minnesota physician june 2015

You may not know it, but Min-nesota is currently in the midst of testing a new model of

health care, the Minnesota Account-able Health Model. At the heart of this model is the idea that authentic collaboration is key to solving Min-nesota’s health challenges. Minnesota currently has one of the best medical care systems in the U.S. and the world. But we are still a ways from having a

“health” system—meaning an effective coordinated system for promoting and achieving health and wellness—for all Minnesotans.

Practicing physicians know that the health and wellness of our patients is often dependent on social and eco-nomic factors outside of our direct

The e-health roadmap to page 18

The Minnesota Accountable Health Model to page 16

Vo lum e x x Ix , N o. 3J un e 2015

Health care is changing and be coming more of a team effort. Part of that is being driven by the

new payment methods on the horizon, intended to pay providers based on the quality, rather than merely the quantity of care we provide patients. To help facili-tate this transition, the state is developing e-health roadmaps in order to advance high-quality, coordinated care. The road-maps will focus on four providers from particular settings as they participate in the Minnesota Accountable Health Model. The model expands patient-cen-tered, team-based care and integrates it with medical care. The four settings upon which the roadmaps will focus are:

• Long-term and post-acute care

• Local public health

• Behavioral health

• Social services

These roadmaps will help Minneso-ta understand what’s needed to engage in accountable care models. The U.S. Department of Health & Human Services (HHS) has set rigorous goals for using alternative payment models and val-

The e-health roadmap A collaborative effort to improve care

By Paul Kleeberg, MD

The Minnesota Accountable Health Model

Creating community partnerships

By Rahul Koranne, MD, MBA, FACP

P ost-acute rehabilitation services from the Good Samaritan Society.

Post-acute care is designed to heal and assist patients with care and support following a hospitalization from serious illness, injury or elective surgical procedure. Multiple in-patient and out-patient post-acute locations are located throughout the Twin Cities metro area and state of Minnesota.

The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, gender, disability, familial status, national origin or other protected statuses according to applicable federal, state or local laws. Some services may be provided by a third party. All faiths or beliefs are welcome. © 2015 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 15-G0066

To learn more about our post-acute services, call us at 866-GSSCARE or visit www.good-sam.com/minnesota.

An approach to consider for type 2 diabetes therapy starts here

WARNING: RISK OF THYROID C-CELL TUMORSIn male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance could not be determined from clinical or nonclinical studies.

Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Routine serum calcitonin or thyroid ultrasound monitoring is of uncertain value in patients treated with Trulicity. Counsel regarding the risk factors and symptoms of thyroid tumors.

Trulicity™ is a glucagon-like peptide-1 receptor agonist (GLP-1 RA) that is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

Limitations of Use: Not recommended as first-line therapy for patients inadequately controlled on diet and exercise. Has not been studied in patients with a history of pancreatitis; consider another antidiabetic therapy. Not for the treatment of type 1 diabetes mellitus or diabetic ketoacidosis. Not a substitute for insulin. Has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis. Not for patients with pre-existing severe gastrointestinal disease. Has not been studied in combination with basal insulin.

Please see Important Safety Information for Trulicity, including Boxed Warning about possible thyroid tumors including thyroid cancer, and Brief Summary of Prescribing Information on following pages. Please see Instructions for Use included with the pen.

Select Important Safety Information

031252_eldhcp_DG95134_jrl_ad_mpp_fa.indd 1 3/23/15 12:26 PM

June 2015 Minnesota Physician 3

*In clinical trials, the range of A1C reduction from baseline was 0.7% to 1.6% for the 0.75 mg dose and 0.8% to 1.6% for the 1.5 mg dose.1

Trulicity may be a good option for adult patients with type 2 diabetes who need more control than oral medications are providing.1

To learn more about Trulicity and the savings card for patients, talk to your Lilly sales representativeor visit Trulicity.com.

DG95134 02/2015 PRINTED IN USA ©Lilly USA, LLC 2015. All rights reserved.

Important Safety Information

Trulicity is a glucagon-like peptide-1 receptor agonist (GLP-1 RA) that is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

Limitations of Use: Not recommended as fi rst-line therapy for patients inadequately controlled on diet and exercise. Has not been studied in patients with a history of pancreatitis; consider another antidiabetic therapy. Not for the treatment of type 1 diabetes mellitus or diabetic ketoacidosis. Not a substitute for insulin. Has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis. Not for patients with pre-existing severe gastrointestinal disease. Has not been studied in combination with basal insulin.

Trulicity™ offers proven A1C reduction* and once-weekly dosing in the Trulicity pen1

WARNING: RISK OF THYROID C-CELL TUMORSIn male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance could not be determined from clinical or nonclinical studies.Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Routine serum calcitonin or thyroid ultrasound monitoring is of uncertain value in patients treated with Trulicity. Counsel regarding the risk factors and symptoms of thyroid tumors.

Trulicity is contraindicated in patients with a prior serious hypersensitivity reaction to dulaglutide or any of the product components.

Risk of Thyroid C-cell Tumors: Counsel patients regarding the risk of medullary thyroid carcinoma and the symptoms of thyroid tumors (eg, a mass in the neck, dysphagia, dyspnea, persistent hoarseness). Patients with elevated serum calcitonin (if measured) and patients with thyroid nodules noted on physical examination or neck imaging should be referred to an endocrinologist for further evaluation.

Pancreatitis: Has been reported in clinical trials. Observe patients for signs and symptoms including persistent severe abdominal pain. If pancreatitis is suspected discontinue Trulicity promptly. Do not restart if pancreatitis is confi rmed. Consider other antidiabetic therapy in patients with a history of pancreatitis.

Please see Important Safety Information continued on following page.


Data represent least-squares mean ± standard error.

*Multiplicity-adjusted 1-sided P value <.025 for superiority of Trulicity vs Byetta for A1C.†Multiplicity-adjusted 1-sided P value <.001 for superiority of Trulicity vs placebo for A1C. Mixed model repeated measures analysis.

After 26 weeks, placebo-treated patients were switched in a blinded fashion to Trulicity 1.5 mg or Trulicity 0.75 mg.‡American Diabetes Association recommended target goal. Treatment should be individualized.4

Byetta® (10 mcg BID)(n=276; Baseline A1C: 8.1%)

Trulicity™ (0.75 mg) (n=280; Baseline A1C: 8.1%)


Placebo(n=141; Baseline A1C: 8.1%)

• 52-week, randomized, placebo-controlled phase 3 study (open-label assignment to Byetta or blinded assignment to Trulicity or placebo) of adult patients with type 2 diabetes treated with maximally tolerated metformin (≥1500 mg/day) and Actos (up to 45 mg/day)

• Primary objective was to demonstrate superiority of Trulicity 1.5 mg vs placebo on change in A1C from baseline at 26 weeks (-1.5% vs -0.5%, respectively; difference of -1.1%; 95% CI [-1.2, -0.9]; multiplicity-adjusted 1-sided P value <.001; analysis of covariance using last observation carried forward); primary objective met

References

1. Trulicity [Prescribing Information]. Indianapolis, IN: Lilly USA, LLC; 2014.

2. Data on file, Lilly USA, LLC. TRU20140910A.

3. Data on file, Lilly USA, LLC. TRU20140919C.

4. American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(Suppl 1):S14-S80.

A1C reduction from baseline1-3

6.2

6.4

6.6

6.8

7.0

7.2

7.4

7.6

7.8

8.0

8.4

8.2

Week 13 Week 26Baseline

LS m

ean

A1C

(%)

-1.3*†

‡

-1.5*†

-1.0

-0.5

93% fewerinjections3

LS m

ean A

1C (%

)

Once-weekly Trulicity 1.5 mg showed signifi cant A1C reduction1

Important Safety Information,continued

Hypoglycemia: The risk of hypoglycemia is increased when Trulicity is used in combination with insulin secretagogues (eg, sulfonylureas) or insulin. Patients may require a lower dose of the sulfonylurea or insulin to reduce the risk of hypoglycemia.

Hypersensitivity Reactions: Systemic reactions were observed in clinical trials in patients receiving Trulicity. Instruct patients who experience symptoms to discontinue Trulicity and promptly seek medical advice.

Renal Impairment: In patients treated with GLP-1 RAs there have been postmarketing reports of acute renal failure and worsening of chronic renal failure, sometimes requiring hemodialysis. A majority of reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. In patients with renal impairment, use caution when initiating or escalating doses of Trulicity and monitor renal function in patients experiencing severe adverse gastrointestinal reactions.

Severe Gastrointestinal Disease: Use of Trulicity may be associated with gastrointestinal adverse reactions, sometimes severe. Trulicity has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis, and is therefore not recommended in these patients.

Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Trulicity or any other antidiabetic drug.

The most common adverse reactions reported in ≥5% of Trulicity-treated patients in placebo-controlled trials (placebo, Trulicity 0.75 mg, and Trulicity 1.5 mg) were nausea (5.3%, 12.4%, 21.1%), diarrhea (6.7%, 8.9%, 12.6%), vomiting (2.3%, 6.0%, 12.7%), abdominal pain (4.9%, 6.5%, 9.4%), decreased appetite (1.6%, 4.9%, 8.6%), dyspepsia (2.3%, 4.1%, 5.8%), and fatigue (2.6%, 4.2%, 5.6%).

Gastric emptying is slowed by Trulicity, which may impact absorption of concomitantly administered oral medications. Use caution when oral medications are used with Trulicity. Drug levels of oral medications with a narrow therapeutic index should be adequately monitored when concomitantly administered with Trulicity. In clinical pharmacology studies, Trulicity did not affect the absorption of the tested, orally administered medications to a clinically relevant degree.

Pregnancy: There are no adequate and well-controlled studies of Trulicity in pregnant women. Use only if potential benefi t outweighs potential risk to fetus.

Nursing Mothers: It is not known whether Trulicity is excreted in human milk. A decision should be made whether to discontinue nursing or to discontinue Trulicity taking into account the importance of the drug to the mother.

Pediatric Use: Safety and effectiveness of Trulicity have not been established and use is not recommended in patients less than 18 years of age.

Please see Brief Summary of Prescribing Information, including Boxed Warning about possible thyroid tumors including thyroid cancer, on following pages. Please see Instructions for Use included with the pen.

DG HCP ISI 12NOV2014

Trulicity™ is a trademark of Eli Lilly and Company and is available by prescription only.

Other product/company names mentioned herein are the trademarks of their respective owners.

• 52-week, randomized, placebo-controlled phase 3 study (open-label assignment to Byetta or blinded assignment to Trulicity or placebo) of adult patients with type 2 diabetes treated with maximally tolerated metformin (≥1500 mg/day) and Actos® (up to 45 mg/day)

• Primary objective was to demonstrate superiority of Trulicity 1.5 mg vs placebo on change in A1C from baseline at 26 weeks (-1.5% vs -0.5%, respectively; difference of -1.1%; 95% CI [-1.2, -0.9]; multiplicity- adjusted 1-sided P value <.001; analysis of covariance using last observation carried forward); primary objective met

References


2. Data on file, Lilly USA, LLC. TRU20140910A.3. Data on file, Lilly USA, LLC. TRU20140919C.4. American Diabetes Association. Standards

of medical care in diabetes—2014. Diabetes Care. 2014;37(Suppl 1):S14-S80.

Data represent least-squares mean ± standard error.* Multiplicity-adjusted 1-sided P value <.025 for superiority of Trulicity vs Byetta for A1C. † Multiplicity-adjusted 1-sided P value <.001 for superiority of Trulicity vs placebo for A1C.

Mixed model repeated measures analysis. After 26 weeks, placebo-treated patients were switched in a blinded fashion to Trulicity 1.5

mg or Trulicity 0.75 mg. ‡ American Diabetes Association recommended target goal. Treatment should be

individualized.4

Recommended starting dose is 0.75 mg. Dose can be increased to 1.5 mg for additional glycemic control.


Placebo (n=141; Baseline A1C: 8.1%)

Byetta® (10 mcg BID) (n=276; Baseline A1C: 8.1%)




4 Minnesota Physician June 2015

*In clinical trials, the range of A1C reduction from baseline was 0.7% to 1.6% for the 0.75 mg dose and 0.8% to 1.6% for the 1.5 mg dose.1

Trulicity may be a good option for adult patients with type 2 diabetes who need more control than oral medications are providing.1

To learn more about Trulicity and the savings card for patients, talk to your Lilly sales representativeor visit Trulicity.com.

DG95134 02/2015 PRINTED IN USA ©Lilly USA, LLC 2015. All rights reserved.

Important Safety Information

Trulicity is a glucagon-like peptide-1 receptor agonist (GLP-1 RA) that is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

Limitations of Use: Not recommended as fi rst-line therapy for patients inadequately controlled on diet and exercise. Has not been studied in patients with a history of pancreatitis; consider another antidiabetic therapy. Not for the treatment of type 1 diabetes mellitus or diabetic ketoacidosis. Not a substitute for insulin. Has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis. Not for patients with pre-existing severe gastrointestinal disease. Has not been studied in combination with basal insulin.

Trulicity™ offers proven A1C reduction* and once-weekly dosing in the Trulicity pen1

WARNING: RISK OF THYROID C-CELL TUMORSIn male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance could not be determined from clinical or nonclinical studies.Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Routine serum calcitonin or thyroid ultrasound monitoring is of uncertain value in patients treated with Trulicity. Counsel regarding the risk factors and symptoms of thyroid tumors.

Trulicity is contraindicated in patients with a prior serious hypersensitivity reaction to dulaglutide or any of the product components.

Risk of Thyroid C-cell Tumors: Counsel patients regarding the risk of medullary thyroid carcinoma and the symptoms of thyroid tumors (eg, a mass in the neck, dysphagia, dyspnea, persistent hoarseness). Patients with elevated serum calcitonin (if measured) and patients with thyroid nodules noted on physical examination or neck imaging should be referred to an endocrinologist for further evaluation.

Pancreatitis: Has been reported in clinical trials. Observe patients for signs and symptoms including persistent severe abdominal pain. If pancreatitis is suspected discontinue Trulicity promptly. Do not restart if pancreatitis is confi rmed. Consider other antidiabetic therapy in patients with a history of pancreatitis.

Please see Important Safety Information continued on following page.


Data represent least-squares mean ± standard error.

*Multiplicity-adjusted 1-sided P value <.025 for superiority of Trulicity vs Byetta for A1C.†Multiplicity-adjusted 1-sided P value <.001 for superiority of Trulicity vs placebo for A1C. Mixed model repeated measures analysis.

After 26 weeks, placebo-treated patients were switched in a blinded fashion to Trulicity 1.5 mg or Trulicity 0.75 mg.‡American Diabetes Association recommended target goal. Treatment should be individualized.4

Byetta® (10 mcg BID)(n=276; Baseline A1C: 8.1%)



Placebo(n=141; Baseline A1C: 8.1%)

• 52-week, randomized, placebo-controlled phase 3 study (open-label assignment to Byetta or blinded assignment to Trulicity or placebo) of adult patients with type 2 diabetes treated with maximally tolerated metformin (≥1500 mg/day) and Actos (up to 45 mg/day)

• Primary objective was to demonstrate superiority of Trulicity 1.5 mg vs placebo on change in A1C from baseline at 26 weeks (-1.5% vs -0.5%, respectively; difference of -1.1%; 95% CI [-1.2, -0.9]; multiplicity-adjusted 1-sided P value <.001; analysis of covariance using last observation carried forward); primary objective met

References


2. Data on file, Lilly USA, LLC. TRU20140910A.

3. Data on file, Lilly USA, LLC. TRU20140919C.

4. American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(Suppl 1):S14-S80.


6.2

6.4

6.6

6.8

7.0

7.2

7.4

7.6

7.8

8.0

8.4

8.2

Week 13 Week 26Baseline

LS m

ean

A1C

(%)

-1.3*†

‡

-1.5*†

-1.0

-0.5

93% fewerinjections3

LS m

ean A

1C (%

)

Once-weekly Trulicity 1.5 mg showed signifi cant A1C reduction1

Important Safety Information,continued

Hypoglycemia: The risk of hypoglycemia is increased when Trulicity is used in combination with insulin secretagogues (eg, sulfonylureas) or insulin. Patients may require a lower dose of the sulfonylurea or insulin to reduce the risk of hypoglycemia.

Hypersensitivity Reactions: Systemic reactions were observed in clinical trials in patients receiving Trulicity. Instruct patients who experience symptoms to discontinue Trulicity and promptly seek medical advice.

Renal Impairment: In patients treated with GLP-1 RAs there have been postmarketing reports of acute renal failure and worsening of chronic renal failure, sometimes requiring hemodialysis. A majority of reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. In patients with renal impairment, use caution when initiating or escalating doses of Trulicity and monitor renal function in patients experiencing severe adverse gastrointestinal reactions.

Severe Gastrointestinal Disease: Use of Trulicity may be associated with gastrointestinal adverse reactions, sometimes severe. Trulicity has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis, and is therefore not recommended in these patients.

Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Trulicity or any other antidiabetic drug.

The most common adverse reactions reported in ≥5% of Trulicity-treated patients in placebo-controlled trials (placebo, Trulicity 0.75 mg, and Trulicity 1.5 mg) were nausea (5.3%, 12.4%, 21.1%), diarrhea (6.7%, 8.9%, 12.6%), vomiting (2.3%, 6.0%, 12.7%), abdominal pain (4.9%, 6.5%, 9.4%), decreased appetite (1.6%, 4.9%, 8.6%), dyspepsia (2.3%, 4.1%, 5.8%), and fatigue (2.6%, 4.2%, 5.6%).

