Primary Care Provider Initiatives:

Review & Results - Part II

Moderator:

Robert Hoch, MD VP of Medical Affairs, Harbor Health Services, Inc.

Jonathan Pincus, MD Codman Square Health Center, Haiti CHC and Kreyol Immersion

Eliza Jones, MD Whittier Street Health Center, Program for Families and Children with Special Health Care Needs

Peter Loewinthan, MD Dorchester House Multi-Service Center, Nicaraguan Medical Experience

Louis Strauss, MD Baystate Mason Square Neighborhood Health Center, Shared Medical Appointments Program

Melissa Rathmell, MD Family Health Center of Worcester, Complementary Medical Training

Annual Community Health Institute

May 9-11, 2012

Resort & Conference Center of Hyannis

Hyannis, MA

Haiti CHC and Kreyol Immersion

Jonathan Pincus, MD

Codman Square Health Center

Second oldest democracy in the Western Hemisphere

Singular historical example of slaves overthrowing their oppressors

25 physicians and 11 nurses per 100,000 people Life expectancy – men 60, women 63, under 5 mortality 87/1,000

births, maternal mortality 300/100,000, attended births 26%, drinking water 63%, sanitation 17%, per capita health expenditure $69

The Rasin Foundation is dedicated to collaborating with the people of Leogane, Haiti to improve the physical and mental health of the community and assist in economic and technology development.

Kay koule twompe soley soley men li pa twompe lapil. A leaky house can fool the sun, but it can't fool the rain.

Health Care

Electricity

Education

Road construction

Business development

Agriculture/Food Security

Global Health Effectiveness Program, Harvard School of Public Health

2 additional trips to Haiti Medical Programs

Lab Dental Eye Care

Community Board Community Programing

Micro-finance Electricity Farming and Aquaculture

Codman

Program for Families and Children

with Special Health Care Needs

Eliza Jones, MD

Whittier Street Health Center

1

Supporting Families With Special

Needs

An Intensive Family Therapy Program for

Families in Crisis

Objectives

• To describe the focus on Special Needs at

Whittier Street

• To describe the family therapy program and

expansion to special needs

• To describe families served

• To discuss specific successes and challenges

Special Needs at Whittier

• Massachusetts DPH special needs care

coordinator (2008-2011)

• Worked on parent partnerships and ultimately

offered a parenting class

• Started a Special Needs Clinic (Rainbow

Clinic)

• Expand Intensive Family Therapy program to

specifically target families with special needs

Intensive Family Therapy Model

• Families are identified by pediatricians and

referred to behavioral health which is

embedded in pediatrics

• Enrolled in 12 week session

• Meal served weekly

• Coordination of other appointments on same

day of service

• Individual counseling

Families

• Child in crisis

• deportation of parent

• living in a shelter

• psychiatric illness or medical illness

• reunification after a separation

• DCF mandated counseling

Definition of Special Needs

• We had been working with a case manager

from the Massachusetts department of Public

Health with a definition of special needs that

included severe medical problems as the bulk

of her caseload

• At Whittier she used a broader definition

encompassing kids with some medical illness

and complicated social situations

Definition of Special Needs

American Academy of Pediatrics (AAP)

definition of special needs:

"those who have or are at increased risk for a chronic

physical, developmental, behavioral, or emotional

condition and who also require health and related

services of a type or amount beyond that required by

children generally”

Case 1: Initial Presentation

• A.T. is a 9 year old girl who came for her

physical in December at which time her

mother asked for help with the transition from

A.T. living with grandmother to living with

her mother

Case 1: Family Members

• Mother with depression, substance abuse

• A.T. Almost 10 year old female with obesity

• B.T. Almost 6 year old male with albinism

and congenital nystagmus

• C.T. 4 year old male

• D.T. Almost 3 year old male

Case 1: Intake

• Chief complaint: “I need to get counseling

because I feel like I have a hard time

communicating with her [A.T.]”

• A.T. expressed that she was having trouble

getting used to being with mother after being

with grandmother for 8 months due to

mother’s substance abuse

Case 1: Intake

• Maternal substance abuse led to placement

with grandmother

• Witnessed domestic violence

• A.T. experienced bullying at school

• Mother with difficulty managing challenging

behaviors in public

• Overwhelmed by her kids not listening

• A.T. was trying to help parent her brothers

Case 1: Therapy

• Behavior charts

• Mother worked on getting tasks done at night

so morning would go smoothly

• Thinking about each child’s schedule and

behavioral needs

• Improve communication by asking children

about their days

• Therapeutic mentor for A.T.

