wcpm october 2013

4

10 in the spotlight dr. maggie burkhead

contents

27 alliance medical ministry and urban ministries are striving for better health outcomes

wcms & wcms alliance family annual picnic

8

6

11

14

2023

wcms alliance update

welcome new wcms members

care transitions to the community and home

innovation & change at duke raleigh hospital

the supernatural in hamlet and ajax

the 2013 wake county community health needs assessment

24 community care of north carolina approach to asthma management

WAKE COUNTY PHYSICIAN | 1

the supernatural in hamlet and ajax

the 2013 wake county community health needs assessment

community care of north carolina approach to asthma management

Publisher

Editor

Wake County Medical Society

Officers and Executive

Council

Council Members

WCMS Alliance

Co-Presidents

Wake County Medical Society

Paul Harrison

2013 President | M. Dick McKay MD Secretary | Patricia Pearce, MDTreasurer | Patricia Pearce, MD President-elect | Patrica Pearce, MD Past President | Susan Weaver MD, PhD Founding Editor | Assad Meymandi, MD, PhD, DLFAPA

Terry Brenneman, MDMaggie Burkhead, MDWarner L. Hall, MDKen Holt, MDM. Dixon McKay, MDAssad Meymandi, MD, PhD, DLFAPARobert Munt, MDDale Oller, MDPatricia Pearce, MDDerek Schroder, MDMichael Thomas, MD Brad Wasserman, MDSusan T. Weaver, MDAndrew Wu, MD

Deb Meehan Louise Wilson

WCPM

Wake County Medical Society2500 Blue Ridge Road, Suite 330

Raleigh, NC 27607 Phone: 919.782.3859

Fax: 919.510.9162 [email protected]

“The Wake County Physician Magazine is an instrument of the Wake County Medical Society; however, the views expressed are not necessarily the opinion of the Editorial Board or the Society.”

October 2013

A special thanks to our Advertisers

Lori Banks is a registered nurse and serves as the Deputy Director of Community Care of Wake and Johnston Counties, a care management and quality improvement program of the Wake County Medical Society – Community Health Foundation. In her role, Lori provides oversight for the clinical operations within the program. Lori has over 12 years of nursing experience. She is currently applying to graduate programs for a Master’s Degree in Nursing.

Elizabeth Cuervo Tilson, MD, MPH graduated John Hopkins University School of Medicine and is Board Certified in Preventive and Pediatrics. She currently provides primary care in the Wake County Human Service Child Health Clinic and is the Medical Director of Community Care of Wake/Johnston Counties.

contributors

Wake County Physician Magazine (WCPM) is a publication for and by the members of the Wake County Medical Society. WCPM is a quarterly publication and is digitately published January, July, April, and October.

All submissions including ads, bio’s, photo’s and camera ready art work for the WCPM should be directed to:

Tina FrostGraphic Editor [email protected] 919.671.3963

Photographs or illustrations:Submit as high resolution 5” x 7” or 8” x 10” glossy prints or a digital JPEG or TIF file at 300 DPI no larger than 2” x 3” unless the artwork is for the cover. Please include names of individuals or subject matter for each image submitted.

Contributing author bio’s and photo requirements: Submit a recent 3” x 5” or 5” x 7” black and white or color photo (snapshots are suitable) along with your submission for publication or a digital JPEG or TIF file at 300 DPI no larger than 2” x 3”. All photos will be returned to the author. Include a brief bio along with your practice name, specialty, special honors or any positions on boards, etc. Please limit the length of your bio to 3 or 4 lines.

Ad Rates and Specifications:Full Page $800 1/2 Page $400 1/4 Page $200

L. Jarrett Barnhill, MD is a professor of Psychiatry at the UNC School of Medicine and the director of the Developmental Neuropharmacology Clinic within the Department of Psychiatry. He is a Distinguished Fellow in the American Psychiatric Association and Fellow in the American Academy of Child and Adolescent Psychiatry.

Ben McDonald, R.N. is a care management registered nurse with Community Care of Wake and Johnston Counties. He also holds a degree in English Literature from UNC-Asheville.

Additional contributors include:

Pam Carpenter | Membership Manager, WCMS Megg Rader | Executive Director, Alliance Medical MinstryPeter Morris | Exececutive Director, Urban Ministries of Wake CountyDeborah Meehan | Co-President, WCMS AllianceLouise Wilson | Co-President, WCMS AllianceThe UNC Gillings School of Global Public Health TeamWake County Human Services Staff Team Dr. Edie Alfano-Sobsey, PhD, MT (ASCP); Regina Y. Petteway, MSPH; Lechelle Wardell, MPH; Petra Hager, BCS; Sue Lynn Ledford, RN BSN MPA

4 | OCTOBER 2013

WCMSand

WCMS Alliance Annual Family Picnic

Betty GriffinCal and Alistair Cunningham

Shaun Doneganand Amit MehtaIn September the WCMS and WCMS

Alliance hosted the Annual Family Picnic at Tara Farms. Thankfully the rain held off and great fun was had by all. Thank you WCMS Alliance for putting together another wonderful and success event. And a special thanks to: Donald Alson with Creative Entertainment Q-Shack Mimi the Clown Giant Castle Moonbounce Henry’s Gelato and to everyone who attended.


Pam Carpenter and Susan Davis

Benton & Emma-Garnett Satterfield

Paul Harrison and Dick McKay

Lyndon and Laurie Jordon

Kashif and Zohra Osman

Dick McKay and Deborah Meehan

Barb Savage, Dick & Deborah Meehan

Dr. Bill and Zoe Durland

6 | OCTOBER 2013

It’s a pretty fabulous thing when you find new friends with whom you have lots in common….

especially, when you move into a new and unfamiliar city, you have no one you trust…other than your real estate agent… and no one to ask all those all-important questions about everything! Oh, sure, you can check online, reach out to neighbors…(do people do that anymore???)…talk to someone you just met at your new office….hope the Welcome

Wagon drives down your street…or maybe even search the local newspaper for ideas. But, there’s just something amazing when you meet that person or those people who really GET you! They understand what you’re going through and there’s an unmistakable bond. They’ve really walked in your shoes and they are more than willing to help you through the rough patches and happy to celebrate the small victories as you settle into your new life. Those folks are precious and few…but they can be found!

For Medical Families moving into the Triangle, that’s the kind of friendship that the Wake County Medical Society Alliance offers to spouses and partners of physicians. We are here for you. Yes, there

are modest membership dues, but I can promise you that the rewards of the friends you make and relationships you build will far exceed any financial obligation.

Whether you have a professional career, you’re a stay-at-home mom or dad, a student or perhaps a partner who just wants to learn more about coping in a medical family, the WCMSA can make your journey so much easier and definitely more FUN! Trust me….

WE GET YOU! And…WE WANT YOU to become ONE OF US! And, it doesn’t matter if you are male or female….Your relationship as a spouse and/or partner is the ONLY requirement to join!

Louise Wilson and I are the Co-Presidents of the WCMSA this 2013-2014 year. We are committed to building our organization by reaching out to the Triangle medical community, introducing ourselves and our wonderful organization and creating new and lasting friendships. We hope YOU will consider becoming our ‘new best friend’ and sharing the joys of being an Alliance member! Your spouse and/or partner are welcome to join, too!!!

Feel free to call or text me anytime at 919.333.3914 or reach out to Louise at 919.737.5544. We would be happy to meet you for coffee or drinks…Our treat! Looking forward to meeting YOU and welcoming you to our organization!