Gastric emptying is slowed by Trulicity, which may impact absorption of concomitantly administered oral medications. Use caution when oral medications are used with Trulicity. Drug levels of oral medications with a narrow therapeutic index should be adequately monitored when concomitantly administered with Trulicity. In clinical pharmacology studies, Trulicity did not affect the absorption of the tested, orally administered medications to a clinically relevant degree.

Pregnancy: There are no adequate and well-controlled studies of Trulicity in pregnant women. Use only if potential benefi t outweighs potential risk to fetus.

Nursing Mothers: It is not known whether Trulicity is excreted in human milk. A decision should be made whether to discontinue nursing or to discontinue Trulicity taking into account the importance of the drug to the mother.

Pediatric Use: Safety and effectiveness of Trulicity have not been established and use is not recommended in patients less than 18 years of age.

Please see Brief Summary of Prescribing Information, including Boxed Warning about possible thyroid tumors including thyroid cancer, on following pages. Please see Instructions for Use included with the pen.

DG HCP ISI 12NOV2014

Trulicity™ is a trademark of Eli Lilly and Company and is available by prescription only.

Other product/company names mentioned herein are the trademarks of their respective owners.

• 52-week, randomized, placebo-controlled phase 3 study (open-label assignment to Byetta or blinded assignment to Trulicity or placebo) of adult patients with type 2 diabetes treated with maximally tolerated metformin (≥1500 mg/day) and Actos® (up to 45 mg/day)

• Primary objective was to demonstrate superiority of Trulicity 1.5 mg vs placebo on change in A1C from baseline at 26 weeks (-1.5% vs -0.5%, respectively; difference of -1.1%; 95% CI [-1.2, -0.9]; multiplicity- adjusted 1-sided P value <.001; analysis of covariance using last observation carried forward); primary objective met

References


2. Data on file, Lilly USA, LLC. TRU20140910A.3. Data on file, Lilly USA, LLC. TRU20140919C.4. American Diabetes Association. Standards

of medical care in diabetes—2014. Diabetes Care. 2014;37(Suppl 1):S14-S80.

Data represent least-squares mean ± standard error.* Multiplicity-adjusted 1-sided P value <.025 for superiority of Trulicity vs Byetta for A1C. † Multiplicity-adjusted 1-sided P value <.001 for superiority of Trulicity vs placebo for A1C.

Mixed model repeated measures analysis. After 26 weeks, placebo-treated patients were switched in a blinded fashion to Trulicity 1.5

mg or Trulicity 0.75 mg. ‡ American Diabetes Association recommended target goal. Treatment should be

individualized.4

Recommended starting dose is 0.75 mg. Dose can be increased to 1.5 mg for additional glycemic control.


Placebo (n=141; Baseline A1C: 8.1%)

Byetta® (10 mcg BID) (n=276; Baseline A1C: 8.1%)





Trulicity DG HCP BS 12NOV2014 Brief Summary 7 x 9.75 PRINTER VERSION 1 OF 2

TrulicityTM (dulaglutide) DG HCP BS 12NOV2014 TrulicityTM (dulaglutide) DG HCP BS 12NOV2014

TrulicityTM (dulaglutide) Brief Summary: Consult the package insert for complete prescribing information.

WARNING: RISK OF THYROID C-CELL TUMORS• In male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. It is unknown whether Trulicity causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as human relevance could not be determined from clinical or nonclinical studies.• Trulicity is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Routine serum calcitonin or thyroid ultrasound monitoring is of uncertain value in patients treated with Trulicity. Counsel regarding the risk factors and symptoms of thyroid tumors.

INDICATIONS AND USAGE Trulicity™ is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitations of Use: Not recommended as a first-line therapy for patients who have inadequate glycemic control on diet and exercise. Has not been studied in patients with a history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis. Should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. It is not a substitute for insulin. Has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis. Not recommended in patients with pre-existing severe gastrointestinal disease. The concurrent use of Trulicity and basal insulin has not been studied.CONTRAINDICATIONSDo not use in patients with a personal or family history of MTC or in patients with MEN 2. Do not use in patients with a prior serious hypersensitivity reaction to dulaglutide or to any of the product components.WARNINGS AND PRECAUTIONSRisk of Thyroid C-cell Tumors: In male and female rats, dulaglutide causes a dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and carcinomas) after lifetime exposure. Glucagon-like peptide (GLP-1) receptor agonists have induced thyroid C-cell adenomas and carcinomas in mice and rats at clinically relevant exposures. It is unknown whether Trulicity will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of this signal could not be determined from the clinical or nonclinical studies. One case of MTC was reported in a patient treated with Trulicity. This patient had pretreatment calcitonin levels approximately 8 times the upper limit of normal (ULN). Trulicity is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2. Counsel patients regarding the risk for MTC with the use of Trulicity and inform them of symptoms of thyroid tumors (eg, a mass in the neck, dysphagia, dyspnea, persistent hoarseness). The role of serum calcitonin monitoring or thyroid ultrasound monitoring for the purpose of early detection of MTC in patients treated with Trulicity is unknown. Such monitoring may increase the risk of unnecessary procedures, due to the low specificity of serum calcitonin as a screening test for MTC and a high background incidence of thyroid disease. Very elevated serum calcitonin value may indicate MTC and patients with MTC usually have calcitonin values >50 ng/L. If serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Patients with thyroid nodules noted on physical examination or neck imaging should also be referred to an endocrinologist for further evaluation. Pancreatitis: In Phase 2 and Phase 3 clinical studies, 12 (3.4 cases per 1000 patient years) pancreatitis-related adverse reactions were reported in patients exposed to Trulicity versus 3 in non-incretin comparators (2.7 cases per 1000 patient years). An analysis of adjudicated events revealed 5 cases of confirmed pancreatitis in patients exposed to Trulicity (1.4 cases per 1000 patient years) versus 1 case in non-incretin comparators (0.88 cases per 1000 patient years). After initiation of Trulicity, observe patients carefully for signs and symptoms of pancreatitis, including persistent severe abdominal pain. If pancreatitis is suspected, promptly discontinue Trulicity. If pancreatitis is confirmed, Trulicity should not be restarted. Trulicity has not been evaluated in patients with a prior history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis. Hypoglycemia with Concomitant Use of Insulin Secretagogues or Insulin: The risk of hypoglycemia is increased when Trulicity is used in combination with insulin secretagogues (eg, sulfonylureas) or insulin. Patients may require a lower dose of sulfonylurea or insulin to reduce the risk of hypoglycemia. Hypersensitivity Reactions: Systemic hypersensitivity reactions were observed in patients receiving Trulicity in clinical trials. If a hypersensitivity reaction occurs, the patient should discontinue Trulicity and promptly seek medical advice. Renal Impairment: In patients treated with GLP-1 receptor agonists, there have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis. Some of these events were reported in patients without known underlying renal disease. A majority of reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. Because these reactions may worsen renal failure, use caution when initiating or escalating doses of Trulicity in patients with renal impairment. Monitor renal function in patients with renal impairment reporting severe adverse gastrointestinal reactions. Severe Gastrointestinal Disease: Use of Trulicity may be associated with gastrointestinal adverse reactions, sometimes severe. Trulicity has not been studied in patients with severe gastrointestinal disease, including severe gastroparesis, and is therefore not recommended in these patients.

Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Trulicity or any other antidiabetic drug.ADVERSE REACTIONSClinical Studies Experience: Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice. Pool of Placebo-controlled Trials: These data reflect exposure of 1670 patients to Trulicity and a mean duration of exposure to Trulicity of 23.8 weeks. Across the treatment arms, the mean age of patients was 56 years, 1% were 75 years or older and 53% were male. The population in these studies was 69% White, 7% Black or African American, 13% Asian; 30% were of Hispanic or Latino ethnicity. At baseline, the population had diabetes for an average of 8.0 years and had a mean HbA1c of 8.0%. At baseline, 2.5% of the population reported retinopathy. Baseline estimated renal function was normal or mildly impaired (eGFR ≥60mL/min/1.73 m2) in 96.0% of the pooled study populations. Adverse Reactions in Placebo-Controlled Trials Reported in ≥5% of Trulicity-Treated Patients: Placebo (N=568), Trulicity 0.75mg (N=836), Trulicity 1.5 mg (N=834) (listed as placebo, 0.75 mg, 1.5 mg) nausea (5.3%, 12.4%, 21.1%), diarrheaa (6.7%, 8.9%, 12.6%), vomitingb (2.3%, 6.0%, 12.7%), abdominal painc (4.9%, 6.5%, 9.4%), decreased appetite (1.6%, 4.9%, 8.6%), dyspepsia (2.3%, 4.1%, 5.8%), fatigued (2.6%, 4.2%, 5.6%). (a Includes diarrhea, fecal volume increased, frequent bowel movements. b Includes retching, vomiting, vomiting projectile. c Includes abdominal discomfort, abdominal pain, abdominal pain lower, abdominal pain upper, abdominal tenderness, gastrointestinal pain. d Includes fatigue, asthenia, malaise.) Note: Percentages reflect the number of patients that reported at least 1 treatment-emergent occurrence of the adverse reaction. Gastrointestinal Adverse Reactions : In the pool of placebo-controlled trials, gastrointestinal adverse reactions occurred more frequently among patients receiving Trulicity than placebo (placebo 21.3%, 0.75 mg 31.6%, 1.5 mg 41.0%). More patients receiving Trulicity 0.75 mg (1.3%) and Trulicity 1.5 mg (3.5%) discontinued treatment due to gastrointestinal adverse reactions than patients receiving placebo (0.2%). Investigators graded the severity of gastrointestinal adverse reactions occurring on 0.75 mg and 1.5 mg of Trulicity as “mild” in 58% and 48% of cases, respectively, “moderate” in 35% and 43% of cases, respectively, or “severe” in 7% and 11% of cases, respectively. In addition to the adverse reactions ≥5% listed above, the following adverse reactions were reported more frequently in Trulicity-treated patients than placebo (frequencies listed, respectively, as: placebo; 0.75 mg; 1.5 mg): constipation (0.7%; 3.9%; 3.7%), flatulence (1.4%; 1.4%; 3.4%), abdominal distension (0.7%; 2.9%; 2.3%), gastroesophageal reflux disease (0.5%; 1.7%; 2.0%), and eructation (0.2%; 0.6%; 1.6%). Pool of Placebo- and Active-Controlled Trials: The occurrence of adverse reactions was also evaluated in a larger pool of patients with type 2 diabetes participating in 6 placebo- and active-controlled trials evaluating the use of Trulicity as monotherapy and add-on therapy to oral medications or insulin. In this pool, a total of 3342 patients with type 2 diabetes were treated with Trulicity for a mean duration 52 weeks. The mean age of patients was 56 years, 2% were 75 years or older and 51% were male. The population in these studies was 71% White, 7% Black or African American, 11% Asian; 32% were of Hispanic or Latino ethnicity. At baseline, the population had diabetes for an average of 8.2 years and had a mean HbA1c of 7.6-8.5%. At baseline, 5.2% of the population reported retinopathy. Baseline estimated renal function was normal or mildly impaired (eGFR ≥60 ml/min/1.73 m2) in 95.7% of the Trulicity population. In the pool of placebo- and active-controlled trials, the types and frequency of common adverse reactions, excluding hypoglycemia, were similar to those listed as ≥5% above. Other Adverse Reactions: Hypoglycemia : Incidence (%) of Documented Symptomatic (≤70 mg/dL Glucose Threshold) and Severe Hypoglycemia in Placebo-Controlled Trials: Add-on to Metformin at 26 weeks, Placebo (N=177), Trulicity 0.75 mg (N=302), Trulicity 1.5 mg (N=304), Documented symptomatic: Placebo: 1.1%, 0.75 mg: 2.6%, 1.5 mg: 5.6%; Severe: all 0. Add-on to Metformin + Pioglitazone at 26 weeks, Placebo (N=141), TRULICITY 0.75 mg (N=280), Trulicity 1.5 mg (N=279), Documented symptomatic: Placebo: 1.4%, 0.75 mg: 4.6%, 1.5 mg: 5.0%; Severe: all 0. Hypoglycemia was more frequent when Trulicity was used in combination with a sulfonylurea or insulin. Documented symptomatic hypoglycemia occurred in 39% and 40% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with a sulfonylurea. Severe hypoglycemia occurred in 0% and 0.7% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with a sulfonylurea. Documented symptomatic hypoglycemia occurred in 85% and 80% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with prandial insulin. Severe hypoglycemia occurred in 2.4% and 3.4% of patients when Trulicity 0.75 mg and 1.5 mg, respectively, was co-administered with prandial insulin. Heart Rate Increase and Tachycardia Related Adverse Reactions : Trulicity 0.75 mg and 1.5 mg resulted in a mean increase in heart rate (HR) of 2-4 beats per minute (bpm). The long-term clinical effects of the increase in HR have not been established. Adverse reactions of sinus tachycardia were reported more frequently in patients exposed to Trulicity. Sinus tachycardia was reported in 3.0%, 2.8%, and 5.6% of patient treated with placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively. Persistence of sinus tachycardia (reported at more than 2 visits) was reported in 0.2%, 0.4% and 1.6% of patients treated with placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively. Episodes of sinus tachycardia, associated with a concomitant increase from baseline in heart rate of ≥15 beats per minute, were reported in 0.7%, 1.3% and 2.2% of patient treated with placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively. Immunogenicity : Across four Phase 2 and five Phase 3 clinical studies, 64 (1.6%) TRULICITY-treated patients developed anti-drug antibodies (ADAs) to the active ingredient in Trulicity (ie, dulaglutide). Of the 64 dulaglutide-treated patients that developed dulaglutide ADAs, 34 patients (0.9% of the overall population) had dulaglutide-neutralizing antibodies, and 36 patients (0.9% of the overall population) developed antibodies



Trulicity DG HCP BS 12NOV2014 Brief Summary 7 x 9.75 PRINTER VERSION 2 OF 2

TrulicityTM (dulaglutide) DG HCP BS 12NOV2014 TrulicityTM (dulaglutide) DG HCP BS 12NOV2014

against native GLP-1. The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, the incidence of antibodies to dulaglutide cannot be directly compared with the incidence of antibodies of other products. Hypersensitivity : Systemic hypersensitivity adverse reactions sometimes severe (eg, severe urticaria, systemic rash, facial edema, lip swelling) occurred in 0.5% of patients on Trulicity in the four Phase 2 and Phase 3 studies. Injection-site Reactions : In the placebo-controlled studies, injection-site reactions (eg, injection-site rash, erythema) were reported in 0.5% of Trulicity-treated patients and in 0.0% of placebo-treated patients. PR Interval Prolongation and Adverse Reactions of First Degree Atrioventricular (AV) Block : A mean increase from baseline in PR interval of 2-3 milliseconds was observed in Trulicity-treated patients in contrast to a mean decrease of 0.9 millisecond in placebo-treated patients. The adverse reaction of first degree AV block occurred more frequently in patients treated with Trulicity than placebo (0.9%, 1.7% and 2.3% for placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively). On electrocardiograms, a PR interval increase to at least 220 milliseconds was observed in 0.7%, 2.5% and 3.2% of patients treated with placebo, Trulicity 0.75 mg and Trulicity 1.5 mg, respectively. Amylase and Lipase Increase: Patients exposed to Trulicity had mean increases from baseline in lipase and/or pancreatic amylase of 14% to 20%, while placebo-treated patients had mean increases of up to 3%. DRUG INTERACTIONSTrulicity slows gastric emptying and thus has the potential to reduce the rate of absorption of concomitantly administered oral medications. Caution should be exercised when oral medications are concomitantly administered with Trulicity. Drug levels of oral medications with a narrow therapeutic index should be adequately monitored when concomitantly administered with Trulicity. In clinical pharmacology studies, Trulicity did not affect the absorption of the tested, orally administered medications to any clinically relevant degree.USE IN SPECIFIC POPULATIONSPregnancy - Pregnancy Category C: There are no adequate and well-controlled studies of Trulicity in pregnant women. The risk of birth defects, loss, or other adverse outcomes is increased in pregnancies complicated by hyperglycemia and may be decreased with good metabolic control. It is essential for patients with diabetes to maintain good metabolic control before conception and throughout pregnancy. Trulicity should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. In rats and rabbits, dulaglutide administered during the major period of organogenesis produced fetal growth reductions and/or skeletal anomalies and ossification deficits in association with decreased maternal weight and food consumption attributed to the pharmacology of dulaglutide. Nursing Mothers: It is not known whether Trulicity is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for clinical adverse reactions from Trulicity in nursing infants, a decision should be made whether to discontinue nursing or to discontinue Trulicity, taking into account the importance of the drug to the mother. Pediatric Use: Safety and effectiveness of Trulicity have not been established in pediatric patients. Trulicity is not recommended for use in pediatric patients younger than 18 years. Geriatric Use: In the pool of placebo- and active-controlled trials, 620 (18.6%) Trulicity-treated patients were 65 years of age and over and 65 Trulicity-treated patients (1.9%) were 75 years of age and over. No overall differences in safety or efficacy were detected between these patients and younger patients, but greater sensitivity of some older individuals cannot be ruled out. Hepatic Impairment: There is limited clinical experience in patients with mild, moderate, or severe hepatic impairment. Therefore, Trulicity should be used with caution in these patient populations. In a clinical pharmacology study in subjects with varying degrees of hepatic impairment, no clinically relevant change in dulaglutide pharmacokinetics (PK) was observed. Renal Impairment: In the four Phase 2 and five Phase 3 randomized clinical studies, at baseline, 50 (1.2%) Trulicity-treated patients had mild renal impairment (eGFR ≥60 but <90 mL/min/1.73 m2), 171 (4.3%) Trulicity-treated patients had moderate renal impairment (eGFR ≥30 but <60 mL/min/1.73 m2) and no Trulicity-treated patients had severe renal impairment (eGFR <30 mL/min/1.73 m2). No overall differences in safety or effectiveness were observed relative to patients with normal renal function, though conclusions are limited due to small numbers. In a clinical pharmacology study in subjects with renal impairment including end-stage renal disease (ESRD), no clinically relevant change in dulaglutide PK was observed. There is limited clinical experience in patients with severe renal impairment or ESRD. Trulicity should be used with caution, and if these patients experience adverse gastrointestinal side effects, renal function should be closely monitored. Gastroparesis: Dulaglutide slows gastric emptying. Trulicity has not been studied in patients with pre-existing gastroparesis. OVERDOSAGE Overdoses have been reported in clinical studies. Effects associated with these overdoses were primarily mild or moderate gastrointestinal events (eg, nausea, vomiting) and non-severe hypoglycemia. In the event of overdose, appropriate supportive care (including frequent plasma glucose monitoring) should be initiated according to the patient’s clinical signs and symptoms.PATIENT COUNSELING INFORMATION See FDA-approved Medication Guide • Inform patients that Trulicity causes benign and malignant thyroid C-cell tumors in rats and that the human relevance of this finding is unknown. Counsel patients to report symptoms of thyroid tumors (eg, a lump in the neck, persistent hoarseness, dysphagia, or dyspnea) to their physician. • Inform patients that persistent severe abdominal pain, that may radiate to the back and which may (or may not) be accompanied by vomiting, is the hallmark symptom of acute pancreatitis. Instruct patients to discontinue Trulicity promptly, and to contact their physician, if persistent severe abdominal pain occurs. • The risk of hypoglycemia may be increased when Trulicity is