Case 1: Successes

• Completed sessions

• Started family movie night

• Enrolled younger children in school

• Mother started attending a parenting class at

Whittier

• Exercise at the YMCA with A.T and mother

getting time alone together

• Family members enrolled in individual

therapy

Case 1: Challenges

• Coordinating care for medical needs

• Unable to fully address issue of obesity during

12 week session but great that started exercise

• Family now quite engaged with health center

so we hope to address that issue in the coming

months

Case 2: Behavioral Problems

• Family initially sought care for A.L. (7 year

old male) who had ADHD

• Then sought treatment for B.L. (6 year old

male) who was found to have ODD

• Enrolled in family therapy program

• Crisis was the behaviors

Case 2: Anxious Eating

• Pediatrician expressed concern about A.L.’s

weight

• Therapist noticed that he often asked for extra

helpings at family meal before finishing

• Ate very fast and asked for food to gain

attention

• Able to start working on this behavior because

a meal is served at each session

Case 2: Sibling Work

• Younger sibling modeling behaviors about

frustration tolerance for older sibling saying

“It’s okay if I’m losing”

• Older sibling encouraged to help younger

sibling which gives him a sense of

accomplishment

• Older sibling needs self esteem work and will

be starting individual therapy

Case 2: Parenting Skills

• Cards to take away points when misbehaving

in public --> this meant lost screen time

• Consistency

• Rule chart --> kids initially unable to name a

single rule at home

• Huge success so far --> therapist forgot B.L.

had diagnosis of ODD he was so much better!

A more difficult case • Family extremely well known to pediatrics

• Several grown children and father not involved in IFT

program

• Mother attended with 7 year old twin girls, 13 year old

son, 17 year old son

• 17 year old with Asperger’s

• 1 twin likely with mental retardation, both with

behavioral issues

• 13 year old with school avoidance, major behavioral

issues, taking up a lot of time in pediatrics

Successes and Limitations • Able to get new school placement for 13 year old

• Improved communication with outside therapists

• Little progress on out of control behaviors of twins

• Seemed that father undermined mother’s attempts at

change

• Lesson learned--better screening for domestic violence

prior to enrolling families

Career Benefits • Learning from the close interaction with

behavioral health

• Opportunities to learn more about special

needs care by visiting other sites

• Excited about future work with special needs

populations and future collaborations with

behavioral health department

Benefits to Health Center

• Recruit new patients into program

• Get existing patients to be seen for all their

unmet needs (eye care, dental, routine

healthcare)

• Really meeting our patients where they are

and helping them help themselves which

benefits the community and helps Whittier

serve it’s mission

Thank You

• Thank you to the Mass League for the

opportunity to work on this project. It’s been

a phenomenal experience

• Thank you to the wonderful therapists that

work with me on this, Brenda Daley and

Melissa Marquez

Whittier’s Mission Statement

• Our mission is to provide high quality,

reliable and accessible primary health care

and support services for diverse populations

to promote wellness and eliminate health and

social disparities

Nicaraguan Medical Experience

Peter Loewinthan, MD

Dorchester House Multi-Service

Center

Dorchester House and Superemos

What is Superemos?

Superemos was founded at the end of 1999 as a

non-profit foundation devoted to education and

training programs based in the city of Estelí for

low-income families in northern Nicaragua.

Dr. Peter Loewinthan

with Superemos board

members

Superemos supports

community programs:

• Secondary education for low-income women - 80

scholarships

• Two community pre-schools in peripheral barrios - 70

children

• Training activities - 80 women/young people

– Includes computer skills, ceramics, metal work/welding, sewing,

handcrafts, baking

• Social work – Counseling for programe participants -10 or

12 beneficiaries each month

• Control of blood pressure and diabetes for programe

participants - 15 - 20 beneficiaries each month

cont.