Cheers!

Deborah Deborah Harrell Meehan Co-President, Wake County Medical Society Alliance

We’re here for You!

Hey, Doc...Show this article to your spouse or partner!

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8 | OCTOBER 2013

Valerie L. Cumbea, PA-CPractice: WakeMed CaryMedical School: Duke University Medical Center Physician Assistant ProgramGraduation: 2011

Claudia Y. DiGiaimo-Nunez, MDPractice: Carolina Partners in Mental HealthMedical School: University of South Florida College of MedicineGraduation: 2004

Dawn P. Evancho, PA-CPractice: David Paul Adams, MD, PAMedical School: Charles Drew UnviersityGraduation: 1990

Carol A. Filomena, MDPractice: Duke Raleigh Hospital, Dept of PathologyMedical School: Hahnemann University School of MedicineGraduation: 1984

Theresa M. Flynn, MDPractice: Wake County Child Health ClinicsMedical School: Duke UniversityGraduation: 1996

Jennifer C. Gamache, PA-CPractice: Wakefield Medical Care

Medical School: Nova Southeastern University Physician Assistant ProgramGraduation: 2001

Michael Golding, MDPractice: Triangle Family ServicesMedical School: Ohio State University - ColombusGraduation: 1991

Gay M. Gooden, MDPractice: Wake Emergency PhysiciansMedical School: Duke University Medical Center Physician Assistant ProgramGraduation: 1996

Valerie L. Cumbea, PA-CPractice: WakeMed CaryMedical School: UNC Chapel HillGraduation: 1996

Jessica L. Henderson, DOPractice: American Anesthesiology of NCMedical School: Duke University Medical Center Physician Assistant ProgramGraduation: 2006

Brian A. Kessler, DOMedical School: Lake Erie College of Osteopathic MedicineGraduation: 1998


Addison J. Korzun, PA-CPractice: Raleigh Orthopaedic ClinicMedical School: Duquesne University Physician Assistant ProgramGraduation: 2010

Melvin G. Lee, MDMedical School: Dalhousie University Faculty of MedicineGraduation: 1980

Kimberly W. McDonald, MDPractice: Wake County Health ClinicMedical School: Eastern Virginia Medical SchoolGraduation: 1995

Kathleen W. Nissman, MD, MPHPractice: American Anesthesiology of NCMedical School: Medical University of South

Carolina College of MedicineGraduation: 2005

Mohit Pasi, MDPractice: Rex Heart & Vascular SpecialistsMedical School: Shahdra Univ Col of Med ScienceGraduation: 1988

Rig S. Patel, MDPractice: Digestive Healthcare, PAMedical School: St. Bartholomews and Royal London SOMGraduation: 1989

Nevin M. Shrimanker, MDPractice: American Anesthesiology of NCMedical School: Wake Forest University School of MedicineGraduation: 2004

Nevin M. Shrimanker, MDPractice: American Anesthesiology of NCMedical School: Wake Forest University School of MedicineGraduation: 2004

Scott D. Wagner, MDPractice: American Anesthesiology of NCMedical School: Wake Forest University School of MedicineGraduation: 2004

Nevin M. Shrimanker, MDPractice: Wakefield Medical CareMedical School: University of PittsburghGraduation: 1997

James P. Zidar, MDPractice: Rex Heart & Vascular SpecialistsMedical School: Loyola Univ-StritchGraduation: 1985

Dr. Post Dr. Erickson Dr. Edwards Dr. Messer Dr. Schricker

10 | OCTOBER 2013

Each year, a select group of NCMS members from a wide range of disciplines and specialties are selected to participate in the NCMS Leadership

College, a year-long course designed to train scholars for future leadership roles. Leadership College scholars meet five times a year for training in leadership principles, practices, and strategies. Additionally, each scholar commits to developing a project to benefit their local society, community, and/or the NCMS.

This year, Maggie Burkhead, MD, was among the group of physicians selected to participate as a Leadership College scholar. A former Navy physician and clinical instructor in family medicine at UNC-Chapel Hill, Dr. Burkhead is now a partner at Raleigh Family Practice. She also currently serves on the board of directors for the Wake County Medical Society Community Health Foundation. Dr. Burkhead was kind enough to share about her experience as Leadership College scholar, and about her unique leadership project.

Overview of the Leadership College Experience:Dr. Burkhead describes participating in the Leadership

College as “one of the most important and rewarding elements” of her medical profession. The reasons for this are multifaceted. First, there’s the explicit function of the Leadership College: developing leadership skills. As Dr. Burkhead explains, “It’s about training us to be good leaders. They teach us skills such interpersonal and public communication. Without question they’re training us to help in whatever way we can to promote the care of whole community, the statewide community of citizens in NC.” The role of the Leadership College goes deeper than developing leadership skills, however. It fosters creative and dynamic relationships between scholars that span their professional and personal lives. It also serves as a wellspring of new ideas and perspectives, and provides the opportunity for growth and collaboration. “It goes beyond personal growth and leadership skills. It’s about collective sharing and collective experience. We’re growing as a

group,” says Dr. Burkhead.

Dr. Burkhead’s Leadership Project:The completion of a leadership project is one of the core

elements of the Leadership College. For Dr. Burkhead, the leadership project allowed her to focus her energies on an issue that impacts thousands of patients and families across the state. As she explained, NC has one of the highest rates of fatal overdoses from prescriptions drugs in the United States. Communities are currently struggling to find effective methods for combating the prescription overdose epidemic in NC, and projects such as Community Care’s Chronic Pain Initiative are taking major steps to reduce the number of fatal prescription drug overdoses across the state.

As Dr. Burkhead points out, prescribers have both the opportunity and the responsibility to significantly reduce the number of prescription drug overdoses and reduce patient harm. This requires responsible prescribing of controlled substances, close monitoring of patients, and a holistic approach to treating the physical, mental, emotional, and spiritual dimensions of each patient. One of the most effective tools in combating prescription drug overdoses that prescribers have at their disposal is the centralized Controlled Substance Reporting System. This database is linked to most pharmacies in NC, and provides a record of all controlled substance that have been filled for a patient. Any prescriber with a DEA number can register to access the database. As Dr. Burkhead points out, by accessing the database, a prescriber can find out what controlled substances a person is taking, and can thus make an informed decision about what medications to prescribe based on possible interactions, contraindications, or fill history patterns. As Dr. Burkhead puts it, accessing the database allows her to make sure she’s “not going to harm someone.”

The problem, however, is that the reporting system is often underutilized by prescribers. Dr. Burkhead’s project, therefore, has been to educate key providers about the


database, discover what barriers may be preventing wider use of the system, and to encourage and facilitate greater use of the system to promote harm reduction for patients. By sending out surveys and toolkits and participating in dialogues with these key providers, Dr. Burkhead has already seen a positive shift toward greater use of the database.

For Dr. Burkhead, the project

resonates on a deeply personal level. “I lost my brother and his fiancé to a drunk driver about 6 years ago,” she explains. “It was the driver’s second DWI conviction. I wonder, if his doctor had intercepted him and had a conversation with him, could that have changed it? If there’s a problem, I want to help my patient before harm is done. If I have objective data from the database, I can go into an exam

room and say to the patient ‘This is concerning to me, let’s have a conversation about it. Let’s talk about it. This is not normal behavior.’”