used in combination with a medicine that can cause hypoglycemia, such as a sulfonylurea or insulin. Review and reinforce instructions for hypoglycemia management when initiating Trulicity therapy, particularly when concomitantly administered with a sulfonylurea or insulin. • Patients treated with Trulicity should be advised of the potential risk of dehydration due to gastrointestinal adverse reactions and take precautions to avoid fluid depletion. Inform patients treated with Trulicity of the potential risk for worsening renal function and explain the associated signs and symptoms of renal impairment, as well as the possibility of dialysis as a medical intervention if renal failure occurs. • Inform patients that serious hypersensitivity reactions have been reported during postmarketing use of GLP-1 receptor agonists. If symptoms of hypersensitivity reactions occur, patients must stop taking Trulicity and seek medical advice promptly. • Advise patients to inform their healthcare provider if they are pregnant or intend to become pregnant. • Prior to initiation of Trulicity, train patients on proper injection technique to ensure a full dose is delivered. Refer to the accompanying Instructions for Use for complete administration instructions with illustrations. • Inform patients of the potential risks and benefits of Trulicity and of alternative modes of therapy. Inform patients about the importance of adherence to dietary instructions, regular physical activity, periodic blood glucose monitoring and HbA1c testing, recognition and management of hypoglycemia and hyperglycemia, and assessment for diabetes complications. During periods of stress such as fever, trauma, infection, or surgery, medication requirements may change and advise patients to seek medical advice promptly. • Each weekly dose of Trulicity can be administered at any time of day, with or without food. The day of once weekly administration can be changed if necessary, as long as the last dose was administered 3 or more days before. If a dose is missed and there are at least 3 days (72 hours) until the next scheduled dose, it should be administered as soon as possible. Thereafter, patients can resume their usual once weekly dosing schedule. If a dose is missed and the next regularly scheduled dose is due in 1 or 2 days, the patient should not administer the missed dose and instead resume Trulicity with the next regularly scheduled dose. • Advise patients treated with Trulicity of the potential risk of gastrointestinal side effects. • Instruct patients to read the Medication Guide and the Instructions for Use before starting Trulicity therapy and review them each time the prescription is refilled. • Instruct patients to inform their doctor or pharmacist if they develop any unusual symptom, or if any known symptom persists or worsens. • Inform patients that response to all diabetic therapies should be monitored by periodic measurements of blood glucose and HbA1c levels, with a goal of decreasing these levels towards the normal range. HbA1c is especially useful for evaluating long-term glycemic control.

Eli Lilly and Company, Indianapolis, IN 46285, USA

US License Number 1891

Copyright © 2014, Eli Lilly and Company. All rights reserved.

Additional information can be found at www.trulicity.com

DG HCP BS 12NOV2014




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Features

June 2015 MINNESOTA PhySIcIAN 9

june 2015 • Volume XXIX, no. 3

Publisher Mike Starnes | [email protected]

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Ten outstanding building projects 22By MPP Staff

2015 HeAlTH cARe ARcHITecTuRe HonoR Roll

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meDIcuS 13

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PHySIcIAn SuPPoRT SeRVIceS 20Physician burnoutBy Rebecca Hafner-Fogarty,

MD, MBA

AllIeD PRofeSSIonS 38Community health workersBy Joan Cleary, MM

PolIcy 42Medicare’s new payment reform planBy Timothy A. Johnson, JD, and

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The Minnesota Accountable Health Model 1Creating community partnershipsBy Rahul Koranne, MD, MBA, FACP

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DHS Outlines Plan to Address Opioid Addictionthe Minnesota Department of human services (Dhs) has outlined a response to the growing problem of death and injury associated with opioid use and overdose. Lucinda Jesson, Dhs commissioner, outlined the plan in response to a letter from sylvia Burwell, U.s. secretary of health and human services, which asked Gov. Dayton to provide an update on opioid use in Minnesota, as well as how the state is responding to the prob-lem and its effectiveness.

“this is something we’ve been working on a lot over the past year,” said Jesson. “We have great concerns and we’ve made a real push on this issue. When i got the letter, i was happy to be able to say we had a head start on this in Minnesota. We have a team already in place that’s working on this, and i was really glad to see that the federal gov-

ernment was also making opioid addiction a focus.”

in the letter, Jesson not-ed concerns associated with over-prescription of opioids and the availability of heroin, a drug that many people addicted to prescription pain killers turn to. among the concerns cited by Jesson: Minnesota ranked first among all states for deaths due to drug poisonings among american indians and alaskan natives; about 3,000 people en-rolled in Minnesota health care Plans (MhcP) become chronic opioid users each year; more than 80 percent of new chronic opioid users have a recent men-tal illness or substance abuse disorder, or both, increasing the risk of developing a dependen-cy; more than half of pregnant women in the state who are dependent on opioids continue to receive opioid prescriptions for pain throughout pregnancy; and the number of pregnant amer-ican indian women prescribed these drugs during pregnancy is twice as high as that of other

Minnesotans.“it was not an easy letter

to respond to,” said Jesson. “it makes you step back and think about many concerns, like the increase in heroin addiction in the state, which is ultimately driven by prescription drug abuse. We’ve seen treatment admissions for heroin addiction about double over the last five years. that’s very concerning.”

Jesson’s proposed response would form a community-based opioid Prescribing Work Group (oPWG) that would recommend protocols to address all phases of the opioid prescribing cycle. oPWG would notify providers enrolled in MhcP when they fall behind on quality improve-ment thresholds, require them to submit a plan to get back on track, and disenroll those whose practices are “so inconsistently extreme that they meet oPWG- recommended opioid disenroll-ment thresholds.” another strate-gy includes changing the way opioid addiction treatment is ad-dressed to include expansion of

medication-assisted therapies, as the traditional 12-step programs aren’t effective for some patients with opioid dependence. Dhs will work with the Minnesota Medical association to deter-mine stricter opioid medication prescription standards.

Dhs also plans to address neonatal exposure to opioids, with a specific plan to address the impact of opioid addiction among american indian women of childbearing age, including developing a culturally based model spanning prevention, treatment, and recovery and encouraging substance abuse screening for all pregnant wom-en with a referral for treatment services when necessary.

“half of pregnant native american women who are known to be dependent on opioids are still prescribed them for pain during pregnancy,” said Jesson. “our goal is to work with the tribes to develop more cul-turally appropriate services for pregnant women so we can help them with this issue.”

June 2015 Minnesota Physician 11Capsules to page 12

Allina Health, Mayo Foundation Named Top Large Hospital Systems in U.S.two Minnesota hospital systems rank first and second among the nation’s top five large hospital systems, according to the sev-enth annual report released by truven health analytics. Minne-apolis-based allina health was ranked first and Rochester-based Mayo Foundation was ranked second, followed by hospital systems in ohio, Michigan, and indiana.

according to truven, these hospitals demonstrate top performance in how patients are cared for through clinical measures and how the hospital performs as a business, includ-ing cost of care and operational efficiency.

“Behind each of the figures they analyzed lies real people who were positively affected by the care we provided to them,” said Penny Wheeler, MD, presi-dent and chief executive officer at allina health. “our employees and our hospitals are changing lives for the better and i couldn’t be more proud that we’re being recognized for this important work.”

truven analyzed data from 340 health systems and 2,812 member hospitals to determine the top five large, medium, and small health systems. Large hospital systems were defined as having annual revenue greater than $1.5 billion. no facilities in Minnesota made the top five medium or small health sys-tems, but geographically it had the highest concentration of top health systems along with indi-ana, which also had two health systems in the top 15.

overall, the top 15 health systems spent 7 percent less per care episode, experienced 1.2 percent fewer deaths, had 5 percent fewer complications in patients, had 10.9 percent better patient safety performance, and had better adherence to core measures than those that did not rank.

“superior health system leadership has become the fun-

damental impetus for success in the post-reform healthcare environment,” said Mike Bos- wood, president and ceo of truven health analytics. “By outperforming their peers across a wide range of key clinical and administrative performance measures, the leaders of the 15 top health systems have shown that it is possible to consistently deliver higher quality care at a better value. it is an honor to recognize the efforts of these leadership teams.”

MN Obesity Rates Lower than Those in Neighboring Statesobesity rates in Minnesota have stayed steady, unlike other states in the region, according to a re-cent report from the Minnesota Department of health (MDh).

MDh analyzed data from the centers for Disease control and Prevention’s (cDc) Behavioral Risk Factor surveillance system, which surveys 400,000 Minne-sotans annually. they found that obesity rates in Minnesota dropped below 26 percent in 2010 and have stayed below that rate since. it was the only state in the region to bring the rate below this threshold. Meanwhile, other states in the region, which includes iowa, north Dakota, south Dakota, and Wisconsin, saw obesity rates increase to be-tween 29 percent and 31 percent in 2013, the most recent cDc data available.

the report also shows that the number of Minnesotans that were at a healthy weight in 2013 increased by more than 60,000 since 2010. according to MDh, this is more than 11 percent higher than the U.s. overall. the reduction in obesity rates leads to significant cost savings as well. MDh estimates that the state saved $265 million in obesity-related medical expenses as of 2013. in addition, about 18,600 Minnesotans covered by state health care plans moved to a healthy weight in 2013, which MDh estimates saves up to $9 million for taxpayers each year.

ed ehlinger, MD, Minnesota

Background and Focus: Increasing evidence supports the link between access to mental health care and reducing health care costs. Primary care physicians often lack the expertise to diagnose behavioral health correctly and are not always able to easily refer a patient to a mental health care provider. Many initiatives nationwide are addressing this issue. It is so important that the ACA stipulated the development of the Behavioral Health Home in 2015. Some states, including Minnesota, are also creating Behavioral Health Home programs.

Objectives: We will review numerous initiatives that support the development of the Behavioral Health Home. We will define this term and discuss how to incorporate it into our health care delivery system. We will examine the value it can bring and the challenges it will face. Our panel of industry experts will outline the steps that must be taken to increase the overall access to mental health care and the broad improvement in population health that this increased access will bring.

Panelists include: • L. Read Sulik, MD, PrairieCare

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MINNESOTA HEALTH CARE ROUNDTABLE

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Capsules from page 11

commissioner of health, reports that Minnesota’s progress on obesity rates is related to the statewide health improvement Program, a program enacted in 2008 in response to increasing health care costs due to obesity.

“obesity is a complex condi-tion with many contributing fac-tors,” said ehlinger. “We know diet and exercise are key, and i am confident that Minnesota’s success is closely tied to invest-ments by the statewide health improvement Program and its community and private sector partners to increase Minneso-tans’ opportunities for healthy eating and physical activity.”

Hospitals Awarded for Excellence in Cancer Carethree Minnesota facilities have been recognized with an out-standing achievement award

from the american college of surgeons’ commission on cancer (coc) for achieving excellence in patient cancer care, including prevention, early diagnosis, research, and educa-tion. only 75 cancer programs in the U.s. received the award, representing about 15 percent of programs surveyed in 2014.

“these 75 cancer programs currently represent the best of the best—so to speak—when it comes to cancer care,” said Dan-iel McKellar, Mc, Facs, chair of the coc. “each of these facilities is not just meeting nationally recognized standards for the delivery of quality cancer care, they are exceeding them.”

Park nicollet Frauenshuh cancer center in st. Louis Park; st. Joseph’s Medical center in Brainerd; and st. Francis Re-gional Medical center in shako-pee received the award.

“More and more, we’re finding that patients and their families want to know how the health care institutions in their

communities compare with one another,” said McKellar. “they want access to information in terms of who’s providing the best quality of care, and they want to know about overall patient outcomes.

through this recognition program, i’d like to think we’re playing a small, but vital role, in helping them make informed decisions on their cancer care.”

North Memorial Recognized for Stroke Carenorth Memorial hospital has received the Get With the Guidelines target: stroke honor Roll-elite Quality achievement award from the american heart association/american stroke as-sociation. the award is given at three levels—honor Roll, honor Roll-elite, and honor Roll-elite Plus, based on the average time it takes to provide ischemic stroke

patients with tPa, the drug given intravenously to reduce the ef-fects of a stroke.

over a 12-month period, north Memorial treated at least 75 percent of its ischemic stroke patients with tPa within 60 min-utes of arriving at the hospital.

north Memorial was one of 559 hospitals to qualify for one of the levels of target: stroke honor Roll awards.

“studies have shown that hospitals that consistently follow Get With the Guidelines qual-ity improvement measures can reduce length of stay and 30-day readmission rates and reduce disparities in care,” said Deep-ak Bhatt, MD, MPh, national chairman of the Get With the Guidelines steering committee, executive director of interven-tional cardiovascular Programs at Brigham and Women’s hospi-tal, and professor of medicine at harvard Medical school.

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Rahul Koranne, MD MBA, FACP

Terrence Cascino, MD

Patrick Zook, MD

Paul Hartleben, MD, MBA


Rahul Koranne, MD, MBA, FACP, board-cer-tified in internal medicine and geriatrics, has joined the Minnesota hospital associa-tion as its first senior vice president for clin-ical affairs and chief medical officer. he has served in Minnesota health care systems for the past 16 years, beginning at a 19-bed rural hospital in starbuck, Minn. for five years and, most recently, as vice president and executive medical director at healtheast care system for 10 years. Koranne also serves on the board

of the Wilder Foundation in st. Paul and on the faculty at sev-eral schools at the University of Minnesota, including the carlson school of Management. he attended medical school at the Univer-sity of Delhi in india, completed his internal medicine residency at the state University of new york in Brooklyn, and his fellowship in geriatrics at the University of Minnesota, where he also earned a master’s degree of business administration.

Terrence Cascino, MD, a board-certified neu-rologist at Mayo clinic, has been chosen as the 34th president of the american academy of neurology (aan), the world’s largest pro-fessional association of neurologists. he has been with Mayo clinic since 1982, where he is professor of neurology and neuro-oncology. he has taken several leadership roles in his time at Mayo: the vice chair of the department of neu-rology, the chair of the clinical Practice com-mittee, and the Juanita Kious Waugh executive

dean for education. he earned his medical degree at Loyola Uni-versity chicago stritch school of Medicine, completed an intern-ship at Rush-Presbyterian–st. Luke’s Medical center in chicago, and a residency at Mayo Graduate school of Medicine. cascino has already served in several leadership positions within aan.

Patrick Zook, MD, board-certified in family medicine has been named a cDc childhood immunization champion for his success in increasing pertussis vaccination rates in st. cloud through community partnerships. Zook has worked with st. cloud Medical Group since 1977. he serves as president of the stearns Benton Medical society, a community of phy-sicians that works to improve the well-being of people in central Minnesota, and is a member of the Minnesota Medical association. Zook

earned his medical degree at creighton University school of Med-icine, and completed a residency and internship at st. Joseph hos-pital in omaha, nebraska.

Paul Hartleben, MD, MBA, board-certified in orthopedic surgery, has joined st. croix ortho-paedics as a spine surgeon. he has practiced as an orthopedic surgeon for 30 years, and has served as a teacher and held executive lead-ership positions in Minneapolis and st. Paul. hartleben is licensed to practice in Minne-sota, Wisconsin, and california. he earned his medical degree at the University of Minne-sota, where he also completed a residency and internship in orthopedic surgery, and com-

pleted spine fellowship training at the University of california, Los angeles. hartleben is now seeing patients at st. croix orthopae-dics clinics in stillwater and Wyoming.

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Improving dialysis patient care

Allan J. Collins, MD, FACP

Chronic Disease Research Group

Dr. Collins is board-certified in internal medicine and

nephrology and has more than 30 years of experience

in nephrology and ESRD treatment. He is director of

the Chronic Disease Research Group and professor of

medicine at the University of Minnesota. Dr. Collins served as president of the

National Kidney Foundation (NKF) from 2006–2008 and received the Belding H. Scribner Award from the American Society of

Nephrology in 2014.