• Preventive health care in 6 communities - about 350

children a month

– El Limon, Paso Ancho, San Pedro, San Roque, Nuevo Amanecer,

Felipe y Mery Barreda

• Support for low-income patients requiring laboratory

tests/medicines

• Music education in Estelí and Palacagüina - over 100

students

• Teacher training for primary school teachers - 50 teachers

a year

• Environmental protection/conservation of the area around

the Superemos site

Goal of the project:

• Bring providers from Dorchester House Multi-

Service Center (DHMSC) to Nicaragua and

involve them in delivering care

• Strengthen relationships between DHMSC and

Superemos

Participants:

1. Grant participants

– 2 pediatricians

– 1 pediatric nurse practitioner

– 3 internists

– 2 medical assistants

2. Non-grant participants

– 2 pediatricians

– 2 family practice physicians

– 1 internist

– 1 adult medicine resident

– 1 adult nurse practitioner

– 7 children of grant participants

Patients seen:

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

Total Patients = 1,800

Adult

Pediatric

Adult: 800

Pediatric: 1,000

Affect on providers:

• What follows are providers’ personal reflections on their

experiences in Nicaragua, and on how that experience

impacts their practice at DHMSC

• Emily Feinberg:

– Personally, I was amazed at what a health system can accomplish with extremely

limited resources but a clear sense of mission and commitment to a common goal.

The progress that the country has made re: immunization coverage, contraception,

and reductions in maternal mortality is impressive.

– One of my goals was to strengthen connections between US and Nicaragua. I

wanted to identify projects that US public health students could participate in and

make a significant contribution. I was able to identify several projects in

collaboration with the local ministry of health. There are 4 public health students

who will be traveling to Nicaragua this summer to work on these projects.

Emily Feinberg:

• “Personally, I was amazed at what a health system can accomplish with

extremely limited resources but a clear sense of mission and

commitment to a common goal. The progress that the country has made

re: immunization coverage, contraception, and reductions in maternal

mortality is impressive.”

• “One of my goals was to strengthen connections between US and

Nicaragua. I wanted to identify projects that US public health students

could participate in and make a significant contribution. I was able to

identify several projects in collaboration with the local ministry of

health. There are 4 public health students who will be traveling to

Nicaragua this summer to work on these projects.”

Huy Nguyen:

• “Traveling to Nicaragua and treating children in rural clinics in Esteli

was an eye-opening experience for me. This opportunity extended my

understanding of the health challenges children face everyday beyond

my day to day clinical practice in Boston and re-invigorated my

commitment to providing care to inner city families in a community

health center setting. This trip would not have been possible without the

grant support I received through the Mass League.”

Julita Mir:

• “The trip brought lots of memories of my times in medical school in

Venezuela. It reminded me of how much we can give to people who

have so little and was an opportunity to practice with few tools, just

using the clinical judgment.”

• “Maybe one of the biggest values of such an experience was being able

to spend time with my colleagues in such a different environment. It

created a bonding that I did not expected which makes my daily work at

Dorchester House much more rewarding.”

Julie Crosson:

• “The biggest effect is my tie to DH- traveling together to a different place and

doing a project together with my everyday co-workers made a tie that persists

here back at DH. For example, when I go to pediatrics now, I get a big smile

from the friends I have there, previously it was a polite recognition from

colleagues I didn't know. Also there is a DH pride in the Nicaragua work

which I felt coming back- that many people in the clinic who have never gone

to Nicaragua, feel pride in what their clinic is doing there. It was invigorating

how 1 week had a great effect after working at DH for 14 yrs in terms of my

happiness working there- it was like a booster shot. ”

• “Professionally, a notable realization occurred to me the day I was taking care

of a man in moderate CHF and determining his disposition- I realized that

being sued did not come into play ( something which I realized subconsciously

does affect my determinations back in the States) , and that my decision was

made purely on medical decision making and on my desire to do the right thing

to help this man. It felt like the medicine I went into.”

Pat Egan:

• “I got the chance to establish an international location where I can use

my skills to work with a population and an environment that are very

different from where I currently work; to be able to simply drop in to

this environment and feel like I am helping satisfies my need to get

away and my need to contribute; bring the kids exposed them to

another culture which is something we have been trying to do for a

while.”

• “Seeing how medicine is practiced in Nicaragua provides a wonderful

counter balance to the craziness of the US medical system-I am

reinvigorated knowing that people and systems can accomplish so

much despite the lack of resources; there are great ideas we can bring

back to make our own practice better; further having this outlet to look

forward to each year provides a nice distraction from the frustrations

of work.”