Dr. Burkhead’s hope is that other prescribers will utilize the database as an avenue to prevent accidental overdoses, and to increase the health, safety, and quality of life of their patients and the greater community. §

Medicare Part A and B beneficiaries do not have the benefit of transitional care services from a care manager when they

are discharged from the hospital. Transitional care services are important and have shown reduced rates of readmissions. With more and more pressure being placed on hospitals and other facilities to reduce readmission rates by regulating organizations, the Centers for Medicare and Medicaid Services (CMS) created a program to address this problem. “The Community-based Care Transitions Program (CCTP), created by Section 3026 of the Affordable Care Act, tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries. The goals of the CCTP are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to

improve quality of care, to reduce readmissions for high risk beneficiaries, and to document measurable savings to the Medicare program.”1

Community Care of Wake and Johnston Counties (CCWJC) is one of fourteen local networks under Community Care of North Carolina (CCNC). CCNC and all of the local networks have “made great strides in improving care and reducing costs in the Medicaid population. Multiple studies document substantial savings for an approach that is respected by clinicians and patients alike.”2 The care managers within the networks provide transitional care services to high risk Medicaid patients, making the CCTP a natural fit for the networks.

CCWJC and WakeMed Health and Hospitals wrote an initial proposal to CMS for grant funding to provide transitional care

Care Transitions to the Community and Home

By Lori Banks, RN, BSN, CCM Deputy Director, Community Care of ake and Johnston Counties

[article continued on page 13]

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management services to high-risk Medicare beneficiaries. CMS did not award funding because there was not enough community partners involved in the proposal. CCWJC and WakeMed Health and Hospitals joined forces with many other partners, including two other local Community Care networks, eight other hospitals, and five local Area Agencies on Aging and Community Resource Connections for Aging and Disabilities with a plan to target patients who live in one of eleven counties in central North Carolina. Funding was awarded for this proposal in the summer of 2012 and the program, known as the Care Transition to the Community and Home (CATCH) grant started in January, 2013.

The CATCH program is based on the Care Transitions Intervention by Eric Coleman, MD, MPH. The target population is Medicare fee-for-service patients who have been admitted to one of the nine hospitals who live in one of the eleven project counties with one or more of the following diagnoses: Congestive Heart Failure, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Acute Myocardial Infarction, and Pneumonia.

There are four care transition intervention pillars that are used when working with identified patients in an effort to effectively assist with the transition from the hospital back to the community. The first is medication self management. When working with the patient, the care manager works to ensure that the patient is knowledgeable about medications and has a medication management system. The second is the use of a dynamic patient-centered record. The goal of this pillar is for the patient to have an

understanding of and utilizes a Personal Health Record (PHR) provided by the care manager. Managed by the patient or informal caregiver, the PHR is intended to facilitate communication and ensure continuity of care across providers and settings. The third pillar focuses on Primary Care and Specialist follow up. The care manager impresses upon the patient the importance of scheduling and completing follow up visits with providers and is empowered to be an active participant in these interactions. Finally, the fourth pillar is teaching patients about red flags so they are knowledgeable about indications that their condition is worsening and how to respond.

The CATCH program has hired and embedded a Registered Nurse in each of the hospitals in the triangle area. The Registered Nurses are known as Transitional Care Coaches, or TCCs. Each TCC works in the assigned hospital five days per week and communicates with the hospital staff in various ways, such as receiving verbal referrals and a hospital generated list of patients who have Medicare, to identify patients who are eligible to receive CATCH program services. Once identified, patients are approached by the TCC, the program is introduced, and the TCC begins providing education and coordinating services that will be needed following discharge for the patient. The transitional care process begins the day of discharge and continues for

30 days following discharge. Each patient receives scheduled interventions during the transitional care period.

The hospitals and hired staff involved in the CATCH program were brought on using a phased-in approach. The volume of patients who meet eligibility criteria for the program exceed our projections and so we have quickly expanded our resources and staff to meet the need o the patient population. There is now an embedded TCC in each hospital and since March of 2013. Data collected thus far indicates that the targeted interventions being provided to the patients are beneficial and readmissions rate for Medicare patient discharge from CMS has decreased 12% in the first quarter activities and 10% for all other local hospitals. Other process data is being used to inform quality improvement in our program elements, including increasing patient engagement. §

1. http://innovation.cms.gov/initiatives/CCTP/?itemID=CMS1239313 2. “Diversification and CCNC,” 2012

Care Transitions continued

Innovation and Change at Duke Raleigh Hospital

Over the past year, Duke Raleigh Hospital has experienced significant growth and change including new hospital leadership, upgraded technology and innovation of hospital services. Like many hospitals in the area and across the nation, the Duke Raleigh team is working to optimize efficiency while also

providing the highest quality care to patients.

14 | OCTOBER 2013


New Leadership

Richard Gannotta, NP, DHA, FACHEPresident

Effective January 1, 2013, Duke Raleigh Hospital welcomed new President, Richard Gannotta, NP, DHA, FACHE. Gannotta served as Duke Raleigh’s Chief Operating Officer for more than six years and knows the hospital’s mission, operations and dedication to service.

Gannotta is a nurse practitioner who has spent significant time working at the patients’ bedside and great insight into creating a caring environment for patients and staff.

“My mentor, colleague and friend, Doug Vinsel, has laid an incredible foundation for the hospital, and I plan to maintain the same focus areas Doug has established and worked tirelessly to build,” Gannotta said.

As a part of the Duke University Health System, Gannotta says Duke Raleigh is furthering its commitment to providing the very best care for patients and leading the way in clinical areas including oncology, cardiovascular, neurosciences, and orthopaedics.

“We will also continue our mission to be a community leader. I believe we play an integral role in the health and well-being of the citizens of Raleigh, Wake County and the Greater Triangle, and that won’t change,” he said. “A healthy community is good for all of us, and I want to inspire healthy behaviors and make sure that Duke Raleigh will be there when you need us.”

Duke Raleigh will continue active outreach with community organizations that focus on healthcare delivery as well as continue collaboration with other hospitals and organizations like Alliance Medical Ministries and the Open Door Clinic.

“With our expanded facilities and passionate caring physicians and staff, we will continue to deliver the best care for our patients,” said Gannotta.

Michael Spiritos, MDChief Medical Officer

Duke Raleigh’s new Chief Medical Officer, Michael Spiritos, MD says his continued work with patients will be an important part of his new administrative role which began in August.

“It’s very important to me that I continue my clinical work. Patients want and deserve timely, effective and cost-efficient care,” he says. “My goal—and everyone’s goal, really—is to have our institution focused on creating a

Richard Gannotta

Dr. Michael Spiritos[article continued on page 16]

patient-centered experience while providing the highest-quality care.”Dr. Spiritos will work with retiring CMO Ted Kunstling, MD, through the end of 2013 to ensure a smooth

transition. Duke Raleigh Hospital President Rick Gannotta commended Dr. Kunstling for “very ably serv[ing] both the hospital and the medical staff for many years.” In announcing Dr. Spiritos’s new role to hospital staff, Gannotta said, “This appointment comes after an extensive interview process that involved the participation of Duke University Health System and Duke Raleigh Hospital leadership, members of the hospital medical staff and representation from the Duke Raleigh Advisory Board.”