Please tell us about the mission of the Peer Kidney Care Initiative.

The mission of Peer is to improve the quality of dialysis patient care in the United States. Peer and the chief medical officers (CMOs) of 13 participating dialysis provider or-ganizations together analyze and interpret data to identify patterns of treatment, trends in clinical outcomes, and both regional and national opportunities for quality improve-ment. Peer aims to clearly describe the complex interaction of all health care providers that touch dialysis patients, including not only dialysis facilities, but also hospi-tals, pharmacies, and phy-sician practices. Peer offers an alternative voice in the formation of policy (espe-cially Medicare policy) that affects both patients and their health care providers.

How did the Initiative get started?Peer sprouted from the CMO Initiative, which began with a March 2013 meeting convened by physicians Doug Johnson (Dialysis Clinic, Inc.), Allen Nissenson (DaVita Kidney Care), and Tom Parker (Renal Ventures Management). A second meeting of the CMO Initiative, held in March 2014, began to discuss a comprehensive effort to improve patient outcomes through collaborative analytics and standardized reporting, with Medicare data as the foundation.

How did the Chronic Disease Research Group (CDRG) become involved with this program?

I was an invited speaker at the second CMO Initiative and spoke about how the richness of data might be harnessed to track local and national progress toward improving patient outcomes. During the ensuing months, the CDRG, a nonprofit research group with a long history of publishing epidemiologic studies of chronic kidney disease, partic-ularly using administrative data (e.g., Medicare claims), and the leaders of the CMO Initiative organized the Peer Kidney Care Initiative.

What type of work does the Peer Kidney Care Initiative do?

The CDRG essentially operates a Data Coordinating Center (DCC) for Peer. Peer’s most important task is to design, perform, and interpret studies of Medicare claims to ad-dress clinical questions that the Peer Steering Committee is particularly interested in, such as the management of cardiovascular disease (a leading cause of morbidity and mortality in dialysis patients) and the control of infection. Thus, many studies are designed to address these issues. The DCC also provides facility-level and organization-level analytics to Peer members. Some examples of these analyt-ics include cause-specific mortality and hospital admission rates in patients at individual dialysis facilities; use of cardiovascular-related medications in individual organi-

zations; and mortality rates in patients receiving care from individual nephrologists.

It is important for Peer to disseminate data. Our web-site and Twitter account, @peerkidney, allow us to dis-tribute Peer research for free. The most important output to date is an inaugural report, Peer Kidney Care Initiative 2014 Report: Dialysis Care and Outcomes in the United States, which addresses the number and health status of new dialysis patients; hospitalization; mortality; and the

5-Star Quality Rating System for Medicare-certified dialy-sis facilities.

What are the big-gest challenges to improving dialysis care?

Adequate preparation of the new dialysis patient is a key issue. Rates of hospitalization and death are highly elevated during the first three to six months of dialysis. The majority of new dialysis patients are prescribed in-center hemodialy-sis with initial vascular access via a central venous catheter. We must do a better job of educating patients about the different dialysis modalities that are available, including modalities in the home setting, like peritoneal dialysis (PD) and home hemodialysis (HHD). For patients who choose to receive dialysis in-center, early creation of a permanent ac-cess is important. The arteriovenous fistula is the preferred access type, but grafts may be underused in some patient subgroups, such as the very elderly, in which the probability of fistula maturation is likely lower.

Another challenge is cardiovascular disease manage-ment. This field is generally lacking in high-quality data from randomized clinical trials. Cardio-protective drugs widely used in the general population were never subjected to trials in dialysis patients. For example, it is unknown whether ACE inhibitors and ARBs are effective therapies for congestive heart failure in dialysis patients. Lisinopril, the dominant ACE inhibitor in dialysis patients, is removed by dialysis, whereas ARBs, including losartan and valsar-tan, are not. To this point, Canadian researchers recently published observational data that the dialyzability of indi-vidual beta blockers may be meaningfully associated with risk of death.

Infection control is another major issue. Infection-re-lated admission rates have remained stubbornly high, de-spite increased reliance on fistulas for vascular access. How can we better prevent infectious disease? We administer influenza and pneumococcal vaccines to dialysis patients, but these patients have compromised immune function. So the standard influenza vaccine or one pneumococcal vaccine every five years may not be enough; instead, high-dose influenza vaccines and more frequent pneumococcal vaccines may be warranted. When in-center hemodialysis patients present symptoms of respiratory infection, do they receive dialysis in isolation areas or do they receive dialysis

IntervIew


The only way for dialysis providers to maintain revenue growth …

is to extend patients’ lives.

near other patients who are otherwise healthy? Does dialysis facility staff clean all surfaces in the facility, or is periodic cleaning limited to dialysis machines and chairs? These are practical issues that demand attention.

What can you share with us about the scope of the problems faced by the Peer Kidney Initiative?

In addition to clinical issues, dialysis providers currently face a number of regulatory issues. Medi-care introduced a Quality Incentive Program (QIP) several years ago and added a 5-Star Quality Rating System for dialysis facilities at the beginning of 2015. Each of these systems involves a combination of metrics that directly relate to the care provided by dialysis providers (e.g., the distribution of Kt/V and the prevalence of hypercalcemia) and metrics that relate to global outcomes, like mortality, hos-pitalization, and 30-day rehospitalization. The chal-lenge with metrics about global outcomes is that they demand risk adjustment. However, the data underlying current risk adjustment schema are mostly derived from Medicare claims. Although claims are a useful source of data about patient health, they are not medical charts and they reveal relatively little about the severity of individual comorbid conditions and, critically, socioeconomic status. Peer will offer a voice in the development and validation of important quality metrics.

Can you analyze the problems facing the Initiative from a financial per-spective?

Dialysis providers are at an interesting crossroads. About 110,000 people start chronic (or mainte-nance) dialysis each year. At this moment, some-where near 475,000 people are receiving chronic dialysis. The number of new dialysis patients per year has stabilized recently. Importantly, the reimbursement landscape appears to be tightening. Medicare is unlikely to increase reimbursement rates for outpatient dialysis treatment in the next five to 10 years. However, inflation in medical professional wages and dialysis supplies, including the drugs administered during dialysis, will likely continue. From a business perspective, the only way for dialysis providers to maintain revenue growth (and remain financially viable) is to extend patients’ lives and reduce patients’ time in the hospital.

How do these problems impact im-proved quality and length of life?

Dialysis patient survival has steadily improved in recent years. On the other hand, hospitalization rates have declined only modestly and, between 2010 and 2012, use of the emergency and observa-tion rooms (followed by discharge home) actually increased. Decreasing the burden of morbidity will require better care, which requires more resources,

but without increases in reimbursement, providers will need to consider novel solutions. Participation in ESRD Seamless Care Organizations (ESCOs) may be a viable route. Delivering more dialysis in patients’ homes may be another way as well.

How will the Peer Initiative benefit future dialysis patients?

Surprisingly, dialysis providers do not have direct access to Medicare claims and, in practice, have difficulty acquiring records from acute and post-acute care providers in a timely manner. Providers certainly know what happens inside their dialysis facilities, but have relatively less knowledge of the morbidity that necessitates emergency and inpa-tient care of their patients. Peer will provide ana-lytics about such care to its members, so that each might target the domains in which performance is poor. The collaborative nature of 13 dialysis pro-viders participating in one consortium also permits the free exchange of ideas that have led to clinical successes in one or more organizations.

How can doctors refer their dialysis patients to this initiative?

At this point, doctors may encourage patients to examine Peer research at www.peerkidney.org. In the future, Peer intends to engage patient advocacy organizations more directly.


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control. Sometimes the medical piece seems easy compared to the social piece. Stable hous-ing is likely the most effective prescription for a homeless patient with diabetes. Research on what creates and shapes health indicates that only about 10 to 20 percent of health is attributable to medical care. The remaining 80 to 90 per-cent is often shaped by social, behavioral, and environmental factors.

This connection between health and social determinants, such as financial security, safe-ty, education, and other social supports is why collaboration has become so central to inno-vative attempts to improve the health of populations. Minne-sota is at the forefront of these innovations with a number of private and public initiatives. Currently Minnesota’s reform efforts include a $45 million State Innovation Model (SIM)

Grant to implement and test the Minnesota Accountable Health Model.

SIM and the Minnesota Ac-countable Health Model In February 2013, Minnesota was one of six states (Minne-sota, Massachusetts, Maine, Vermont, Oregon, Arkansas) awarded a federal testing grant of $45 million to implement the Minnesota Accountable Health Model over three and a half years. The project is a joint effort between the Minnesota Department of Human Services (DHS) and the Minnesota De-partment of Health (MDH) with support from Gov. Mark Day-ton’s office. The grant is part of the State Innovation Models Initiative through the Centers for Medicare & Medicaid Inno-vation (CMMI). Key aspects of the initiative include:

• A new payment model: The Minnesota model includes a move away from a fee-for-service payment model

toward financial arrange-ments that reward provid-ers and communities for keeping patients healthy. The model shifts the ma-

jority of health care pay-ments to a shared risk and shared-savings payment arrangement. For example, the model expands Min-nesota’s current Medicaid Integrated Health Part-nerships (IHP) and other Accountable Care Orga-nization (ACO) models in the market. Providers are held accountable for the health of their patients and receive financial benefits when their patients stay healthy and out of high-er-cost settings when not medically necessary.

• Partnering with commu-nities: The model also will include incentives for communities and care providers to partner and work together. The proj-ect has identified up to 15 Accountable Communities for Health (ACH) across the state that will put for-ward innovative proposals and strategies for coordi-nating care across settings and improving the health of a particular population of people (see the sidebar on page 17). A community may be a county, a res-ervation, a city housing project, or the patients in a

health care system.

• Exchanging and using data: A large portion of the funds will go to giving health care providers addi-

tional support to collect, use, and exchange clinical data using elec-tronic medical records and pa-tient registries, and to enhance the state’s abil-ity to provide meaningful and actionable data about the cost and quality of care to providers. This informa-tion will allow providers to better manage the care of a population of

people, and improve the quality and cost of their care.

• Practice transforma-tion: About 14 percent of Minnesota’s SIM funds are dedicated to practice transformation. A key goal is to transform care in Minnesota so that every patient receives coordinat-ed care that considers the whole person and is pa-tient centered. The model seeks to do this by promot-ing short-term learning communities, practice facilitation through inten-sive internal coaching, and practice transformation grants up to $20,000 for small and rural providers. In addition, the project supports expansion of health care homes and the development of behavioral health homes and integrat-ing new professions into care delivery teams.

Tapping into the Minnesota Accountable Health Model In broad strokes, all of the above efforts are designed to support physicians in their efforts to provide team-based care that focuses on the whole

16 MInneSOTA PHySICIAn June 2015

The Minnesota Accountable Health Model from cover

Financial arrangements … reward providers and communities for keeping

patients healthy.

June 2015 MInneSOTA PHySICIAn 17

patient. new payment methods can free health care teams to improve outcomes without the constant constraints of billing codes. Adding emerging pro-fessionals such as community paramedics, dental therapists, and community health workers can help expand the reach of the care team into the commu-nity.

Improved electronic health information systems and im-proved analysis of population and care data can help physi-cians better tailor individual treatment plans and popula-tion-based clinic initiatives. Along these lines, standard-ized performance targets and quality measures coupled with useful data analytics can help clinics and hospitals under-stand their practice patterns and outcomes and design inno-vative horizontal care pathways that span the entire continuum of care.

Accountable Communities for Health will help deliver services that wrap around and closely align with medical care, particularly for complex patients. Take for example, a patient in her 70s, who is slowly declining from congestive heart failure. One of her doctor’s chief concerns is whether she can care for herself when she re-turns to the community. This is where the ACH partners could step in as a trusted source because they know about the transportation options to take her down the street to the adult day care center and to the pharmacy around the corner. The goal is that clinicians and the ACH partners would work together to provide a full complement of services for the whole person.

Or perhaps the ACH part-ners working in collaboration with the primary care provider help keep patients out of the clinic all together. For exam-ple, a health system might use data to identify that many of its patients with asthma live in a particular substandard housing complex. The ACH could take this data and work with local housing regulators and officials to eliminate asthma triggers

from the housing facility.

Change is underwayThis transformational jour-ney has begun and the work is already underway. The SIM project is close to achieving its goal of having 200,000 Minnesota Medicaid enrollees receiving care from an Inte-grated Health Partnership. SIM has also distributed grants for e-health, practice transforma-tion, emerging professionals, and Accountable Communities for Health.

In the area of e-health, the initiative awarded 12 e-health grants to community collabora-tives for a total of $3.8 million. A $600,000 contract was award-ed to partner with MDH and the Minnesota e-Health Initia-tive to develop e-health road-maps. Two grants focused on privacy, security, and consent management for the electronic health information exchange were also awarded. In the area of practice transformation, the initiative awarded 10 grants for a total of $194,768 and has released a second round to fund 10 to 15 projects with a maxi-mum of $300,000 in available funds.

The ACH grants started between november 2014 and

The SIM initiative funded 15 Accountable Communities for Health through a competitive process. Grant awards went to communities in all regions of the state and at different levels of participation in ac-countable care models.

1. Allina/Northwest Metro Healthy Student Partnership, Minneapolis

2. CentraCare Health Foundation, St. Cloud

3. Essentia Health–Ely Clinic, Ely

4. Generations Health Care Initiatives, Duluth

5. Hennepin Health, Minneapolis

6. Hennepin County Medical Center, Minneapolis

7. Lutheran Social Service of Minnesota, St. Paul

8. Mayo Clinic, Rochester

9. New Ulm Medical Center, New Ulm

10. North Country Community Health Services, Bagley

11. Otter Tail County Public Health, Fergus Falls

12. Southern Prairie Community Care, Marshall

13. UCare Minnesota, Minneapolis

14. Unity Family Healthcare, Little Falls

15. Vail Place, Hopkins

Accountable Communities for Health

The Minnesota Accountable Health Model to page 46

members such as social service organizations and consumers in a collaborative effort to improve health for a target population in a holistic way. They are to pro-vide a full spectrum of supports and services (besides medical services) that an individual might need for health including access to healthy food, physical safety, mental health or chem-ical dependency counseling, housing, home care, or rehabili-tation services.

For example, the Henne-pin Health ACH grant project connects individuals within the Hennepin County correc-tional system with health care programs, housing, jobs and training, healthy food, and other supports necessary for staying out of jail. Project goals are to reduce homelessness and recidivism among jail and adult correctional facility clients, im-prove key indicators of health such as blood pressure and

February of this year and will be in effect through December 2016. ACH grants stress the involvement of community

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ue-based payments. By the end of 2016, 30 percent of payments will be tied to these models. By 2018, 50 percent will be. HHS also plans to tie 90 percent of all traditional Medicare pay-ments to quality or value by 2018 through programs like Hospital Value-Based Purchas-ing and Hospital Readmissions Reduction.

One colleague recently shared that 70 percent of his clinic’s patients are already coming in as pay-for-perfor-mance. The future of payment reform is definitely upon us. Physician offices and hospitals need to work more closely with partners across the care con-tinuum to ensure the best care for their patients overall and as patients transfer between settings.

Federally Qualified Health Centers (FQHCs) will tell you that they are living these chang-es now and trying to fix issues on the fly. In the absence of having access to patient med-

ical records due to the lack of connectivity to other providers who have cared for the popu-lations they serve, one FQHC clinic used claims data as a crude substitute. Although not current, the data still made a difference in the clinic’s ability to serve patients by giving them

a rudimentary medical history. Having an accurate history is why all providers need to work together using better tools, such as e-health.

Each physician is one of many players on the team that supports a patient’s care. Other caregivers and community members are also integral to supporting the best health for patients. It is important to con-sider the community when it

comes to a patient’s health and not only focus on clinical care. The community offers services that can impact the success of a transition in care or improve a patient’s access to proper nutrition. Social determinants can affect up to 80 percent of someone’s health.

e-health to improve careThe Minnesota e-Health Road-maps will provide a frame-work for the four settings of long-term and post-acute care, local public health, behavior-al health, and social services. It will help them effectively implement health information exchange (HIE) and electronic health record (EHR) systems to support patient care internally and across the care continuum. The roadmaps will aid these settings in adopting interopera-ble health information technol-ogy and improving everyone’s ability to provide coordinated care and manage population health.

I am an advocate for the adoption and effective use of health information technology (HIT). My experience with these systems as a physician in a clin-ic and hospital has convinced me of its ability to facilitate better care, improve health care quality, increase patient safety, reduce health care costs, and enable individuals and com-munities to make better health decisions. It is important that all players in the health care continuum have access to these tools and use them effectively.

The good news is that EHR adoption rates for clinics, hos-pitals, and local health depart-ments are well over 90 percent in Minnesota. Nursing homes come in just under 70 percent. The Minnesota e-Health Road-map Project will conduct an en-vironmental scan of each of the four settings to determine their e-health status and begin to un-derstand EHR use in behavioral

health and social services. On the flip side, a 2013 Minnesota Department of Health (MDH) study documented a significant gap for local public health in health information exchange with both hospitals and prima-ry care clinics. While nearly all of Minnesota’s communi-ty health boards, which run the local health departments, identified the need to exchange information with hospitals and clinics, less than half actually exchanged data with partners.