Shared Medical Appointments

Program

Louis Strauss, MD

Baystate Mason Square

Neighborhood Health Center

Sharing the Shared Medical Appointment (SMAs) Model

Made Possible by the good people at the Mass League

of Community Health Centers

Louis Strauss MD

Mason Square Neighborhood Health Center

May 10, 2012

Agenda

Background

Brief Description

Accomplishments

History of SMA at Mason Square

Fall 2009 – Running Shared Medical Visits in your practice CME by Massachusetts Medical Society

Fall 2009 – MSQ team Coalesces

Winter 2010 - 1st SMA lasts 3 hours

Summer 2011 – Weekly SMA

Summer 2011 – Grant from Mass League of Community Health Center to spread Model to other providers across 3 Community Health Centers

What is an SMA?

Individualized medical care in context of a shared appointment

90 minute clinical session

Service packed visits

Maximizes physician directed patient education

Allows for patient to patient education

Our Model is based on Edward Noffsinger's “Running Group Visits in Your Practice”

Benefits

Improved Access

Patient Education

Orientation to Clinic

Patient Satisfaction

Provider Satisfaction

Increased Productivity

Can This Possibly Work?

Yes We Can!

The Grant

Funds used to spread the model to other providers at Mason Square and 2 other Community Health Centers – Brightwood and High Street

Longditudinal over course of year – Approx 4 hrs/week

Time spent educating other providers and staff about the model as well

What We Accomplished Thus Far

Initially one provider providing weekly new patient SMA

Spread to 7 different providers and their teams

Generated a lot of interest across Baystate Health Systems beyond the community health centers = Increased visibility for Health Centers in a large system

New SMAs started

New Patient Physicals in English and Spanish

Weight Management in English and Spanish

Diabetes Clinic

Asthma – In pipeline

Discussing SMAs in specialty groups and private practice model practices at Baystate

Challenges

Marketing – Convincing providers to do “something different”

Juggling human resources

Manpower intensive

Need for strong physician champion at each site

Support from management

??????????????????

Physicals Model

Target Number: 7 – 9

Increase access for new patients to practice

Recruited primarily off wait list

Male or Female

Monolingual

Light, healthy snacks

Physicals Model 1st Third

4 rooms running

Roomed individually as they arrive

Physical exam only

First 30 is spent doing physical exams

Patients not roomed are in group room getting information from behaviorist, Privacy agreements, History forms, providing specific concerns

Physicals Model 2nd Third

Once all physical exams are done, provider arrives at group room.

Welcome

Discussion of key medical information

Eg. Importance of immunizations, appropriate screenings etc.

MA and Scribe update med lists, HCM, problem lists

Physicals Model 3rd Third

Each patient is addressed in turn, medical history is reviewed, refills and labs ordered, concerns addressed, follow-up ordered by physician

Scribe documents med decision making

MA finished depart paperwork

Physicals Challenges

Keeping focused

Healthcare Maintenance

Appropriate baseline labs and refills only

More complex conditions will be scheduled for follow up

The crazy patient

Billing

Physician bills as “Level of Care” or “Comprehensive Well Visit”

Facilities Charge is based on ancillary services provided – typically Level IV or V

Cannot bill based on time

Cannot bill for behaviorist or documentor functions

Productivity gains pay for behaviorist and documentor

Staffing Requirements – SMA vs Regular Session

Resource SMA Session Regular Session

Physician 120 240

MA 240 240

PA 60 120

Behaviorist 120 0 SMW or Nurse

Pipe Line to Start New SMA

10 week lead time

Identify team

Training team

Advertising Materials

Coordinating facilities needs

Complementary Medical Training

Melissa Rathmell, MD

Family Health Center of Worcester

Integrative Medicine

Bringing non-allopathic approaches to health, wellness, and disease

into the Community Health Center

An educational experience funded by the Massachusetts League of Community Health Centers

Allopathic vs Integrative Approaches

• Health is the absence of disease

• Roots are in acute care (infection and trauma)