Dr. Spiritos is well prepared for his new role. He has served since 2007 as chief of medical oncology for the Duke Raleigh Cancer Center. He has also been the lead representative in Wake County for the Private Diagnostic Clinic (PDC), an organization to which all Duke University Health System physicians belong. One of Dr. Spiritos’s biggest challenges will be guiding hospital staff through many changes in healthcare delivery, including the adoption of an electronic medical record. All health records will be converted from paper to electronic by 2014. Dr. Spiritos says having all patient records in one central place will be a benefit to caregivers and their patients. It’s a tremendous undertaking, but he’s up to the task. “This is a dynamic time for the healthcare field,” Dr. Spiritos says. “Our entire system is gearing up to figure out ways to do things differently. But, we’ll always keep our focus on the multidisciplinary, team approach we’re known for, and our patients will remain the central focus of everything we do.”

Priscilla Ramseur, MSN, RN, CNORChief Nursing Officer

Priscilla Ramseur, MSN, RN, CNOR joined Duke Raleigh Hospital as Chief Nursing Officer in September. Ramseur came to Duke Raleigh from Duke University Hospital where she most recently served as Associate Chief Nursing Officer of Perioperative Services.

With more than 18 years of management experience and 25 years of perioperative services experience at Duke University Health System, Ramseur has served as a member of the senior nursing leadership team at Duke University Hospital and has past experience as a clinical operations director, OR nurse educator and staff nurse. She has successfully coordinated unit mergers, construction projects, and managed change through communication, collaboration, team building and her passion for nursing.

“I am excited to join the Duke Raleigh team,” Ramseur says. “My transition is focused on meeting everyone and learning the current

workflows. I anticipate amazing things happening as teams continue to collaborate to provide excellence in patient care.”

Ramseur completed her Bachelor of Science in Nursing at North Carolina Central University and her Master of Science in Nursing and Post-Master’s Certificate in Nursing Administration at Duke University.

Priscilla Ramseur

New Technology: Biplane Angiography SuiteDuke Raleigh’s biplane angiography suite is the

first of its kind in Wake County. As the name implies, biplane angiography captures x-ray images from two different “planes” or angles, allowing physicians a more realistic visualization of the anatomy that is projected on a monitor in real time.

“Traditional x-ray imaging flattens our view of

the body to two dimensions,” Dr. Ali Zomorodi, neurosurgeon and medical director of skull base and cerebrovascular surgery at Duke Raleigh says. “By directing an x-ray beam from both the side and the front of the body, we can gather continuous imaging of complex structures three-dimensionally. This allows us to perform procedures without having to open up and directly visualize the inside of the human body.”

Biplane technology spares surgeons having to perform open procedures and enables them

16 | OCTOBER 2013

to access the affected area endovascularly, instead—which is not only less invasive, but also less risky. Thanks to endovascular techniques and the use of biplane imaging, patients who undergo neurosurgery at Duke Raleigh can experience the benefits of a faster recovery, fewer complications and less postoperative pain and discomfort.

The new biplane lab also allows electrophysiology physicians to diagnose and treat atrial fibrillation (AF), occurring when the upper chambers of the

heart beat fast and irregularly. Through catheter ablation, long, flexible tubes are passed to the heart through the blood vessels and used to identify and cauterize regions of the heart that are responsible for producing or sustaining AF. Advanced computer mapping systems are routinely used to pinpoint the source of the abnormal electrical signals and to direct catheters to the target sites.

“It’s unique for a hospital of our size to have this capability,” Dr. Zomorodi says. “With amenities such as the biplane angiography suite, Duke Raleigh Hospital can offer the same advanced services as a large hospital while still providing personalized care.” Visit Duke Raleigh Hospital online for a 360-degree tour of the biplane angiography suite.

Advanced Digestive Care Duke Raleigh Hospital’s newly developed Advanced Digestive Care

program is the only one of its kind in Wake County and features an interdisciplinary team of subspecialists with a high degree of expertise in hepatobiliary and pancreas disorders, advanced endoscopy, colorectal diseases and esophageal diseases.

The unique program’s multidisciplinary approach gives patients access to a broad range of specialists. Those specialists are using the most advanced techniques to treat colorectal diseases including

Duke Primary Care continues to expand our network of providers with convenient locations throughout Wake County. To learn more, visit dukehealth.org/primarycare.

Duke Primary Care Blue Ridge2406 Blue Ridge Road, Suite 250Raleigh, NC 27607

Duke Primary Care Brier Creek10211 Alm StreetRaleigh, NC 27617

Duke Primary Care Creedmoor Road7200 Creedmoor Road, Suite 208Raleigh, NC 27613

Duke Primary Care Harps Mill7021 Harps Mill Road, Suite 100Raleigh, NC 27615

Duke Primary Care Knightdale162 Legacy Oaks DriveKnightdale, NC 27545

Duke Primary Care Morrisville10950 Chapel Hill RoadMorrisville, NC 27560

Duke Primary Care Peak Family Medicine1011 Pemberton Hill road, Suite 101Apex, NC 27502

Duke Primary Care Wakelon Internal Medicine301 Hospital RoadZebulon, NC 27597

Duke Primary Care Waverly Place540 New Waverly Place, Suite 200Cary, NC 27518

North Hills Internal Medicine3320 Wake Forest RoadRaleigh, NC 27609

Duke Primary Care Wake Forest Family Physicians11635 Northpark Drive, Suite 200Wake Forest, NC 27587

Program Innovation

[article continued on page 18]

Dr. Ali Zomorodi

laparoscopic surgery, robotic surgery and transanal endoscopic microsurgery.

The program additionally includes a dedicated patient navigator to guide patients through the process from initial consultation through treatment and follow-up. Patient navigators are responsible for setting and coordinating appointments with the program’s team of physicians. The patient-centric approach allows patients the freedom to concentrate on healing rather than logistics and simplifies the referral and scheduling process for physician practices with one point of contact.

“This is a new approach to delivering GI care,” says Jorge Obando, MD, Medical Director of the Advanced Digestive Care program. “Our center offers the highest level of expertise in the areas of all GI diseases, as well as ease of access and coordination of patient-centered care.”

To make a referral to the Advanced Digestive Care program at Duke Raleigh Hospital, please use the convenient online form at dukeraleighhospital.org/adc call directly at 1-855-278-7418 or fax your patient’s information to 919-954-3916.

Duke Spine Center Treatments for back disorders run the gamut,

depending on the cause—hot and cold packs, exercise, medication, injections, complementary and alternative therapies, and surgery. Making the right choice from a myriad of options often requires consulting several experts. Now conveniently offered at Duke Raleigh Hospital, The Duke Spine Center of Raleigh brings together specialties in pain management, exercise science, and the nervous and skeletal systems, making it easier for sufferers to access the help they need in one location.

“Our center cares for the entire range of spine pathology, from a simple back strain to epidural injections to minimally invasive surgery,” said Keith Michael, MD, a Duke Orthopaedic spine surgeon and a member of the Duke Spine team in Raleigh. “We want patients to feel like they are cared for like family when they come to the Duke Spine Center of Raleigh.”

“The multidisciplinary nature of the Spine Center allows us to focus on the patient’s needs, not just find a possible treatment that fits within our specialties,”

says Carlos A. Bagley, MD, FAANS, neurosurgeon and co-director of the Duke Spine Center. “My patients aren’t limited to the neurosurgery I offer or to the orthopaedic surgery my colleagues provide. Instead, we bring everyone together so

18 | OCTOBER 2013

Dr. Jorge Obando

Dr. Carlos A. Bagley

Dr. Keith Michael

patients don’t have to guess which spine specialist would best meet their needs. We work together to answer that question for them.”