EHRs and health informa-tion exchanges are key tools that facilitate communication and promote coordinated care. Communication among health care professionals and their pa-tients and families is necessary. It ensures that everyone under-stands the care plan, including the patient’s responsibility for self-care, and that they are able to identify any additional help that may be needed such as respite care. Communication among teams of health and so-cial service professionals is also important, particularly when individuals transfer between care settings. Recognizing this, the Minnesota e-Health Initia-tive identified the four settings as being instrumental in mov-ing the state toward coordina-tion and collaboration.

There is clear evidence that we physicians need to under-stand more about our patients. The 2014 Institute of Medicine (IOM) report, Capturing Social and Behavioral Domains in Electronic Health Records, rec-ommended inclusion of social and behavioral health domains in EHRs. IOM believes this data is vital to providers treating in-dividual patients; to health sys-tems and public health officials about the health of populations; and to researchers studying the determinants of health and the effectiveness of treatment. Some of this data—like food and housing insecurity, depres-sion, social connections, and so-cial isolation—might best come from our partners providing care in other settings like social services and behavioral health to help shine a light on more of our patients’ needs.

18 MINNESOTA PHySICIAN June 2015

The e-health roadmap from cover

The future of payment reform is definitely upon us.

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If care is to be coordinated effectively, all communication must be timely and include the information that all team mem-bers need so the care they pro-vide is aligned with a patient’s goals and desires.

The Minnesota e-Health Roadmap ProjectThe Minnesota e-Health Road-map Project is a collaborative effort to describe a path for-ward for using e-health more effectively to deliver high-qual-ity, coordinated care and healthier communities in the settings of behavioral health, local public health, long-term and post-acute care, and social services. As part of the Minne-sota Accountable Health Model, this work is funded by a $45 million State Innovation Model (SIM) cooperative agreement, awarded to the Minnesota Departments of Health and Human Services in 2013 by the Center for Medicare & Medic-aid Innovation.

The roadmaps will include

concrete, achievable short-term goals and longer-term aspirational goals. This work, facilitated by Stratis Health and the Minnesota Department of Health, is being led by work-group co-chairs who are leaders in their respective settings. About 60 people are partici-pating in four setting-specific workgroups to develop the road-maps. Additionally, over 800 in-dividuals have asked to be kept apprised of this work through email updates—that level of interest reflects the broad impli-cations for this work.

A foundational part of the roadmap work will be to develop use cases of typical patient scenarios. Use cases will highlight the various factors that come into play as a patient moves across settings of care. For example, the care coordi-nation of an 83-year-old female with limited income and assets, who is enrolled in a managed care program, will be under-stood in relation to business drivers, consumer engage-

ment, technology, information needs, mandates and reporting requirements, legal issues, workforce development, and other components. From these scenarios, the workgroups will develop approaches for success-ful care delivery in the use cas-es, noting how e-health can play a role. These approaches will be combined to develop strategies for the roadmaps.

The roadmaps are not in-tended to be detailed implemen-tation guides. Instead, they will describe a path forward and identify the steps to be used by providers, organizations, lead-ership, the state, EHR and HIT vendors, and other stakehold-ers. The roadmaps will produce greater collaboration within the network that supports patients.

It’s certain that the paths described in the roadmaps will identify key roles for physicians as part of the interconnect-ed community that supports patients in Minnesota. We can stay informed about the prog-ress of the Minnesota e-Health

Roadmaps Project by signing up to get email updates (http://www.health.state.mn.us/e-health/roadmaps.html) or read-ing the roadmaps when they come out in spring 2016. The recommendations for policy-makers, payers, service provid-ers in the four settings of care, health IT vendors, and others will have implications for all of us. Organizations across the country are watching Minne-sota’s leadership in furthering these settings’ use of e-health. Accelerating e-health adop-tion and effective use has the potential to enhance individual and community health. We physicians should be watching too.

Paul Kleeberg, MD, is a family phy-sician who has practiced rural family medicine and has implemented and used several EHR systems. He is chief medical informatics officer for Stratis Health, a nonprofit quality improve-ment organization based in Bloom-ington and clinical director for the Minnesota/North Dakota Regional Extension Assistance Center for HIT. He chairs the Healthcare Information and Management Systems Society (HIMSS) board of directors.

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This morning as I was opening up my computer, a Medscape email head-

line caught my eye, “Physician Burnout Increases 16 Percent in Just Two Years.” Unfortunately, similar alerts and headlines are becoming increasingly com-mon in both the medical and popular press. A 2015 survey by VITAL WorkLife and Cejka Search showed that stress and burnout is not only prevalent, but is increasing (see Figure 1 on page 21). Almost 66 percent of the over 2,000 re-spondents indicated they experienced more stress and burnout than in the 2011 study; 88 percent of

all respondents identified them-selves as moderately to severely stressed; and 46 percent speci-fied severe stress and burnout.

Why pay attention to this?Stressed out and burned out physicians are more likely to leave the profession. In addi-

tion to the imminent bubble of retiring baby boomer physi-cians, the departure of burned out physicians may compound looming physician shortages. Burned out physicians can become angry and disruptive or can develop mental health and chemical dependency prob-lems. This pattern can lead to decreased quality of care where errors could potentially harm patients. For the physician, the ultimate result of this down-ward spiral may be career dam-aging or end in disciplinary action by state medical boards.

The 2015 VITAL Work-Life and Cejka Search survey indicates physician stress and burnout continues to increase at virtually every level, yet only a small number of respondents, 18.5 percent, report that their organizations have initiatives in place to deal with stress and/or burnout (see the sidebar on this page). These findings are up from 15.7 percent in 2011. The continued rise in burned out physicians suggests these initia-tives are either not enough, not relevant, not accessible, or un-known to physicians. It seems physicians and patients would be better served if we could all

do a better job and invest more resources into both preventing the burnout from occurring in the first place, and identifying and caring for physicians at the first sign of burnout.

Burnout preventionBoth society and the individual physician make huge invest-ments of time and money to train a doctor. We need to consciously and thoughtfully safeguard this investment by explicitly teaching resilience and self-care skills to medical students and residents, and make burnout prevention a

priority for hospitals, clinics, and health sys-tems.

Educa-tion is one way to help prevent burnout. According to

Elizabeth Grace, MD, medical director of the Center for Per-sonalized Education for Physi-cians (CPEP), “CPEP believes stress and burnout contribute to the professional difficul-ties many of our participants experience. It is disturbing to see such a large percentage of health care providers experi-encing stress and burnout. Un-fortunately, the upward trend in the percentage of health care professionals experiencing such high levels of stress will likely continue for the foreseeable future, due to the rapid rate of change and increasing de-mands on physicians’ time.”

Normalizing work/life bal-ance—what it is, how to achieve it—is another way physicians and their organizations can safeguard against burnout. It ties directly to what most physicians say they want—a better work/life balance. Yet, this is the most difficult thing to achieve. Encouraging physi-cians to achieve healthy behav-ior through training for well-ness, changing ingrained habits and perceptions, and adopting cultural change are important steps. This change must also be supported by changes in their

Physician suPPort services

Physician burnoutA growing problem

By rebecca hafner-Fogarty, MD, MBa

20 MINNESoTA PhYSICIAN June 2015

Burned out physicians are more likely to leave the profession.

“As much as physician burnout is discussed,

it seems administrators sweep it under a rug. I have received two one-page handouts from

the Physician Retention Committee. That is

their net contribution to physician support.”

“Poor hospital administrators who are not supportive of

physicians are one of the greatest challenges we face

in health care today.”

“Greater support by administration. Society needs to go back to the

basic principle that respect goes both ways.”

2015 Physician Survey Respondents

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and effective approach for helping physi-cians deal with increasing levels of stress and burnout comes from Lake Region health (LRh) in Fergus Falls. Patricia Lindholm, MD, FAAFP and former presi-dent of the Minnesota Medical Association states, “Burnout is created in an environment of high responsibility/demands on a health care provider coupled with a low sense of control over their workload. This only worsens with the increased reporting required of our prac-tices and doctors. Meaningful use measurements for EhRs and meeting quality reporting measurements are especially time consuming.” Dr. Lindholm continues, “At LRh I started a group with our chaplain several years ago and invited certain physicians to attend. This group has expanded and developed over time, but is periodically in need of new infusions of energy. The group has been a career saver and lifesaver for some of our physicians where they can be supported and heard in a safe and confidential setting. The LRh administra-tion has been supportive from the beginning. We are given a private meeting room and meal costs are covered. In visiting other communities, I find that it seems very difficult to get these groups started because some-one needs to take the initiative, and physicians already feel overwhelmed. organizations providing this level of support can be the catalyst to positive change.”

Dr. Lindholm’s program is effective, but not expensive. By contrast, turnover due to physician stress and burnout is increasing for health care organizations and is an expen-sive problem. Annual physician turnover is at an all-time high. The expense and challenge of recruiting new physicians and the cost of onboarding a new physician can add up to

work environments and how they do their jobs. Creating a better work/life balance ensures that physicians are healthier, happier, more productive, and satisfied with their current jobs and roles.

While some physicians simply choose to leave the profession completely, others seek educational support to learn better skills. CPEP offers a number of personalized education programs for physi-cians, incorporating a burnout inventory as part of a clinical competence assessment. This helps participants gain insight into the impact of burnout on their practice.

caring for colleagues experi-encing stress and burnoutorganizations can help phy-sicians understand it is okay to ask for help and provide confidential and convenient resources to accomplish this. Many physicians are reluctant to ask for help, yet they’re often in desperate need of a com-passionate listener, mentor, or coach who understands the professional, personal, and family challenges they face. When organizations invest in their physicians and health care providers by offering support and well-being solutions, they differentiate themselves as caring and concerned and may experience lower physician turnover.

Some organizations, rang-ing from health systems to medical societies, are devel-oping their own physician burnout prevention and care programs. The number one solution physicians believe will help reduce stress and burnout is a better work/life balance. Some organizations are doing an excellent job of helping indi-viduals and teams reduce stress and burnout through internal programs and education. oth-ers may contract with outside organizations to provide this service or provide effective, preventive support programs to not only educate, but to also provide resources, counseling, mentoring, or peer coaching.

An example of an innovative June 2015 MINNESoTA PhYSICIAN 21

over $500,000 on average for each physician not retained (based on the cost of recruiting and onboarding, plus fees for sourcing, advertising, inter-viewing, relocating, and signing bonuses).

Physicians are a precious resource and they are suffering. When physicians suffer, the downstream effects are magni-fied across the entire medical community, impacting patient safety and satisfaction, risk management, staff retention, and recruiting.

Rebecca Hafner-Fogarty, MD, MBA, is the chief medical officer of Zipnosis. She is also a long-time member of the Minnesota Board of Medical Practice, serving as president in 2009, and is currently chair of the Licensure Committee. She has also been an active member of the Minnesota Medical Association for over 35 years and has held numer-ous leadership positions within the organization. Dr. Hafner has served as a physician consultant for VITAL WorkLife, Inc. (formerly known as Physician Wellness Services) since 2010 and is a member of their Advi-sory Team.

Figure 1. change in physician reported stress

Source: VITAL Worklife, Inc., 2015

2

Source: VITAL Worklife, Inc., 2015

Why pay attention to this?

Stressed out and burned out physicians are more likely to leave the

profession. In addition to the imminent bubble of retiring baby

boomer physicians, the departure of burned out physicians may

compound looming physician shortages. Burned out physicians can

become angry and disruptive or can develop mental health and

chemical dependency problems. This pattern can lead to decreased

quality of care where errors could potentially harm patients. For the

physician, the ultimate result of this downward spiral may be career

damaging or end in disciplinary action by state medical boards.

The 2015 VITAL WorkLife and Cejka Search survey indicates

physician stress and burnout continues to increase at virtually every

level, yet only a small number of respondents, 18.5 percent, report

that their organizations have initiatives in place to deal with stress

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Minnesota Physician’s 2015 Health Care Architecture Honor Roll recognizes 10 outstanding projects in urban and suburban Minneapolis and in Hudson, Wis. This year’s Honor Roll

projects include new clinics, medical office buildings, a hospital renovation and addition, a long-term care facility, and senior housing. The medical services range from routine clinic visits to specialized care. Populations served include the standard roster of patients seen at outpatient clinics as well as specialized groups such as children, women, and seniors.

Although the facilities differ in intended use and population served, they share a focus on providing a healing environment, cutting-edge technology, and patient privacy. Several projects incorporated sustainability and elements of nature into their designs. Senior accommodations have been designed to encourage independence and a sense of community.

Minnesota Physician Publishing thanks all those who participated in the 2015 Honor Roll.2015

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interlude Restorative suites is a three-story addition to Unity hospital designed as

a premier transitional care unit that focuses on exceptional care, quick recovery, and staff efficien-cy. Guest rooms were designed with a “no wake” policy in mind so patients can sleep without dis-turbance. nurse servers let staff stock supplies for patient rooms from the hallway limiting inter-ruptions. Bathrooms have sliding doors to keep swinging doors out

of the room, and roll-in showers let patients bathe in private.

each floor has an open serv-ing kitchen and personal chef who will cater to a guest’s needs. the therapy space has direct elevator access, so patients can come and go without traveling through public areas. the focus on hospitality and the whole pa-tient experience makes it easy for staff to provide excellent care.

the Gardens is a seven-story, 60-unit skilled care resi-dence offering long-term

and memory care in st. Paul. it is the first nursing home in Minne-sota to follow the Green house Model of care. the residence was designed with six “homes” of 10 residents each, with one home on each floor of the building. Resi-dents have private bedrooms and bathrooms arranged around a central commercial kitch-en, dining area with a large, communal table, a hearth room, den, and sunroom. this arrangement encourages interaction between residents and

their caregivers. in this setting, residents and staff benefit as they develop meaningful rela-tionships in their daily activities. the Gardens shares a warm-wa-ter therapy pool, fitness center, salon, theater, pub, bistro, secure outdoor garden, business center, and meeting spaces with oth-er residences on the episcopal homes of Minnesota campus.

Interlude Restorative SuitesType of facility: Transitional care unit addition to Unity Hospital

Location: Fridley

Client: Benedictine Health System (owns 90 percent) and Allina Health (owns 10 percent)

Architect/Interior design: Horty Elving

Engineer: Steen Engineering (mechanical/electrical); Pierce-Pini + Associates (civil)

Contractor: McGough and Yanik

Completion date: January 2015

Total cost: $12,169,080

Square feet: 47,418

Episcopal Church Home–The GardensType of facility: Skilled nursing home/long-term and

memory care

Location: St. Paul

Client: Episcopal Homes of Minnesota

Architect/Interior design: Trossen Wright Plutowski Architects

Engineer: Lindell Engineering (mechanical/electrical); BKBM Engineers (structural); Civil Site Group (civil)

Contractor: Benson-Orth Associates

Completion date: January 2015

Total cost: $19 million

Square feet: 46,200

Opposite page: Main entranceTop: Reception desk and bistroRight: Lobby and fireplace

Right: AtriumBottom: Home interior

Honor roll 2015


The Cooperage Senior HousingType of facility: Senior housing

Location: Minneapolis

Client: CommonBond Communities

Architect/Interior design: LHB

Engineer: Steen Engineering (mechanical/electrical); Mattson Macdonald Young (structural); Stantec (civil)

Contractor: Watson-Forsberg

Completion date: October 2014

Total cost: $8,785,000

Square feet: 64,338

accessibility, affordability, pri-vacy, and engagement with a larger community were the

priorities for the siting, design, and development of the cooperage se-nior housing project. this 60-unit, energy efficient housing develop-ment provides seniors with secure and independent living accommo-dations. energy efficient hVac and lighting systems, rooftop solar panels, and a high-performance building envelope reduce long-term operating costs. Materials were chosen to increase the lifespan of

the building, while reducing the amount of maintenance required.

Residents can enjoy sitting in the large sunroom or out in the garden. the private one-bedroom apartments with full kitchens allow for independence. shared areas such as a serving kitchen, sun-room, and computer lab encour-age interaction among residents and build a feeling of community. the cooperage has heated under-ground garage spaces and access to the Minneapolis light rail system and the hiawatha Bike trail.

Top: The Cooperage Senior HousingBottom: Sunroom

Creating Healing Environments for 35 Years

“We wouldn’t hesitate to work with Engan Associates again.” (Matt Reinertson, Heartland Orthopedic Specialists)

Contact us: (320) 235-0860 • http://engan.com

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GENERAL CONTRACTORS

Congratulations EpisCopal HomEs on your Honor roll award!

specializing in health care Facilities

medical oFFices and clinicshealth care campuses

research Facilitieslong term care Facilities

rehabilitation and physical therapy Facilities

new construction or remodel

we treat every project as iF it were our own, maximizing the use oF your square Footage and budget

Top: Main entranceBottom: Atrium


Hudson Hospital/HealthPartners Medical Office BuildingType of facility: Medical office building

Location: Hudson, Wisconsin

Client: Hudson Hospital and HealthPartners

Architect/Interior design: Perkins+Will

Engineer: BKBM Engineers (civil/structural)

Contractor: McGough

Completion date: November 2014

Total cost: Withheld

Square feet: 40,000

hudson hospital and healthPartners wanted a new building on the hos-pital campus that would accommo-

date community growth for years to come. separate from, but physically connected to the hospital, the building accommodates a variety of specialty clinics and outpa-tient centers operated by hudson hospital along with several independent practices. Designed with an expanded sense of space, the building incorporates Feng shui con-cepts for a calming environment. a water feature under the stairway to the second

level brings a little bit of nature inside. the atrium has floor-to-ceiling windows to bring in lots of natural light, which invites healing. Wood ceilings assist with wayfin-ding and hallways are lined with rotating artwork from local artists to promote a healing environment. exterior design was intended to complement existing hospital buildings and earth tones were chosen to reflect plants, earth, water, sky, and fire.