• Disease is typically organ based

• Is represented by signs and symptoms

• Treatment is disease or symptom specific

Health is a positive force in itself

Given the right inputs, the body creates and maintains health

Lack of health affects the entire organism

Effects are present before frank disease is diagnosed

Treatment is individualized

> 1/3 Adults Have Used CAM

CAM Approaches

Integrative Approaches studied during this

period include:

Acupuncture

Manual Techniques

Clinical Hypnosis

Functional Medicine

Chinese Diagnostic Systems

Tongue Diagnosis

Primary Pathogens

Pulse Diagnosis

Herbal Therapies

Chinese and Western

Use of Integrative Medicine at Family Health Center of Worcester

Current

½ day per week

6-7 patients per session

Referrals from within the health center

Expectations

Ultimately decreased visits for patient

Increased health

Increased Patient satisfaction

Decreased medication use

Example Cases

DM 12 year old girl with ADHD, A gifted dancer

Significant problems with urinary incontinence

Allopathic Treatments Tried

Medications (made her feel “icky” & didn't work)

Surgery offered

Integrative Treatments

Behavioral modification

Nutritional therapy

Acupuncture

Results:

Fully continent, Requests quarterly treatments

MG 27 year old woman pregnant with her second child

Very much wanted “natural”, unmedicated delivery

Allopathic Treatments (first delivery):

Narcotic medications – little help, side effects

Epidural – not wanted, but patient encouraged to get

Unpleasant / painful, inadequate relief

Integrative Therapy (second delivery):

Hypnotic techniques taught and practiced

Results:

Arrived on L&D in active labor and full trance

Delivered baby girl with no additional analgesia

Requested discharge after 24 hours hospitalization

BS 68 year old Latina with chronic pelvic pain, obesity,

diabetes, depression, etc.

Allopathic Treatments:

History of pain unrevealing.

Exam, CT, MRI, Ultrasound all negative for pathology.

Minimal relief with allopathic pain management.

Integrative Therapy:

Osteopathic Manipulation using Strain / Counterstrain technique at pelvic “tender point”

Results:

Full pain relief after one treatment lasted 4 months, second treatment now > 1 year ago; Pain Free.

Use of Integrative Medicine at Family Health Center of Worcester

Future Goals

Board certification in Integrative Medicine

Increased sessions and services

Medical student and resident electives

Barriers

Longer visits needed, fewer total patients seen

Poor or no insurance coverage for

Therapy type

Non-Medication Recommendations

Resources General:

nccam.nih.gov

en.wikipedia.org/wiki/P:CAM

www.holisticboard.org

Integrative Medicine

By David Rakel MD

Manual Medicine:

Anatomy Trains: Myofascial Meridians for Manual Movement Therapists

By Thomas W. Myers, LMT

The Endless Web: Fascial Anatomy and Physical Reality

By R. Louis Shultz, et al

An Osteopathic Approach to Diagnosis and Treatment

By Eileen L. DiGiovanna, Stanley Schiowitz and Dennis J. Dowling

Resources Acupuncture & Chinese Medicine:

www.MedicalAcupuncture.org

www.HMIEducation.com

Diagnosis in Chinese Medicine: A Comprehensive Guide

by Maciocia, Giovanni

Herbal & Nutritional Therapies:

Healing with Whole Foods: Asian Traditions & Modern Nutrition

By Paul Pitchford

Medical Herbalism: The Science, Principles and Practices of Herbal Medicine

By David Hoffmann, FNIMH, AGH

Guide to Popular Natural Products

By Ara Dermarderosian

Resources Functional Medicine:

www.FunctionalMedicine.org

Textbook of Functional Medicine

By Sidney MacDonald Baker, Peter Bennett, Jeffrey S. Bland and Leo Galland

Clinical Nutrition: A Functional Approach

By Dan Lukaczer, David S. Jones, Robert H. Lerman and Jeffrey S. Bland

Hypnosis:

www.NESCH.org

www.ASCH.net

Patient Sedation without Medication

By Elvira Lang, MD & Eleanor Laser, PhD

Harry the Hypno-Potamus: Metaphorical Tales for the Treatment of Children

By Linda Thomson, PhD

Handbook of Hypnotic Suggestions and Metaphors

By D. Corydon Hammond

Thank You

MELISSA RATHMELL, MD, DABMA

Director of Integrative Medicine Family Health Center of Worcester

MELISSA.RATHMELL@UMASSMED.EDU