To learn more about the Duke Spine Center of Raleigh visit dukespine.org.

NeurosciencesDuke Raleigh Hospital is one

of only a handful of hospitals in the United States now offering a new and innovative surgery for metastatic tumors and blood clots. Peter Grossi, MD, Medical Director of Neurosciences at Duke Raleigh Hospital, has been trained on a new state-of-the-art approach using NICO BrainPath technology.

“The BrainPath system uses a very small incision and results in fewer neurological deficits to the patient,” Dr. Grossi says. “It’s a less invasive way to tackle brain tumors. There’s less blood loss. And we can get the patient home

quicker than we do with traditional neurosurgery.”

The BrainPath technique allows surgeons to reach tumors—especially ones deep in the brain—and clots in a targeted manner. Dr. Grossi describes it as not just one product but a system that offers image guidance and minimally invasive instruments that allow surgeons to target a tumor with pinpoint accuracy.

The new technology is actually a multifunctional system that allows surgeons to remove tumors through a retractor the size of a dime. The design provides improved access to hard-to-reach tumor sites, better visibility for the surgeon and lower risk to the patient.

Transitioning to Electronic Medical

Record Like many other hospitals

across the state and nation, Duke Raleigh Hospital is reshaping our organization to successfully meet the challenges of our changing healthcare landscape. We are looking for new ways to align our care delivery so that we can continue to efficiently provide highly specialized services for our patients.

One exciting change at Duke Raleigh, and across Duke Medicine, includes our transition to a new, state-of-the-art medical records technology produced by Epic Systems which Duke Medicine has named Maestro Care. Once complete in 2014, it will create a single electronic

record for each patient and can be accessed at any Duke location, as well as by affiliated and referring physicians. The technology creates a seamless, real-time and secure communication among all members of the Duke care team.

Duke Maestro Care

will: • Create a single,

comprehensive electronic medical record detailing a patient’s personal health and health care history • Allow for better coordination and faster communication between all members of the Duke care team, at any Duke location, as well as by affiliated and referring physicians • Give patients secure access to their own health information from their personal computer – anytime, anywhere • Coordinate a seamless transition between Duke Medicine clinics and hospitals

This transition prepares us to meet and exceed the requirements of the Affordable Care Act and also allows us to better manage the health of our patients and community. Maestro Care will additionally help cut medical care costs and lessen redundancy in tests, scans or screenings due to patients seeing multiple providers and locations and will boost safety and quality by maintaining consistency for safe practices across our health system. §

Dr. Peter Grossi


20 | OCTOBER 2013

I n a previous article on Ajax, I introduced two Sophoclean innovations. The first was the concept of tragic hero. The second involved

the impact of changing Greek attitudes about the gods, Athena in particular. In this article, I will compare and contrast the actions of the goddess with those of the ghost of Hamlet’s father- H1’s ghost from now on. In spite of their critical roles, both playwrights have decidedly ambivalent attitudes towards these supernatural entities. Historical factors may help us understand this ambivalence. In 5th century BCE Greece, the philosophy was overshadowing the gods in the minds of many educated citizens. Two thousand years later, many Shakespearean audiences still believed in ghosts, witches and devils. Shakespeare also made good use of magic and sorcery. Although Bacon and Elizabeth I were apparently skeptical, her nephew and successor, James I (of King James Bible fame) had already authored a treatise on witches and witchcraft. We’ve met H1’s ghost before. In a 2012 WCP article we explored three Elizabethan theories of ghosts: a manifestation of madness; messenger from Purgatory sent back to warn the living to change their ways; and as the Devil’s hireling for seducing and ensnaring souls. This tripartite classification also reflected a mixture of early modern ideas about the nature of mental illness; Catholic views of Purgatory and lastly Protestant attitudes about the devil’s influence, respectively. H1’s ghost called for an archaic form of justice, blood revenge, and in doing so, completely disregarded Hamlet’s philosophical disposition. H1 demanded that young Hamlet avenge his fratricide in a perversion of the Genesis story of Cain (Claudius) and Abel (H1). That call for revenge undermined any claim that H1 was a visitor from Purgatory. This demand was straight out of hell. Athena’s on the other hand was the goddess

of wisdom. She acted to save Greek warriors from Ajax by tricking him into slaughtering sheep instead. Unfortunately her reasoned choice turned sour. Her actions inflamed, humiliated and then unleashed the ancient code of Homeric warrior in Ajax. Unlike H1, her interference backfired and led to his suicide. For Ajax, there was no anagnorisis and certainly no “to be or not to be” soliloquy. His impulsive action preempted any concerns about an “undiscovered country”, or thought of self-restraint: “conscience doth make cowards of us all”. Hamlet was no Ajax. He had more in common with the wily Odysseus who relied upon reason and compromise. Hamlet added a Baconian twist- designing an experiment to resolve his uncertainty (“the plays the thing wherein I’ll catch the conscience of the king”). But Hamlet eventually murdered Polonius on impulse (ironically juxtaposed to the last appearance of H1’s ghost). Hamlet’s misplaced homicide brought the old man’s children, Laertes and Ophelia, back into the action. Shakespeare converged two story lines and then animated Hamlet’s “to be or not to be” soliloquy. He divided Hamlet in two, and assigned the distraught Ophelia the “not to be” (suicide) and Laertes “to be” (take action in blood vengeance). It turns out that Laertes had more in common with Ajax and both were better sons to H’s ghost than Hamlet.

But a psychological autopsy of any Shakespearean character is no simple task. There are always many explanations for the waxing and waning of Hamlet’s “antic disposition”. Was he mad? There is much evidence to the contrary. As the play progresses, Hamlet rejected his antic disposition and expelled the ghost. Was the ghost mad? After all Hamlet was sensitive to the hideous nature of the ghost’s demands. He defied him as well as augury. As the play progressed, the ghost faded along with the idea that he was a symptom

The Supernatural in Hamlet and AjaxBy L. Jarrett Barnhill, MD

of psychosis. Once freed, a new Hamlet unfolded. He escaped execution ordered by Claudius; took charge and outwitted pirates, and returned to Denmark. By this time Hamlet life was in the hands providence: he acted when necessary, dispensed with long soliloquies or discourses (except for “alas poor Yorick”); ignored ancient traditions, and put himself in the hands of a trial by combat. There was no scheming or experiments. He accepted the ever-changing contingencies. This Hamlet had no need of a ghost or an Athena; a belief that a larger providence was in charge of his uncertain course. Madness gave way to here-and-now action.

What happened? One literary theory of both madness and tragedy involves intolerable circumstances and limited courses of action. But was Hamlet mad or just a very good actor?