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For more than 25 years, the CWN Healthcare Real Estate Advisory team has exclusively represented healthcare clinics and systems, delivering unbiased and uncommon real estate solutions tailored specifically to your unique priorities, not ours. Call or visit us online, and take the first step toward a healther practice through real estate.

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Honor roll 2015

Top: Main entranceBottom: Waiting room and fireplace


Minnetonka Medical CenterType of facility: Medical office building

Location: Minnetonka

Client: MMB Medical Partners

Architect/Interior design: bdh+young interiors | architecture

Engineer: Krech, O’Brien, Mueller & Associates

Contractor: Timco Construction

Completion date: October 2014

Total cost: $18 million

Square feet: 63,500

Minnetonka Medical cen-ter incorporates many sustainable aspects into

its design. it has a LeeD qualified storm water system, rain gardens to prevent runoff, an abundance of green space, and an efficient building envelope that optimizes energy performance. Low-emit-ting interior building materials improve indoor air quality and assure a healthier interior. to let an abundant amount of natural light inside, the center core of the building features a two-story

anodized metal curtain wall. the exterior features regional building materials including a natural stone base and brick. the front entrance has a large drive-under canopy that shelters patrons from the weath-er. the sun-filled lobby features a fireplace, artwork from local art-ists, a waiting room, and an open staircase. the building houses an urgency center, a family practice clinic, and a specialty clinic with a multimedia conference room at their disposal.

U+B architecture & design, an award-winning studio based in Minneapolis, is driven to challenge

conventional healthcare architecture.

We are committed to understanding physician,

staff and patient needs and developing groundbreaking

healing environments.

Please contact us to learn more.

[email protected]

612.870.2538

2015 MINNESOTA PHYSICIAN

ARCHITECTURE HONOR ROLL WINNER

Top: Woodbury ClinicBottom: Waiting room


HealthPartners Woodbury ClinicType of facility: Family practice clinic

Location: Woodbury

Client: HealthPartners

Architect/Interior design: Pope Architects

Engineer: Karges-Faulconbridge, Inc.

Contractor: Kraus-Anderson Construction Company

Completion date: April 2014


Square feet: 32,350 sq. feet of renovated space; 11,960 sq. feet of new construction

t he healthPartners Wood-bury clinic needed more space to meet high patient

volume, improve patient care, and optimize staff efficiency. Registra-tion and patient flow issues were solved by orienting the registra-tion desk so patients are greeted directly when they enter the clinic and then guided to the next spot in line. architectural elements keep patients separated for privacy during registration.

circulation and flow has been

improved within the clinic and more efficient staff areas and a larger lab were added. exam rooms have flexible systems furni-ture so the layout can be changed, which improves patient/provider interaction. new flow stations get physicians out of closed offices so they can collaborate with col-leagues and staff. the design lets natural light into the clinic and offers views of the outdoors, which offers a better healing environ-ment.

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NEWLY RENOVATED MEDICAL OFFICE SPACE FOR LEASE

Honor roll 2015

Top: Main lobbyBottom: Labor/delivery/recovery suite


Methodist Hospital–Family Birth CenterType of facility: Hospital

Location: St. Louis Park

Client: Park Nicollet Health Services

Architect/Interior design: AECOM

Engineer: MBJ Consultants

Contractor: RJM Construction

Completion date: February 2014


Square feet: 40,000

the Methodist hospital–Family Birth center was

remodeled to provide a comfort-able, state-of-the-art environment based on research into what millen-nial moms want in a birth center. taking design cues from hospitality and residential design, the renovat-ed center offers a spa-like aesthetic. Patient rooms are equipped with a sofa bed so partners can spend the night in comfort and innovative headwalls keep medical equipment out of sight. some labor/delivery suites offer water-birth tubs and

hotel-style bathrooms with walk-in rain showers. the post-partum, triage, and special care nursery rooms use a wall-mounted, mod-ular cabinet system for optimal function, appearance, and flexibili-ty. Family amenities include a small café and a lounge with a fireplace. the center includes an expanded newborn intensive care unit and a remodeled nursery. a multifunc-tional conference and presentation lounge provides a comfortable place for visiting prospective par-ents to learn about the birth center.

PERFORMANCE SOLUTIONS LEAN Process Improvement

FACILITY SOLUTIONS Functional and Space Programming

THOUGHT LEADERSHIP Hospital, Clinic and Senior Living Facilities of the Future, Sustainable and Evidence-Based Design Solutions

Alan Dostert AIAPrincipal ArchitectDesign Architect

Gloria Larsgaard AIANCARB

Project Manager

Linda Edgar ASIDHealthcare Interiors

Wayne Dietrich AIAPrincipal ArchitectDesign Architect

Dan Abeln Assoc AIALEED AP BD+CProject Manager

Rick FailingDirector of Healthcare

Support Services

Stan Schimke CIDDirector of Healthcare

Services/Medical Planner

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Chad FrostLean Specialist

Jim Tyler PEMechanical Engineer

Anthony Corcoran PE CGD LEED AP

Mechanical Engineer

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What sets us apart is our ability to integrate seamlessly with the healthcare architectural process. Through evidence-based and time-tested approaches, our HC Team can fully integrate strategy, planning, programming, operations and quality improvement with regionally renowned design.

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Grand Forks, Fargo, Bismarck, Minot, Williston, ND; Sioux Falls, SD; Bemidji, MN;

Top: Lobby and waiting roomBottom: Snoezelen room


Kiran Stordalen and Horst Rechelbacher Pediatric Pain, Palliative and Integrative Medicine ClinicType of facility: Outpatient clinic

Location: Minneapolis

Client: Children’s Hospitals and Clinics of Minnesota

Architect/Interior design: U+B Architecture & Design

Contractor: McGough

Completion date: December 2015

Total cost: $3.1 million

Square feet: 10,777

the “healing environment” of the Kieran stordalen and horst Rechelbacher Pediat-

ric Pain, Palliative and integrative Medicine clinic on the campus of children’s hospitals and clinics is the first of its kind in the U.s. ar-chitects were faced with the unique challenge of creating a calming and anxiety reducing holistic en-vironment. the innovative design incorporates natural wood floors and walls, large-scale landscape images, and a grotto with an inter-active virtual waterfall designed

as a sensory escape for patients. sounds of nature permeate the clinic and lighting throughout is soft, indirect, and mimics the light and dark periods of the diurnal cy-cle to create a serene environment. the innovative snoezelen room is a multisensory space where lighting, sounds, and textures can soothe and stimulate a patient’s senses and reduce anxiety, pain, and stress. the clinic also accommodates in-tegrative therapies such as biofeed-back, aromatherapy, massage, and acupuncture.

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Healthcare Planning and Design

St. Joseph Medical Center - Waiting Area

Honor roll 2015

Top: Self check-in kiosksBottom: Lobby


North Memorial Minnetonka Clinic and Urgency CenterType of facility: Primary care clinic/specialty care clinic/

urgency center

Location: Minnetonka

Client: North Memorial Health Care

Architect/Interior design: Pope Architects

Engineer: Dunham

Contractor: DJ Kranz Co.

Completion date: November 2014


Square feet: 32,000

the Minnetonka clinic and Urgency center occupies the main level of the larger

Minnetonka Medical center. the facility was designed by separate core and shell, and interior teams with Pope architects designing the interior fit-up of the 32,000 square foot main level. this new facility utilizes technology and accessibil-ity to make staff and operations more efficient. Patients enter a modern lobby that resembles an apple store and check themselves

in at kiosks with touchscreen computers that are linked to staff iPads. Patients discuss the reason for their visit in exam rooms rather than in a public lobby. a large waiting area offers digital video boards, laptop plugins, and child activities. Blending an Urgency center staffed with emergency phy-sicians with a primary care clinic fitted with innovative technology and concierge-oriented services creates a new health care option for patients.

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Top: Lobby/waiting roomBottom: Main entrance


Ness Plastic SurgeryType of facility: Clinic/surgical center

Location: Wayzata

Client: Ness Plastic Surgery/John A. Ness, MD

Architect/Interior design: ESG Architects/Nate Enger

Engineer: Anderson Urlacher (structural)

Contractor: Welsh Construction

Completion date: August 2014


Square feet: 11,250

Looking to expand ness Plastic surgery, John a. ness, MD, purchased

a two-story, rundown, over-looked building in Wayza-ta. the renovation involved cosmetic updates for a modern look and alterations to make it suitable for medical use. the front façade of the building got an updated look including new windows, a sunscreen, and wood siding. the design capitalized on the existing fully mature trees surrounding the property. Wood was used as

a primary element both inside and out to soften the edges of the space, and to visually connect the building to its site. the elevator was enlarged and up-graded, and all the stairs were replaced. the main staircase features wood paneled walls and ceilings. the building fea-tures a plastic surgery clinic, a cosmetic surgical center with an accredited surgical suite, and more room for medical spa services.

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the term, “nursing home” has so many negative connotations that many

nursing homes have taken to calling themselves “care cen-ters” instead. you probably al-ready know what those negative connotations are, and now there is research to confirm your thoughts.

the Green house Project is a national movement trans-forming the quality of life for elders. the model addresses typical concerns about nursing homes more fully. each Green house home looks and feels like a real home and elders receive four times more care than they would in a traditional nursing home. this personal attention and the homelike setting en-courages residents to socialize and maintain their indepen-dence, which gives their family members peace of mind.

in september of 2012, the Green house Project complet-ed an in-depth study of family caregivers. the study showed

the concerns that most caregiv-ers have about their loved one living in a conventional nursing home. We think the results of this study probably reflect your concerns and priorities too:

• eighty-three percent are concerned about the lack of individualized attention.

• eighty-two percent are concerned with isolation and loneliness.

• eighty-two percent are concerned with the institu-tional atmosphere.

• eighty percent are con-cerned with loss of inde-pendence.

• While cost and conve-nience were factors, they were lower on the list.

We all agree that we want the people we love to live in their own homes for as long as they can. But when that is no longer an option, we want them to get the best possible care in a set-ting that is as close as possible to a real home. What does “as close as possible to a real home” mean in today’s marketplace? there are two ways to look at this question: From a physical plant perspective and from an operational perspective.

The physical plant perspectivearchitecturally, convention-al nursing homes have been designed like mini hospitals with nursing stations and long hallways, shared rooms and baths, and large central dining rooms. no matter how pleasant-ly decorated these facilities may be, they look and feel institu-tional. For family and friends, visiting mom at “the home” is very much like visiting mom at a hospital.

our organization knows this from our own experience. Up until 2009, episcopal church home was a conventional nurs-ing home. the physical plant was a product of its time when it was built in the early 1970s, but times have changed since then. Past episcopal homes of Minnesota board president Jean Probst was well aware of that and stated, “this place was built for my generation. We’re a go-along generation. We’ve spent our lives rolling with punches and accepting whatever cards we were dealt. But when mem-bers of the Boomer generation get to the age where they need us, they’re not going to put up with this.”

in 2007, our management and board set about answer-ing the question, “how can we make our nursing home less like an institution and more like a real home?” as options were explored, they found that reimagining the physical plant was inextricably linked to reimagining the model of care. the explorations led to an organization called Action Pact (www.actionpact.com) and the Household Model of Care. their message resonated with our team:

“In most nursing homes, and in many assisted living services, a very important element has been forgotten: home. Without it, our elders experience a loss of joy and meaning in their lives. We know you believe that they deserve better. So do we. Action Pact can see you through every step of transforming an insti-tution into a true home, and restoring the pleasures of daily life to our elders.”

that sounded good on paper and online, but how did it work in the real world? Management staff and board members visited a nursing home in Perham, Minnesota, to find out. Perham Living implemented the house-hold Model of care under the tutelage of action Pact. Upon returning from the visit, Marvin Plakut, episcopal homes pres-ident and ceo, said, “it would be immoral for us not to do this.”

in 2008–2009, episcopal church home underwent an 18-month, $11 million trans-formation. as the physical plant was being divided into six distinct households with 12 to 20 residents per household, the staff was being trained in the household Model of care.

our observation is that some providers stop at the physical plant level and continue to operate their “households” as miniature conventional nursing homes. all staffers have the same titles, roles, and responsi-bilities that nursing home staff-ers have always had.“that’s not my job,” is an all-too-common refrain. this underscores the importance of exploring options from the other perspective.

Special FocuS: Medical FaciliTy deSign

The green House project

How it’s changing long-term care

By deb Veit

Read usonlineWherever you are!

www.mppub.com


The operational perspectiveif a provider’s goal is to make a nursing home “as close as possi-ble to a real home,” the model of care is every bit as important as the physical plant.

the conventional nursing home model of care is “hospital light,” hence intrinsically insti-tutional. all staffers have clear-ly-defined roles and responsi-bilities. While the provider’s marketing materials may tout being “resident centered,” in reality, every aspect of daily life is organized around the needs of the provider, not the resident. Residents are told when to rise, when to eat, when to bathe, and when to have fun. one size fits all. how homelike is that?

the household Model of care that episcopal homes implemented is vastly more “resident centered” than the old model. Daily life is organized around the wants and needs of each household’s residents, individually and collectively. Residents decide when to rise, when to eat, when to bathe, and what kinds of activities (mean-ingful engagement) they want to engage in. that’s how families in private homes chart their courses, and that’s how the fam-ilies in each of our households do too.

When our transition from the conventional nursing home model of care to the household Model of care was complete, we thought we had finally achieved nursing home nirvana. Resi-dents who had only pecked at their food in the old central dining room developed healthy appetites in the more homelike surroundings of their household dining rooms. they could rise when they wanted without miss-ing their breakfast. they could bathe when and how often they wished. and they could engage in activities they really cared about. in other words, they got to call the shots much as they always had. could anything be better than this? the answer turned out to be yes!

The Green House Model of Carein 2012, episcopal homes began planning the biggest

expansion since its founding in 1894—a $46 million senior living complex that would house three distinct residences. one of them was to be a new 60-bed nursing home that we now call

The Gardens. each Green house home in the Gardens has 10 residents and two certified nurs-ing assistants (cnas), as well as one nurse for every two homes.

a past episcopal homes Minnesota board member, Lois cutler, PhD, a widely-trav-eled research gerontologist who is with the University of Minnesota’s Long-term care Resource center, introduced our management and board to the Green house Model of care. “the Green house Project has developed what i consider to be a perfect, synergistic integration of physical plant and model of care,” cutler says. “they are very specific about every physical and operational detail, and since we were starting with a blank sheet of paper, we had the opportunity to go for it. We did, and the Gardens opened in January 2015. it is Minneso-ta’s first implementation of the Green house Model of care in a skilled setting. the game has just changed.”

each Green house home is designed with private rooms and private baths for 10 elders. the choice of housing only 10 elders is by design. the rooms surround a central living room with a fireplace, a big family-style dining table, a homelike open kitchen, and additional lounge spaces. in accordance with the Green house Project guidelines, the staff room is “a tight fit for one person and impossible for two people,” so staff spend only necessary time there and more time with the residents.

each home is served by two primary caregivers. they are cnas who have received 130 hours of additional training

to earn the title of “shahbaz” (after a mythical royal Persian falcon that protected, sustained, and nurtured its people). “think of them as family caregivers who really know what they’re

doing,” says cutler.

the ratio is one shahbaz per five elders. the result is four times more personal attention than in conventional nursing homes. the shahbazim (plural) prepare all meals from scratch with the elders helping as they are interested and able. the elders and their caregivers all dine together at the same table like the family they are.

Residents are treated with respect and their wishes and requests are met. they have input into their daily schedule

and can choose the activities they want to participate in. Res-idents can sleep late and have breakfast whenever they want. they have private rooms so can spend time by themselves. staff can read or talk to residents, play games, or bake cookies. Residents can help cook meals, do personal chores like fold-ing clothes, go to concerts or lectures, and watch movies. there are six outdoor gardens and residents are encouraged to garden if they want.

the Green house Project is a national movement that has been transforming the quality of life for our elders for over a decade. to date, it has reached 32 states—including Green house homes operated by the Veterans administration. For the whole story, visit www.thegreenhouseproject.org.

Deb Veit is director of community relations at Episcopal Homes of Minnesota and has over 25 years of nursing experience with an emphasis on geriatrics and nursing home care.

Conventional nursing homes have been designed like mini hospitals.


over the past decade, there have been significant de-velopments in the health

care delivery system, particu-larly in the growth of outpatient surgery centers, specialty clinics, retail health clinics, and urgent care facilities. health care is no longer limited to hospitals or primary care clinics. as a result, medical education influences the role that physicians and other health care professionals play, encompassing patient care as well as convenience, flexibility, patient satisfaction, and collaboration.

how physicians and other health care providers are educat-ed and trained and the environ-ments in which that education and training occurs must also advance. By engaging professors, the community, alumni, and students early in the design pro-cess, architects and designers are able to meet the needs of today’s medical students and more fully prepare them for their future careers. there are four key design factors that can improve medical education today and patient out-comes tomorrow:

• technology

• collaboration

• Flexibility

• sustainable health

Technologythe evolution of technology is growing at a rapid rate and per-sonal technology, such as iPads, laptops, and smartphones have turned today’s students into visu-al, proactive, hands-on learners and made paper textbooks and large lecture halls outdated and largely ineffective because of a shift to real-world scenarios and flexible team-based learning. to-day’s health care students need to understand the procedures they’ll be performing after graduation and learn and perfect these skills in a realistic and safe way. in medical education, it’s important

to have ongoing feedback from day one so when students ap-proach clinicals they do not fear the immersion. Designers and architects need to stay current when it comes to evolving health care technology and develop spac-es that accommodate these shifts. We, also, need to ask the client the right questions when starting a project.

