level, recipients have invested years in mastering and applying the rigorous Baldrige Criteria quality standards to achieve superior results in the areas of leadership, strategic planning, customer and workforce focus, and operations and knowledge management. The awards will be presented during AHCA/NCAL’s 70th Convention & Expo in Orlando, Florida, October 13-16, 2019. For a full list of recipients, visit AHCA/NCAL’s Quality Award website here. orlandomedicalnews

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Profile for Orlando Medical News

Orlando Medical News September 2019  

Can’t-Miss Cannabis Conference Surprising ancillary opportunities, seminars dominate third annual AMMPA meeting

Orlando Medical News September 2019  

Can’t-Miss Cannabis Conference Surprising ancillary opportunities, seminars dominate third annual AMMPA meeting