Polonius wondered so: “though this be madness, yet there is method in it”. Psychoanalysts in the early 20th century focused on the similarities between Hamlet’s predicament and that of Oedipus. Hamlet cannot act because unconsciously, his actions would fulfill incestuous desires to murder his father and possess his mother. From this perspective, his delay was a symptom. Yet most critics challenge this hypothesis, arguing that it oversimplified the complex dynamics of this play. Does the scene in his mother’s closet depict Hamlet’s as mad or in a liminal state of transformative madness or metamorphosis? This question sets the stage for an even more ambiguous comparison- Medea of Euripides and Lady Macbeth. §


In June, 2013 the Wake County Community Health Needs Assessment Document

and Executive Summary were completed. This marked an historical first with a formal collaboration between WakeMed Health and Hospitals, Duke Raleigh Hospital, Rex UNC Healthcare, Wake County Human Services, Wake Health Services, United Way of the Greater Triangle, Wake County Medical Society Community Health Foundation and Urban Ministries. Representatives from these partners met for many months, sifting through new IRS guidelines that required assessments for hospitals, and aligning those sometimes vague requirements with the already existing public health department requirements. The result is a very informative document that can be found electronically by following this link. A Community Health Needs

Assessment is “a systematic collection, assembly, analysis and dissemination of information about the health of a community.” (Page 5, 2013 Wake County Community Health Needs Assessment Executive Summary Document). The 2013 Wake County Assessment outlines statistical data and information on a wide variety of health related topics, as well as community priorities. Working through a contract with the UNC Gillings School of Global Public Health information was collected and analyzed from data from door to door surveys, focus groups,

and existing statistical sources. Additionally, guidance and oversight were provided through a Steering Committee of more than 60 non-profit, government, faith-based, education, media, and business organizations. The many hours volunteered by the Steering Committee and the input provided by Wake County residents has be invaluable to this process. In the 2013 Assessment, the

following priorities were tallied from a process that included five community forums held simultaneously across the County:

1. Poverty and unemployment2. Health care access and

utilization3. Mental health and substance

use

The 2013 Community Health Assessment includes information on these priorities and many other health, social, and behavioral topics in the full document. In March, 2013 Wake County

was ranked as the healthiest county in North Carolina for the fourth consecutive year. This is due to the work and partnerships of public health, the community, government, hospital partners and most importantly our Wake County citizens. This accomplishment underscores the importance of our Community Health Needs Assessment, because it helps us identify and address factors that affect the health of our community. As our County continues to evolve and grow we must make sure that

we take the necessary steps to ensure that the needs of all our citizens are being addressed. We realize that when it comes to public health, the community itself is the patient and the health of the community must be assessed by focusing on key areas such as behavioral and social health, the economy, education, environmental health, physical health and safety. Please know that the Community

Health Needs Assessment Process is not finished! Hospitals continue to work on action plans, and Wake County Government along with community partners will be launching a “Healthiest County Initiative” and action planning process also. We know that with all of us working together, we can create a healthier, safer community while having a better idea of where we need to focus our resources over the next few years.If you are interested in being

involved or want more information on the continuing action planning, please contact Susan Davis, Executive Director of the Wake County Medical Society – Community Health Foundation at [email protected].

The 2013 Wake County Community Health Needs Assessment A Historical Collaboration

Contributing Authors

– The UNC Gillings School of Global Public Health Team– Wake County Human Services Staff Team, Dr. Edie Alfano-Sobsey, PhD, MT (ASCP); Regina Y. Petteway, MSPH; Lechelle Wardell, MPH; Petra Hager, BCS; Sue Lynn Ledford, RN BSN MPA

Prevalence and Impact of Asthma

Asthma is one of the most common chronic diseases of childhood, second only to dental disease. Data from the Child Health Assessment and Monitoring Program (CHAMP) Survey show that prevalence rates of asthma are highest in children aged 5-17 years, and approximately 1 child in 10 was living with asthma in North Carolina in 2011. [1] Prevalence rates for adults are slightly lower at 8.8%. [2] Prevalence rates of asthma in North Carolina vary with race or ethnicity and insurance status. Racial or ethnic minority populations and children covered by public insurance have higher prevalence rates of asthma as compared to white and privately insured populations [1].

Asthma has a significant economic and social impact. In the United States in 2010, asthma accounted for 439,000 hospital discharges, 1.2 million hospital outpatient visits, 2.1 million emergency department (ED) visits, 10 million physician office visits, and $56.0 billion economic cost in the U.S. [2] Asthma is the leading cause of missed days of school in North Carolina [3]

Asthma has a multi-factorial etiology including a growing evidence base of the importance of environmental exposures. [4] Thus, having a comprehensive approach to asthma management is important.

Community Care of North Carolina’s comprehensive

approach to asthma management

Community Care of North Carolina (CCNC) is a state-wide, provider-led primary care medical home and care coordination system that has been growing for the past 10 years. It is a private-public partnership with 14 networks covering all 100 NC counties in the state. It rests on the framework of Carolina Access Medicaid, a managed care program in which Medicaid recipients are linked to a primary care medical home. CCNC activities are added to that framework to further increase access to high quality, cost-effective, coordinated care. By helping providers take care of patients, CCNC has shown that it can improve health, reduce emergency department (ED) visits and hospitals admissions, and save money. Statewide, more than 5000 primary care providers, and more than 1.2 million Medicaid patients are part of CCNC. Community Care of Wake and Johnston Counties (CCWJC) is our local CCNC network and one of the three services programs administered by the Wake County Medical Society Community Health Foundation. Locally, more than 150 primary care practices and approximately 160,000 patients, including Medicaid, Medicare, Health Choice, State Employees Health Plan, and privately insured patients, are part of the CCWJC network.

Asthma management is one of CCNC’s statewide disease management initiatives and a key initiative within the activities of CCWJC. As with all disease management initiatives, the asthma initiative is based on nationally recognized evidence-based or best practice guidelines. Specifically, the National Heart, Lung, and Blood Institute Guidelines for the Diagnosis and Management of Asthma

published in 2007 inform the initiative. Metrics that align with the guidelines are developed and approved by the CCNC Network Clinical Directors and CCNC clinical staff members; when possible, these metrics align with national metrics. Measures developed for asthma include the percentage of patients with asthma who receive a continued care visit with assessment of symptoms; the percentage that undergo assessment of triggers; the percentage who receive a written management plan; the percentage with persistent asthma for whom controller medications are prescribed; the rate of asthma-related ED visits, and the rate of asthma-related hospitalizations.

Providers are given support and tools to foster high quality asthma care. Educational sessions and resources on best practice guidelines are available to practice staff and providers. Asthma symptom questionnaires are provided to facilitate assessment of asthma control. Asthma Management Plans and other patient education material are made available to practices to utilize with patients.

Clinician have access to robust patient information in the CCNC Provider Portal, including a dashboard view of patient data provided by the CCNC Informatics Center. Individual-level information helps guide care of a specific patient. For example, the medication fill history can inform the conversation about medication compliance. Practice-level data can foster population management. For example, practices can download a list of patients with asthma related care alerts which include detection of asthma-related emergency department visits, asthma-related hospitalizations, frequent fills of rescue medications, and no fills for a controller medications.

24 | OCTOBER 2013

Community Care of North Carolina’s Approach to Asthma Management

By Dr. Elizabeth Tilson


Quality Improvement specialists and support are available to foster continuous quality improvement activities and workflow processes within practices. Processes that may be addressed include how to integrate asthma management tools in to practice workflow, facilitate recommended visit frequency, document in electronic health records to meet Meaningful Use criteria of the Centers for Medicare and Medicaid Services, utilize data to inform the care of individual patients and populations, and utilize existing community resources to help with patient care (e.g. care managers, child care health consultants, school nurses). Data feedback is given to track progress and identify areas for improvement or the need for additional resources.

Finally, multi-disciplinary care managers including nurses, social workers, and pharmacists are available to work one-on-one with high risk patients. Providers can make direct referrals to local care managers in their networks. Connections to hospitals via either in-person presence of CCNC staff or Information Technology (IT) systems linkages can alert care managers when a patient is hospitalized or in the Emergency Department for an asthma related illness. As part of the IT linkage, Admission, Discharge, and Transfers information from 57 hospitals across the state allow for twice daily feeds of emergency department visits or hospitalization into the Informatics System. In addition, claims-based risk-adjusted analytics can predict which patients are likely to experience potentially preventable costs related to their asthma. Care managers can use this report to proactively reach out to patients and offer care management services.