Medical simulation allows stu-dents to acquire clinical skills by practicing in a simulated environ-ment on high-fidelity mannequins that provide immediate feedback on their performance. simula-tion technology also lets students role-play the full spectrum of patient care from bedside manner to procedural acuity in a collab-orative environment. in addition, simulation helps bridge the gap in the number of accredited health

care providers despite limited onsite residency opportunities.

at Perkins+Will, we have designed simulation spaces that mimic a patient room with move-able equipment and functional headwalls; home environments with a kitchenette and living room to simulate home care nursing; eRs with bays of beds and a central nurse station; exam rooms; and flexible spaces that can be reconfigured to whatever other simulation scenarios are needed. Practicing students are viewed in an adjacent observation room where an instructor con-trols the simulations and offers instruction. simulation tech-nology encourages personalized learning, engages students, and creates a real-world education so students retain what they’ve learned and apply it in practice.

Collaboration often, the most effective health care outcomes are the result of collaborative care. innovative classroom teaching styles are emerging through interdisciplin-ary instruction where professors

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co-teach classes with professors from different disciplines, allow-ing a universal approach to learn-ing. This style sets an example for how students should work in their profession.

Technology Enabled Active Learning (TEAL) is a teaching format that merges lecture, sim-ulations, and hands-on desktop experiments to create a rich collaborative learning experience. These spaces in medical educa-tion environments are designed so small groups can share tables topped with desktop computers and engage in group problem solving and discussion. Typical-ly, this room is surrounded by projection screens or monitors with the professor situated in the center of the room to promote ac-tive learning and encourage more student engagement.

Today’s most innovative med-ical education facilities teach col-laboration by co-locating interdis-ciplinary departments to create learning environments—chem-istry students and professors working side-by-side with people in nursing, dentistry, or language

pathology. When planning and designing a building, we work with clients to create adjacency diagrams of how faculty and students from different depart-ments can benefit by proximity of placement to each other. These learning environments blur the

lines between departments in an effort to spark new ways of think-ing, problem solving, and deliver-ing superior patient care. Foster-ing this teamwork in an academic setting also encourages deeper collaboration in the professional environment. These collaborative spaces can exist in public loung-es, hallways with built-in seating or benches and white boards, or libraries with spaces designed for group or individual study.

University of North Dakota’s new 181,000-square-foot School of Medicine & Health Sciences is organized around large stacked learning communities that anchor each end of the building connected by a large corridor. Architecturally, these learning

commu-nities are designed to be similar to a high school “home base” with assigned locker storage,

moveable tables for collaboration, small, enclosed rooms for group or individual study, and a kitch-enette/dining area for large group interactions.

FlexibilityHealth care, health care delivery systems, technology, and students all continue to evolve. This ongo-ing evolution requires flexibility and adaptability in the design and delivery of the education and

training of health care profes-sionals. A building should be flexible enough to accommodate future technology and changes. A diverse student population may require areas in and outside of the classroom where they can work alone, engage with faculty, or collaborate with colleagues. Architecturally, we are designing spaces with operable walls for re-configuration, rooms with ample electrical connections for proac-tive technology changes, a variety of classroom types to allow for flexible teaching styles (fixed tech-nology, flexible classrooms, and tiered lecture settings). Designers often recommend that furniture and equipment be on wheels so it’s easy to move things from space to space.

Simulation suites and multi-bed skills rooms are often de-signed with operable walls along with flexible headwalls to easily change the room size or function and reposition electrical and gas outlets. Flexible simulation suites can expand by sliding a wall open to simulate ER bays or a labor/

June 2015 MiNNESoTA PHySiciAN 35

Medical education to page 36

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delivery/recovery room with an adjacent nursery.

In a flipped classroom, stu-dents actively study and learn the material independently and then come together in a classroom to complete assignments collabora-tively with fellow students while the professor acts as mentor. This classroom is typically designed with moveable furniture that can be configured for individual or group classes. The room must have ample writeable surfac-es, electrical connections, and backpack storage so the professor can easily move around the room. This differs from traditional lecture halls with podiums and a projection screen at the front. Flipped classrooms offer more active, personalized teacher/stu-dent interactions and the kind of engaging learning experience that leads to greater retention and improved real-world application.

Sustainable healthMedical education facilities have a strong focus on health and

well-being; that is, educating fu-ture health care professionals to improve the health of their future patients. But the truth of the mat-ter is that those same facilities of-ten do little to improve the health and well-being of their students. Wellness can be affected by a person’s physical, emotional, and social state. Wellness can also be affected by your physical sur-roundings. When someone walks into a space that has no daylight, low ceilings, uncomfortable tem-peratures, and a lack of wayfind-ing, they feel uncomfortable and will spend minimal time there.

Medical education facilities that incorporate daylighting, natural ventilation, staircases, sustainable building materials, and green spaces see a boost in student morale and motivation, greater student physical activity, and accelerated learning. The design should intuitively encour-age a healthy environment by placing staircases as grand focal points, which encourages exercise and exploration. Increasing the amount of daylight into a space creates a strong connection to

the outdoors, offering views and minimizing the use of interior artificial lighting. Using building materials that emit few chemical irritants has a positive impact on indoor air quality. Especially in medical education environments, students who believe their own health and well-being has been taken into consideration are more likely to consider environmental factors that impact human dis-ease, and are more likely to drive conversations about sustainable health with their future patients.

North Hennepin Community College’s Biosciences and Health Careers Center was completed in June 2014. The 62,000-square-foot facility meets Minnesota B3 Standards meaning the building fulfills sustainable goals for site, water, energy, indoor environ-ment, materials, and waste. Beyond meeting these standards, the building’s spatial organiza-tion focuses on bringing natural daylight through the building footprint and into the learning environments. This helps emo-tional stimulation and positively impacts energy, while intuitively

educating the students on the benefits of sustainable design. Some colleges post the sustain-able design drivers as you enter specific spaces to be transparent and celebrate the importance of sustainable health and well-being.

ConclusionWith the ongoing changes in health care and health care deliv-ery systems, medical education facilities have both a responsibil-ity and an opportunity to ensure their students are poised to posi-tively impact their patients, their workplaces, and their commu-nities. These four design drivers represent some important ways that innovative health care design can better meet the needs of today’s students and, as a result, tomorrow’s patients.

Heidi Costello, CID, LEED AP ID+C, IIDA, is an associate project interior designer with the Minneap-olis office of Perkins+Will. She has more than eight years of design and planning experience and has played a key role in a number of medical education projects throughout the Upper Midwest.

Medical education from page 35

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according to national health rankings, Minne-sota typically rates as one

of the nation’s healthiest states. however the Minnesota De-partment of health’s center for health equity reports that de-spite our excellent averages, the state faces some of the country’s worst ethnic and racial health disparities. as our population ages and grows more diverse, our health system is challenged to achieve equitable and opti-mal outcomes for all commu-nities.

Minnesota’s community health workers (chWs) are trained and trusted frontline health personnel, often from the communities they serve, who bridge barriers between under-served patients and health and social services systems, leading to improved health access and outcomes. chWs serve many different roles. they help people overcome barriers to getting cancer screening, find medical homes, ease their distrust of the health care system, and tackle

cultural concerns. they conduct home visits to patients with complex health needs, build self-management skills, address basic needs, link patients to es-sential services, and help them navigate the health system.

Addressing health disparitiesincreasingly, community health workers (chWs) are being rec-ognized as an integral part of the solution to addressing some of the major challenges facing our health care system. chWs help address health disparities, advance the triple aim, and expand and diversify our health care workforce.

typically from the commu-nities they serve, chWs bring their attributes, shared life experience, community knowl-edge, and training to bridge cultural, linguistic, literacy, and other barriers to good health, with a focus on low income, underserved people. as trust-ed, knowledgeable frontline health professionals, they apply their unique understanding of the experience, culture, and/or language of the communities they serve to provide cultural-ly-competent outreach, patient and community education, advocacy, care coordination, and systems navigation in a variety of clinic, home, and community settings. they also serve as cultural resources and mediators for their teams and organizations.

Minnesota chWs reflect our state’s growing diversity, with representation from commu-nities of color, immigrant and refugee populations, and other cultural groups such as the deaf population. chWs go by many different titles such as care guide, care coordinator, peer educator, outreach worker, promotore(a) de salud in the Latino community, and com-munity health representative in the american indian communi-ty. in 2010, the Department of Labor standard occupational classification system recognized chW as a distinct profession.

new to many health provid-ers but characterized by a long history and deep community roots, the chW role is starting to move into mainstream health care settings. Recognized by leading health authorities such as the american Public health association, the centers for Disease control and Prevention, and the institute of Medicine, chW strategies are supported

by a growing evidence base for their effectiveness in improving access to coverage and care, improving screening rates and disease outcomes, and reducing costly emergency room visits and avoidable hospital readmis-sions. By fostering accessible, affordable, and culturally-ap-propriate care, chWs—and the health and social services organizations that employ them—help reduce persistent health disparities for vulnerable populations and create healthi-er, more equitable communities.

at a time when many newly insured are accessing care, the growth of the chW role also expands and diversifies our health care workforce. clinics are moving to patient-centered team-based models in which ev-eryone needs to “work at the top of their license” and account-ability for outcomes requires effective care coordination and culturally-appropriate educa-tion that extends well beyond the exam room and the bro-chure rack. chWs build trust-ing relationships, fill gaps, and serve as valuable extenders in outreach, education, and home visits, as well as connecting people to care, coverage, and other services.

Scope of practice and educationMinnesota is the only state in the U.s. to develop and imple-ment a statewide, competen-cy-based chW curriculum based in higher education. With funds from the Blue cross and Blue shield of Minnesota Foundation and the Robert Wood Johnson Foundation, the model curriculum was designed through a collaborative process involving chWs, educators, health providers, and people from other health disciplines who also developed a chW scope of practice for the state. Launched in 2006, the stan-dardized certificate program requires an internship and 14 credits, including core compe-tencies as well as health promo-tion and disease management competencies. six post-second-ary schools offer the certificate program, including in-person

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Lakewood Health System is seeking to expand the care team for its progressive and patient-focused clinics and hospital. Located in Staples, Minnesota, Lakewood is an independent, growing healthcare system with fi ve primary care clinics, a critical access hospital and senior living facilities. Practice consists of 14 family medicine physicians and 10 advanced practice clinicians, as well as a variety of on-staff specialists. Competitive salary and benefi ts. Relocation and sign-on bonus available.

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as well as online formats that are designed to expand chW training into rural communities to improve access to health care for the state’s rural population.

“Minnesota’s chW certif-icate program was placed in higher education so that cred-its earned could be applied by chWs to continue their educa-tion and enter other health ca-reers such as nursing or allied health. in this way it is designed to be an educational pathway—not a dead end,” explained anne Ganey, MPh, who founded the online chW certificate Pro-gram at south central college, Mankato. “We’ve found that chW students, often the first in their families to enroll in post-secondary schools, both inspire and guide relatives and other community members to pursue higher education. it’s another key benefit because we know that people with more education earn more and live longer.”

More than 500 chWs have completed this training so far, earning a certificate of com-pletion. While this certificate is not currently required for chW employment, it is increasingly identified as a preferred creden-tial for job applicants.

ReimbursementWhile other states are exploring and piloting chW payment, until recently Minnesota and alaska have been the only states to date that have Medicaid au-thorization.

Diagnostic-related patient education services provided by chW certificate holders under clinical supervision are covered under Minnesota health care Programs (MhcP) including Medical assistance and Min-nesotacare—both fee-for-ser-vice and managed care. MhcP guidelines identify physicians, advanced practice nurses, mental health professionals, dentists, and certified public health nurses working in a unit of government (such as a local public health agency) as autho-rized chW supervisors. chW patient education provided on a one-to-one or group basis is covered. home visits are includ-

ed. the Minnesota community health Worker alliance and its partners are now exploring replication of the nationally-rec-ognized, evidence-based Path-ways community hub model which is covered by Medicaid managed care plans in ohio

with excellent birth outcomes among high risk women—an area where Minnesota needs to improve.

Teaming up for better outcomeshealth providers, social service agencies, schools, and commu-nity-based organizations are finding chWs to be critical links with the communities they serve. For example, community clinics and mutual assistance associations employ chWs to facilitate enrollment in public programs, conduct outreach, and provide health education services to uninsured and un-derinsured patient populations. according to Deb holmgren, president of Portico healthnet, “chWs working as Mnsure navigators have facilitated the enrollment of hundreds of uninsured and hard-to-reach in-dividuals and families into cov-erage options under our state’s health insurance exchange.”

increasingly, chWs are being hired by hospitals, clinic systems, and local public health agencies to strengthen team-based services to patients and families. chWs are integral members of clinic care teams at hennepin county Medical center, northPoint health and Wellness center in north Min-neapolis, and healtheast care system in the east metro. in Greater Minnesota, chWs work on teams at centracare health in st. cloud, essentia health–ely clinic, and Mayo clinic, Rochester.

the Minnesota Department of health has made investments

in chW strategies through the state’s eliminating health Dis-parities initiative, the emerging health Professions initiative, and its new accountable com-munities for health project; the latter two come under the fed-erally-funded state innovation

Model (siM) initiative.

chWs reduce the demand on overburdened providers by promoting healthy behaviors and helping patients understand how to access and use care appropriately. “Providers ap-preciate what we do,” explained chW Mariela ardemagni-tollin at hcMc’s east Lake clinic. “in a short visit, it’s impossible for the physician to do every-thing—we need a care team. our health care home (hch)

program promotes team-based holistic care, and health educa-tion and coaching to improve health outcomes and reduce eR visits and hospital admissions. hcMc’s hch program has ex-panded rapidly since its imple-mentation in 2010, and chWs, as members of our care teams, develop trusted relationships with our patients which help bridge or eliminate barriers to good health.”

“Partnering with chWs is an effective way for pediatricians serving foreign-born families to improve cultural competence as well as increase rates of well-child care such as immu-nizations,” reported Katherine cairns, executive director of the Minnesota chapter of the american academy of Pediat-rics (MnaaP). MnaaP has sup-ported a chW pilot at several twin cities and st. cloud area pediatric practices to improve preventive care for somali

Six post-secondary schools offer the certificate program.

Community health workers to page 40

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Measurable impactGrowing evidence and recog-nition of chW contributions to better outcomes indicate an increasing role for chWs in the health system of the future.

“Research shows that chWs improve health outcomes among minority and immigrant populations and they do so in a cost-effective and cultural-ly-sensitive way,” said Kathleen call, a professor at the Universi-ty of Minnesota school of Pub-lic health. For example, studies of chW programs show signif-icant improvement in patient use of preventive services such as mammography and cervical cancer screening among low income and immigrant women. economic analysis published by the amherst h. Wilder Foun-dation in June 2012 found that

every dollar invested in chW cancer outreach and prevention results in a savings to society of $2.30. a review of national studies found a return on in-vestment of 3:1.

another example of the ben-efit of chWs is found in Boston, chicago, seattle, and other

cities where chW interventions improve childhood asthma in low-income neighborhoods, reducing symptom days as well as costly hospital admissions and eR visits. trained chWs conduct home visits to reinforce provider messages about asth-ma control, identify and ad-dress family needs, and provide home interventions. “chWs play an effective role in team-based asthma interventions and

promoting healthy housing, leading to better health and lower costs,” reported amanda Reddy, director of Programs and impact at the national cen-ter for healthy housing, whose affiliate healthy housing solu-tions offers specialized training for chWs on healthy housing

practices through local agencies such as the sustainable Re-sources center in Minneapolis. in order to help address our state’s serious child asthma dis-parities and improve quality of care, Mn community Measure-ment has supported the devel-opment of a new web-based tool on chW integration for asth-ma care providers and home visiting programs with funding

from the Robert Wood Johnson Foundation’s aligning Forces for Quality initiative available at www.successwithchws.org/asthma.

A key to healthier communities“as a best practice for tackling health disparities, chWs are an essential component of Minne-sota’s health reform strategies,” emphasized pediatrician Peter Dehnel, MD, past president of the twin cities Medical society, which has endorsed the role. “integration of team-based chW strategies will help clinics achieve better results with patients facing barriers to good health related to culture, language, literacy, and income.”

Joan Cleary, MM, is executive director of the Minnesota Community Health Worker Alliance, a broad-based partnership of CHWs, health providers, health plans, nonprofits, and public agencies (www.mnchwal-liance.org).

CHWs reduce the demand on overburdened providers.

Community health workers from page 39


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Olmsted Medical Center, a 220-clinician multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. Olmsted Medical Center provides an excellent opportunity to practice qual-ity medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

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In January 2015, the Centers for Medicare and Medicaid Services (CMS) announced

new and ambitious goals in how it will reimburse providers. Spe-cifically, the goals call for CMS to shift more of its reimburse-ment from volume based, such as fee-for-service, to a value-based methodology. While the goals have been deemed a promising improvement by some, others are singing the opposite tune. Based on historic performance, there is some skepticism in the provider community as to whether CMS will actually achieve these goals.