The main goals of care management are to promote self-management of chronic diseases and to strengthen the link between patients and their providers, especially primary care providers. The local, on-the-ground, care manager staff allows for a wide range of care management activities

to achieve these goals. Care managers can work with families over the phone, but in addition, they can have in-person encounters with the families. They can accompany a patient to their medical appointments which can help the care manager understand the plan of care recommended by the provider and can help the family operationalize that plan of care. Care managers can provide extra asthma education on topics such as the physiology of asthma, triggers, symptom recognition, how and when to use medicines and delivery devices (e.g. spacers) and how to follow an Asthma Management Plan. In addition, care managers can make home visits to understand the social and environmental context in which the family is trying to manage a chronic disease. Home based environmental triggers can be identified and advice on how to mitigate those triggers provided. Barriers to accessing care, for example transportation, can be addressed. Organizational systems within the house to facilitate consistent chronic disease management, e.g. where to store medicines and where to post the Asthma Management Plan, can be developed with the family.

Local initiatives and collaborations

Local initiatives and collaborations further add to statewide activities, as exemplified by our local environmental asthma trigger assessment and mediation program. Strong evidence supports the effectiveness of home-based, multi-trigger, multi-component interventions with an environmental focus for children and adolescents with asthma in improving asthma symptoms and quality of life and productivity. [5,6] As such, Community Care of Wake and

Johnston Counties, in partnership with Wake County Environmental Services and Wake County Human Services, has been delivering a robust multi-disciplinary (i.e. Registered Sanitarian and Nurse Care Manager) home-based environmental trigger assessment and mitigation initiative. Data collection specific to this initiative shows an average of savings of $700 per patient secondary to decreased emergency department and hospitalizations. In addition, substantial decreases in network-wide asthma ED rates (40 visits/1000MM to 17 visits/1000MM) and asthma admissions rates (8.3 hospitalizations/1000MM to 1.9 hospitalizations/1000MM) have been achieved from 2003 to 2012. This collaboration received a 2013 Achievement Award in Health from the National Association of Counties. Other networks, including Northern Piedmont Community Care – Community Care Partners and Community Care of Lower Cape Fear are beginning similar activities to address environmental asthma triggers. The UNC Healthy Homes training is helping to spread these activities.

Quality MetricsChart review and claims based measures are used to foster continuous quality improvement initiatives within practices, networks, and the state-wide CCNC program as a whole. Improvements in all metrics have been achieved statewide and in our local network. Figure 1 shows [article continued on page 26]

statewide chart review measures, including the percentage of patients with documentation of at least one continued care visit with assessment of symptom control, trigger assessment, and provision of a written asthma management plan. An additional measure noting the percentage of patients with persistent asthma with documentation of a prescription of a controller medicine was added in 2011. This measure is the only one with a comparable national HEDIS benchmark and CCNC results show high rates of performance on this measure. In 2011, 93.6% of patients with persistent asthma were prescribed a controller medication. This percentage increased to 95.5% in 2012. These percentages exceed the 90th percentile for national 2011 HEDIS benchmarks for Medicaid Managed Care Organizations, which is 90.6%. Figure 2 shows similar improvement and high performance for our local network.

In early evaluations of CCNC’s asthma initiatives, two published studies determined sizeable decreases in hospitalization rates and Emergency Department use for asthma. An evaluation by the University of North Carolina’s Cecil G. Sheps Center for Health Services Research [7] showed substantially lower rates of asthma-related ED and inpatient admissions during the period 2000-2002 for Carolina ACCESS Medicaid patients who were enrolled

in CCNC than for those who were not. A subsequent study [8] showed a 16.6% decline in the rate of ED visits and a 40% decrease in the rate of inpatient admissions for CCNC enrolled patients with a diagnosis of asthma between FY 2003 and FY 2006.

While Emergency Department utilization rates have continued to rise for Medicaid recipients with asthma who are not enrolled in the CCNC program, rates have remained consistently lower within the CCNC program. Additionally, while asthma-related inpatient rates have remained steady for non-CCNC enrolled recipients, inpatient rates have continued to decline for CCNC enrolled patients. (Figure 3) In 2012, the ED visit rate was 38% lower and the inpatient admission rate was 65% lower for Medicaid recipients with asthma who were enrolled in the CCNC program compared to those who were not enrolled (Figure 4). Figure 5 depicts the sustained decline in both asthma-related emergency department visits and hospitalizations for our network.

Future direction and emerging initiatives

To further facilitate population management, an asthma disease registry is under development as a resource for practices engaged in asthma Quality Improvement work. This registry will couple claims data,

such as emergency department visits and medication fills, with EHR clinical data, such as asthma management plans and allergy and trigger management. Initially, the registry will be accessed through the CCNC Provider Portal, and claims and clinical information will be provided by the North Carolina Health Information Exchange. A next step will be to integrate all the information into a single view and to develop an interactive dashboard tool for the asthma registry that will enable a user to manipulate data related to asthma and asthma care in real time. Future capabilities would also include the integration of care alerts to prompt action for asthma management. The registry will also support asthma-related reporting requirements to help practices meet the meaningful use criteria.

Another emerging initiative involves exploring effective ways to disseminate Shared Decision Making (SDM) patient-centered tools that have been shown to produce positive changes in asthma outcomes.[9,10] An Asthma SDM toolkit that includes: (1) a tool to assess baseline asthma control; (2) a guide for eliciting the patient’s goals for treatment priorities; (3) asthma educational materials; (4) a tool to guide the negotiation process to jointly develop a treatment regimen that accommodates the patient’s goals and preferences; and (5) an asthma action plan that has been developed by a Carolinas

25 | OCTOBER 2013

Healthcare System team and been shown to improve asthma outcomes [11]. Through a grant from the Patient-Centered Outcomes Research Institute and in partnership with Carolinas Healthcare System, a novel dissemination process to spread the Asthma SDM Toolkit to practices will be tested. Facilitators will work with select practices to individually tailor the Toolkit into the practice’s unique circumstances. Quantitative outcomes data (e.g. ED, hospital, outpatient clinics, and pharmacies) as well as quantitative data (e.g. provider and patient satisfaction) will be compared with intervention practices and controls. The knowledge gained from this initiative and the partnerships formed between practice-based research networks and CCNC practices will facilitate dissemination of effective shared decision making patient education materials into other CCNC practices statewide. §

Acknowledgments Support for Dr. Tilson’s work as a Medical Director for CCNC is funded largely by the State of North Carolina via North Carolina Medicaid. The author has no relevant conflicts of interest that should be stated.