Current statusOne of the primary underpin-nings of the Affordable Care Act (ACA) was the objective of moving the Medicare program provider reimbursement from a fee-for-service environment (where pro-viders are reimbursed solely on the volume of services provided) to a value-based reimbursement model (where providers would be compensated more on the quality, effectiveness, and affordability

of the services). As part of the ACA, CMS identified four primary categories of provider reimburse-ment:

• Category 1: Fee-for-service (FFS) with no link of pay-ment to quality

• Category 2: Fee-for-service with a link of payment tied to quality

• Category 3: Alternative payment models billed on a fee-for-service architecture

• Category 4: A population- based payment methodology

In adopting the four cate-gories, CMS grouped them into

“value-based’ reimbursement payments, which include all CMS reimbursements under Categories 2 through 4 and the “alterna-tive payment” models that only include CMS reimbursements under Categories 3 and 4. Prior to 2011, virtually all payments to Medicare providers were clas-sified under Category 1, where reimbursement was only tied to volume of services provided without any requirement that providers demonstrate a qual-ity or effectiveness component. But under the ACA, CMS began adding additional quality of care requirements, mandating that some fee-for-service payments be linked to some type of quality requirement. For example, while hospitals generally continued to be paid based on diagnostic re-lated groups (DRGs), CMS started adding “quality requirements” wherein hospitals would be penalized based on the hospital’s patient infection rates and read-mission rates.

According to CMS’s January pronouncement, its goal is to have at least 30 percent of the Medi-care payments in the alternative payment models (Categories 3 and 4) by the end of 2016 and at least half of all services by the end of 2018. Furthermore, CMS aims to have 85 percent of all of its provider payments have some type of value-based component (Categories 2 through 4) by the end of 2016 and 90 percent of its provider payments by the end of 2018. This is an ambitious goal considering only 20 percent of the Medicare fee-for-service pay-ments in 2014 had value-based payment requirements.

Are the goals even attainable?Given the severity of the goals and CMS’s historic track record to date, many providers are

skeptical that CMS will achieve these targets. A primary goal of the ACA is to create a variety of provider reimbursement models that shift away from the fee-for-service reimbursement model and towards a model that rewards providers for providing quality, affordable, and effective care. There is universal agreement that the current fee-for-service provider payment model needs to change—based on recent statis-tics, the Medicare Trust Fund faces insolvency within 20 years unless there is a reduction in pay-ments to providers. The new pro-vider payment goals set by CMS are part of this reform effort.

Some of CMS’s value-based reimbursement goals seem attainable—it should not be too difficult for CMS to add one or more quality requirements to its fee-for-services payments, such as penalizing providers for missed diagnoses or repeat visits for the same illness. However, the goal of having over 50 percent of all provider payments under some form of alternative payment model appears overly optimistic, and the ability of CMS to meet these aggressive new goals will be difficult.

First, the shift to a val-ue-based or alternative payment model will require both the commercial market as well as employers to embrace the model and offer similar types of ar-rangements. Any type of provider reimbursement model where commercial payers and employ-ers continue to pay providers on a fee-for-service model while the government adopts a more aggressive, alternative payment model is destined for failure. While some commercial payers have adopted some alternative payment models such as narrow networks, carve-outs, and bun-dled payments, such reimburse-ment arrangements have only been successful in very limited situations.

Second, to achieve Medicare’s goal of moving to value-based or alternative payment arrange-ments, providers will need to participate in care coordination models like Accountable Care Organizations (ACOs). Under the

PoliCy

Medicare’s new payment

reform planWhat physicians need to know

By Timothy A. Johnson, JD, and Julia C. Marotte, JD

42 MInneSOTA PHySICIAn June 2015

Medicare’s new payment reform plan to page 44

Family Medicine

St. Cloud/Sartell, MN

We are actively recruiting exceptional full-time BE/BC Family Medicine physicians to join our primary care team at the HealthPartners Central Minnesota Clinics - Sartell. This is an outpatient clinical position. Previous electronic medical record experience is helpful, but not required. We use the Epic medical record system in all of our clinics and admitting hospitals.

Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Several of our specialty services are also available onsite. Our Sartell clinic is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with traditional appeal.

HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. We offer a competitive compensation and benefi t package, paid malpractice and a commitment to providing exceptional patient-centered care.

Apply online at healthpartners.com/careers orcontact [email protected]. Call Diane at 952-883-5453; toll-free:800-472-4695 x3. EOE

healthpartners.com

© 2014 NAS(Media: delete copyright notice)

MN Physician4" x 5.25"4-color


Please contact or fax CV to:

Joel Sagedahl, M.D.5700 Bottineau Blvd., Crystal, MN 55429

763-504-6600 Fax 763-504-6622

www.NWFPC.com

Join the top ranked clinic

in the Twin CitiesA leading national consumermagazine recently recognizedour clinic for providing the bestcare in the Twin Cities based on quality and cost. We are currently seeking new physicianassociates in the areas of:

• Family Practice

• Urgent Care

We are independent physician-owned and operated primaryclinic with three locations in theNW Minneapolis suburbs. Work-ing here you will be part of anaward winning team with partner-ship opportunities in just 2 years. We offer competitive salary andbenefits. Please call to learn howyou can contribute to our innova-tive new approaches to improvinghealth care delivery.

Send CV to: [email protected] • www.raiterclinic.com

417 Skyline Blvd. • Cloquet, MN 55720

Our independent, physician-owned clinic is seeking a BC/BE physi-cian with OB for our family practice facility. 1:9 Calls. Competitive salary/benefits, with opportunity for ownership within 1 year. Paid malpractice, health and dental insurance, 401(k), CME and more.

Cloquet is an historic, vibrant community just 15 minutes from Duluth and 10 minutes from Jay Cooke State Park. Adjacent to the St. Louis River, Cloquet has hiking, biking and ATV trails; skiing; boating; fishing; parks; and the only white water rafting in Minnesota. Residents enjoy locally per-formed plays, concerts and the arts; community festivals; dining and more.

Family Practice with OB

It’s your life. Live it well.

MAYO CLINIC HEALTH SYSTEM is a family of clinics, hospitals, and other health care facilities serving over 70 communities in Minnesota, Iowa, and Wisconsin. Sharing Mayo Clinic’s primary value of “the needs of the patient come first,” Mayo Clinic Health System links the expertise of Mayo Clinic in practice, education, and research with the health-delivery systems of our local communities. Today, more than 1000 physicians practice in the health system. Mayo Clinic offers a highly competitive compensation package, which includes exceptional benefits, and has been recognized by FORTUNE magazine as one of the “100 Best Companies to Work for.” The Northwest Wisconsin Region opportunities include:

Dermatology Occupational MedicineEmergency Medicine OphthalmologyFamily Medicine OrthopedicsGeneral Surgery PediatricsHospitalist Psychiatry (Adult & Child)Internal Medicine Pulmonary/Critical CareNephrology Urgent CareNeurology Urology

Mayo Foundation is an affirmative action and equal opportunity employer and educator.Mayo Foundation is an affirmative action and equal opportunity employer and educator.

If you wish to learn more or to express interest in these positions, please contact us at 800-573-2580; email

[email protected]; or apply at http://www.mayoclinic.org/jobs/physicians-scientists

Join the Leader in Correctional Health Care FEDERAL BUREAU OF PRISONS

Full-Time Psychiatrist – FMC Rochester, MN Full Time Clinical Director – FCI Sandstone, MN

Learn more at: www.bop.gov

ACO model, providers are held accountable for the total cost of care provided to a set group of patients. This is not a new reimbursement model, and is very similar to the capitated model used by health maintenance orga-nizations (HMO). The adoption of ACOs has been met with limited success. Similarly, the growth in the adoption of ACOs have only been in those ACO arrangements that share in the success and sav-ings of treating patients—there have been fewer providers willing to participate in arrangements where they also participate in ACO losses.

Thus, a stark increase in ACO participation could be challeng-ing. There are three primary reasons for the limited success of the ACO model. First, the ACO provider network does not necessarily know with certainty which patients are covered under the ACO payment model. Second, ACO network providers do not have any authority to require

patients to only seek care within the ACO provider network. The third and perhaps most pertinent reason is the difficulty in reim-

bursing providers based on the “quality” of care they provide. In most scenarios, quality of care cannot be measured immediately. Rather, it is generally measured based on both the patient’s outcome as well as the patient’s overall cost of care. Because it is virtually impossible to mea-sure quality promptly after care is delivered, the reimbursement model requires that its success be measured over a long period of time—typically a minimum of one year. Accordingly, providers are generally compensated one year following the provision of care. This delay in compensation

is a challenging change for pro-viders, and may impact how, and to what extent, these new models will be adopted.

Practical steps—what should physicians do now?Although the goals may seem daunting, the shift from volume to value is gaining momentum. On April 16, President Obama signed the Medicare Access and CHIP Reauthorization Act of 2015. This new law echoes the shift from volume to value by directing the Secretary of Health and Human Services to establish a new Merit-based Incentive Pay-ment System (MIPS) under which eligible professionals (including physicians) receive payment increases or decreases based on performance. MIPS combines

three existing quality-incentive programs: the EHR incentive program, the Physician Quality Reporting System, and the val-ue-based payment modifier. MIPS implementation begins January 1, 2019.

While MIPS is separate and distinct from CMS’s new reim-bursement plan, the takeaway is that physicians should not dismiss CMS’s goals. Physicians should spend some time thinking about their practice and how the shift from volume to value will impact operational aspects as well as the provision of care. Phy-sicians should become familiar with the new Medicare goals and requirements, assess the options that are available, and plan a course of action—because while the ambitious goals may not ulti-mately be attained, the transition to value-based reimbursement is here to stay.

Timothy A. Johnson, JD, is a principal at Gray Plant Mooty. Julia C. Marotte, JD, is an associate at Gray Plant Mooty. Both are members of Gray Plant Mooty’s Health & Nonprofit Organization Practice Group.

A stark increase in ACO participation could be challenging.

44 MInnESOTA PHySICIAn June 2015

Medicare’s new payment reform plan from page 42

Physician Practice Opportunities

www.averamarshall.org

For details on these practice opportunities go to http://www.avera.org/marshall/physicians/For more information, contact Dave Dertien, Physician Recruiter, at 605-322-7691 • [email protected]

Avera Marshall Regional Medical Center is part of the Avera system of care. Avera encompasses 300 locations in 97 communities in a five-state region. The Avera brand represents system strength and local presence, compassionate care and a Christian mission, clinical excellence, technological sophistication, an array of specialty care and industry leadership. Currently we are seeking to add the following specialists:

• Psychiatrist• Psychologist• Orthopedic Surgeon• General Surgeon

• Family Medicine• Internal Medicine• OBGYN

Avera Marshall Regional Medical

Center300 S. Bruce St.

Marshall, MN 56258


The perfect matchof career and lifestyle.

www.acmc.com |

FOR MORE INFORMATION:

Kari Lenz, Physician Recruitment | [email protected] | (320) 231-6366

Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties:

• ENT• Family Medicine• Gastroenterology• General Surgery• Geriatrician• Outpatient

Internal Medicine

• Hospitalist• Infectious Disease• Internal Medicine• OB/GYN• Oncology• Orthopedic Surgery • Pediatrics

• Psychiatry• Psychology• Pulmonary/

Critical Care• Rheumatology• Sleep Medicine• Urgent Care

For additional information, contact Dr. Kathy Brandli, President, at [email protected] or

Eric Nielsen, Administrator, at [email protected] or 218.485.2000

www.gatewayclinic.com

Physician-owned Gateway Clinic seeks a family medicine physician to join our new Hinckley clinic. 3 or 4-day week practice with shared hospital call. Full-scope primary care and clinic OB practice (prenatal and postpartum care in clinic, option for colleagues to cover OB call and deliveries). Generous salary with sign-on and retention bonus, outstanding benefit package, 15% retirement contribution. Shareholder opportunities available.Gateway Clinic has locations in Moose Lake, Sandstone and Hinckley. Centrally located between Mpls/St. Paul and Duluth, the area provides an excellent family focused, quality of life opportunity in a rural setting with good public schools and abundant with lakes, rivers, state parks, and ideal hunting - all within an hour to metropolitan conveniences.

Family Medicine with Clinic OB

Sioux Falls VA Health Care System

Sioux Falls VA HCS, SD

(605) 333-6852 www.siouxfalls.va.gov

Applicants can apply online at www.USAJOBS.gov

Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package.The VAHCS is currently recruiting for the following healthcare positions in the following location.

EndocrinologistENT(part-time)Emergency MedicineGeriatrician (part-time)NeurologistOncologist/Hematologist

Orthopedic SurgeonPrimary Care (Family Practice or Internal Medicine)PsychiatristPulmonologistUrologist (part-time)

•Allergy/Immunology

•Dermatology

•EmergencyMedicine

•FamilyMedicine

•GeneralSurgery

•GeriatricMedicine

•Hospitalist

•Hospice

•InternalMedicine

•Med/Peds

•Ob/Gyn

•OrthopedicSurgery

•PainMedicine

•Psychiatry

•Rheumatology

•SportsMedicine


weight, and reduce substance abuse and domestic violence.

an ach in st. cloud headed up by centracare health, a nonprofit network of six hospitals and 17 clinics in central Minnesota, will work to reduce the incidence of unmanaged diabetes in the hispanic and east african patient population of stearns county. the project will string together the collec-tive bodies that serve these populations in economic, education, and health care capacities to deliver one unified approach.

This is a test a key fact about siM is that though it provides resources to providers and communities, its central charge is to test the hypothesis that acos, achs, practice transformation, and health it will help Minneso-

ta achieve the triple aim of lower costs, improved care, and patient satisfaction. this means that Minnesota is in the midst of a large test, focusing on integration and collabora-

tion. By 2016, it is expected that nearly 3 million Minnesotans will receive care through some accountable health Model. By taking this approach, Minneso-ta is learning how government, communities, social services organizations, public health departments, and health care

providers of all types can better work together to coordinate care, share data and resources, encourage wellness, treat ill-ness, and prevent disease, thus ultimately pushing in the same

direction to improve the health of the communities and resi-dents that call Minnesota home. our collective hope is that as we move forward we will gain a clearer picture of which collab-orative efforts work and which ones we must bring to scale across Minnesota. as a physi-

cian leader who has been very active with the various siM committees and work groups, including having the privilege of recently chairing the Data analytics workgroup, i strong-

ly encourage health care providers of all types (phy-sicians, clinics, hospitals, post-acute care, etc.) to be-come knowledgeable and engaged in this statewide transformation in order to learn, share, and innovate together. Minnesota has a rich history of being able to lead transformation in health by authentically partnering across stake-holder types and we can do it yet again through this model.

Rahul Koranne, MD, MBA, FACP, is board-certified in internal medicine and geriatric medicine. He is the senior vice president for clinical affairs and chief medical officer of the Min-nesota Hospital Association, which represents 143 hospitals and health systems across Minnesota.

The Minnesota Accountable Health Model from page 17

By 2016, it is expected that nearly 3 million

Minnesotans will receive care through some Accountable

Health Model.

Boynton Health Service

Boynton Health Service

Welcome to Boynton Health Service

Located in the heart of the Twin Cities East Bank campus, Boynton Health Service is a vital part of the University of Minnesota community, providing ambulatory care, health education, and public health services to the University for nearly 100 years. It’s our mission to create a healthy community by working with students, staff, and faculty to achieve physical, emotional, and social well-being.

Boynton’s outstanding staff of 400 includes board certified physicians, nurse practitioners, registered nurses, CMAs/LPNs, physician assistants, dentists, dental hygienists, optometrists, physical and massage therapists, registered dietitians, pharmacists, psychiatrists, psychologists, and social workers. Our multidisciplinary health service has been continuously accredited by AAAHC since 1979, and was the first college health service to have earned this distinction.

Attending to over 100,000 patient visits each year, Boynton Health Service takes pride in meeting the health care needs of U of M students, staff, and faculty with compassion and professionalism.

Gynecologist/Clinical SupervisorBoynton Health Service is seeking a gynecologist or primary care physician with extensive experience in women’s health to serve as Assistant Director of Primary Care in charge of the Women’s Clinic. The Assistant Director will provide clinical services, ensure staff adherence to relevant regulations, assure the highest professional and ethical standards, and work with the Director of Primary Care and Chief Medical Officer to formulate long range planning and policies.

This position offers a competitive salary and a generous academic status retirement plan. Professional liability coverage is provided. Apply online at www1.umn.edu/ohr/employment, select “External Applicants” and then search for keyword: Gynecologist. Job ID#: 300363

To learn more, please contact Hosea Ojwang, Human Resources Director 612-626-1184, [email protected].

The University of Minnesota is an Equal Opportunity, Affirmative Action Educator and Employer

A Diverse and Vital Health Service

410 Church Street SE • Minneapolis, MN 55455 • 612-625-8400 • www.bhs.umn.edu

is looking for primary and specialty physicians who want to help create a cure for the common coverage.

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Physicians, are you SIcK of: Feeling like you work for insurance companies instead of patients?Declining reimbursements while your patients pay higher premiums?Hospitals dictating where you refer patients?Patients delaying or avoiding much needed care because of high deductibles?

Crystal Medical Center 5700 Bottineau BoulevardCrystal, MN 55429

Building Size: 44,865 sq. ft.Space Available: 8,613 sq. ft.

Medical Space For Lease

Eagle Point Medical Building 8515 Eagle Point BoulevardLake Elmo, MN 55042


Helene Houle Medical Center 1155 East County Road EVadnais Heights, MN 55110


Plymouth Medical Building 3007 Harbor Lane NorthPlymouth, MN 55447


Jill K. Rasmussen, CCIM, SIOR612.341.3247 | [email protected]

Contact Us:

minnesota physician june 2015

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