References: 1. North Carolina Center for Health Statistics. 2011 North Carolina Statewide Child Health Assessment and Monitoring Program (CHAMP). Asthma. Does (CHILD) still have asthma? North Carolina State Center for Health Statistics web site. http://www.schs.state.nc.us/schs/champ/2011/ASM_CUR.html.2. American Lung Association, Epidemiology and Statistics Unit, Research and Program Services Division. Trends in Asthma Morbidity and Mortality, Table 12, September 2012. http://www.lung.org/finding-cures/our-research/trend-reports/astham-trend-report.pdf 3. North Carolina Department of Health and Human Services, Division of Public Health, Women’s and Children’s Health Section, School Health Unit. North Carolina Annual School Health Services Report for Public Schools: Summery Report for School Nursing Services, School Year 2006-2007. Ocotber 2007. www.nchealthyschools.org/docs/data/reports/2006-07eoy.pdf 4. National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Washington, DC: US Department of Health and Human Services: 2007. http://www.nhlbi.nih.gov/guidelines/asthma/index.htm5. Asthma Control: Home-Based Multi- Trigger, Multi-component Environmental Interventions. The Guide to Community Preventive Services. http://www.thecom-munityguide.org/asthma/index.html, 6. Crocker DD et al. Effectiveness of Home-Based, Multi-Trigger,

Multicomponent Interventions with an Environmental Focus for Reducing Asthma Morbidity. A Community Guide Systematic Review. Am J Prev Med 2011;41(2S1):S5–S32.7. Ricketts TC, Greene S, Silberman P, Howard HA, Poley S. Evaluation of Community Care of North Carolina Asthma and Diabetes Management Initiatives: January 2000-December 2002. North Carolina Rural Health Research and Policy Analysis Program, Cecil G. Sheps Center for Health Services Research. The University of North Carolina at Chapel Hill. 20048. Community Care of North Carolina Asthma Disease Management Program Summary. Raleigh, NC: CCNC; 2007. https//www.communitycarenc.com/media/related-downloads/asthma-management.pdf. 9. van der Meer V, Bakker MJ, van den Hout WB, Rabe KF, Sterk PJ, Kievit J, Assendelft WJ, Sont JK, Group SS. Internet-based self-management plus education compared with usual care in asthma: a randomized trial. Ann Intern Med 2009;151:110-20.10. Wilson SR, Strub P, Buist AS, Knowles SB, Lavori PW, Lapidus J, Vollmer WM. Shared Treatment Decision Making Improves Adherence and Outcomes in Poorly Controlled Asthma. Am J Respir Crit Care Med 2010;181:566-77.11. Tapp H, Taylor Y, Kuhn L, Dulin M. Evaluating Asthma Management in primary care: Impact of the chronic care model and shared decision making on out-comes for poorly controlled patients with asthma. . In: North American Primary Care Research Group Annual Conference. New Orleans, LA; 2012.


Alliance Medical Ministry and Urban Ministries are Striving for

Better Health OutcomesBy Megg Rader & Peter Morris, MD

According to the recently published Wake County Community Heath Needs

Assessmenti, uninsured people are 1) less likely to receive medical care; 2) more likely to die early; and 3) more likely to have poor health status. Access to quality healthcare is critical for this vulnerable population to achieve health equity and increase the quality of a healthy life. Alliance Medical Ministry and Urban Ministries of Wake County have changed outcomes for thousands of uninsured adults in Wake County.

More than 123,000 people in Wake County are uninsured. Alliance Medical Ministry (AMM) and Urban Ministries Open Door Clinic (UM ODC) provide access to quality affordable healthcare to this vulnerable population in our community of which 82% of these people live in working household. AMM specifically serves these working uninsured adults. For a small fee based on a sliding scale, patients receive time with physicians, lab work, medications, education, bilingual services, counseling and 24- hour coordination of services.

Similarly Urban Ministries Open Door Clinic (UM-ODC) serves working and non- working adults with incomes less than 185% of the Federal Poverty Level. For a nominal fee, patients receive time with physicians, lab work, medications, education, and bilingual services. Patients also have access to Urban Ministries on- site food pantry. Patients at both clinics are not eligible for Medicaid or other insurance. Patients are self-refer and are referred from area emergency departments, the Health Department and social service organizations.

Both organizations have

a focus on chronic disease management issues including diabetes, high blood pressure, high cholesterol, COPD and obesity. To improve the long- term health outcomes for patients with chronic disease, AMM and UM ODC seek to address both educational and behavioral changes necessary to promote lasting change. AMM offers quarterly diabetes educational sessions to both English and Spanish speaking patients and has successfully piloted a Diabetes Group Visit Program. The group visit is an extended doctor’s office encounter where not only physical and medical needs are met, but educational, social and psychological concerns can be dealt with effectively.

UM ODC emphasizes health education to give patients the tools and resources they need to better understand and actively participate in the management of their chronic illnesses. Patients who commit to AMM or UM ODC as their primary care medical home improve their disease control. Eighty percent report “feeling better,” missing less days of work, and avoiding emergency room visits and hospitalizations in the previous year.

Disease management goes beyond the practice doors and outside into the community gardens, collaborations with the Interfaith Food Shuttle nutrition programs and the UM Food Pantry. Through these initiatives patients have access to fresh fruit and vegetables; control over their healthy food choices; and gardening education, skill building, opportunities for physical activity and family development.

Addressing mental health needs is critical to improving health outcomes.

AMM’s Pastoral Care and Counseling Program helps patients

deal with the stress that impacts their daily lives and to identify additional barriers facing patients that may not be readily discussed in clinic visits. Both AMM and UM ODC have collaborated with SouthLight to co- locate a mental health clinician on site to screen, intervene, refer, and treat. Patients are connected to non- clinical community resources as well.

AMM and UM ODC continue to look for innovative ways to overcome the healthcare barriers of our patients and increase capacity to serve a growing number of uninsured adults. Community partnerships—and community resources—are critical to meet unmet needs. Wake County is a generous community, and thousands give their time, treasure and talent to help our neighbors live healthier lives, miss less work, spend quality time with their families and contribute to the quality of life in our community. We welcome the opportunity to talk to you more about these organizations, and how you can get involved by sharing your time and resources. §

Contributors: Megg Rader, Executive Director, Alliance Medical Ministry, www.alliancemedicalministry.org, [email protected], 919- 250-3394

Dr. Peter Morris, Executive Director, Urban Ministries of Wake County, www.urban.org, [email protected], 919-836-1352

iWake County Government. (2013). 2013 Wake County Community Health Assessment. Raleigh, NC: Giddings International School of Public Health, UNC, Chapel Hill, NC. www.wakegov.com/humanservices/data


Membership in the Wake County Medical Society is one of the most important and effective ways for physicians, collectively, to be part of the solution to our many health care challenges. A strong, vibrant Society will always have the ear of legislators because they respect the fact that doctors are uniquely qualified to help form health policies that work as intended. It’s hearteningto know the vast majority of Wake County physicians, more than 700 to date, have chosen to become members of the Wake County Medical Society.

Member’s dues also help support the Society’s three community service programs: Community Care of Wake and Johnston Counties, Project Access of Wake County and the Capital Care Collaborative. We need your support of these services programs, which are serving the disadvantaged in our community in the name of physicians in Wake County, through the Wake County Medical Society.

The Wake County Medical Society (WCMS) is a 501 (c) 6 nonprofit organization that services the licensed physicians and physician assistants of Wake County. Chartered in 1903 by the North Carolina Medical Society.

Become A MemberWake County Medical Society

JOIN TODAY!Wake County Medical Society

A portion of your dues contributes to the volunteer and service programs of WCMS. Membership is also available for PA’s. There is even an opportunity for your spouse to get involved by joining the Wake County Medical Society Alliance.

To become a member of the Wake County Medical Society follow link to our website and complete the online application or contact Pam Carpenter, Membership Manager at [email protected] or by phone at 919.792.3623

wcpm october 2013

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