Chronic disease prevention and management in central coastal CA

DiversityRx – Website devoted to better healthcare communication…Enjoy!



Summary of important primary care articles for 2010 from Journal Watch

I was reviewing my many electronic data inputs recently and found this nice summary (link at end of post). Wonderfully concise report by way of a nice, neighborly fifteen minute podcast discussion between medical columnist Joe Elia and Dr. Danielle Scheurer, from Medical College of South Carolina in Columbia. The final three articles about informed consent and health “quality” in the U.S. are interelated, in my opinion.

http://www.podcasts.jwatch.org/index.php/podcast-111-a-look-back-on-2010/2010/12/17/ Read more…

New idea improving the Workmen’s Compensation Care process

This op-ed piece about an effective program was submitted by our new 28th CA District Assemblyman, Luis Alejo, D-Watsonville


Monday Pulse 03.10.08 – Redux 03.10.11 Disparities/Inequities/Inequalities

This 3 year old edition of my former weekly staff newsletter dealt with cuts to then upcoming cuts to a CA state funded program called EAPC, Extended Access to Primary Care.  As the budget problems in CA became more severe, many cuts were enacted to various health and human service program.  This was one program that allowed reimbursement for services to the uninsured.  As of today it is completely gone.  Additionally, I reported from the final Health Disparities Collaborrative Western Cluster, which included disparities work partners as far west as Hawai’i and Guam.  The HDC is a HRSA project unifying efforts to coordinate governmental healthcare agency work throughout the nation to address the inequities, or its euphemism, disparities in health outcomes.   These meetings ended up being a last chance for health center staffs to meet, socially network and plan ongoing collaborations as the HDC efforts were whittling down.  Despite the disappearance or the HDC’s support, important lessons about process were learned at the convenings.  Most useful to my practice, in an ongoing sense, has been the exposure to the Chronic (Planned) Care Model by Ed Wagner and the importance of its constituent pieces. Particularly the necessities of self management of illness and data base registry to track experience and monitor for better outcomes. Enjoy!

Monday Pulse     03.10.08

“The only certain thing in today’s world is change”-a wise man

 “Catch the Latest Wave in Healthcare!” California Primary Care Assn. Health Disparities Collaborative Conference Recap.

I attended this conference in Anaheim at the end of February.  It is scheduled as the Region’s Final HD Collaborative meeting, which I found rather sad.  One has to wonder what is the future of organized efforts to eliminate disparities in healthcare.  Surely, any efforts at cost reform must consider the effects of poverty on access to care, and the consequences of denied access.  In any case, many creative and resourceful  responses to several concerns troubling our population base were presented as possible solutions.  I was most impressed by the spark stimulating these folks, especially in the worrisome environment of Community Health Center theses days.  Many examples were presented to solve the problems of increasing quantity demand of visits, of understanding options for best documenting quality with the specter of Pay for Performance (P4P) lurking, and most interestingly addressing obesity through community collaboration models. 

The Chronic Care Collaborative Model (see http//:www.healthdisparities.net) offers a schema to address the clinical collaborations.  I was amazed by the enthusiasm and organization of the presenters who were guided by the Model.  But mostly, at the end of the weekend I was wondering about motivation, how is the spark of creativity awakened.   In working with my patients, I particularly am familiar with the Hierarchy of Needs model because of its developmental nature.  That being, one can work to set a strong foundation at the base of the hierarchy then build upon those strengths.  Contrary to many of our patients, we are functioning at a much higher level within the Hierarchy.  As we begin our careers here we’re probably already at the mid-level of belongingness, hopefully, with support, mentoring and experience we can quickly vault to satisfy our esteem needs.  We do understand mastery of all the clinical and administrative skills needed for mastery, at large healthcare institutions, can delay this vault.  I feel that part of the answer here is prioritization, not losing sight of the forest for the trees.  I also admit a tension exists, especially amongst us perfectionists.  There is a lot of external and internal pressure to scale each tree correctly.  To get to the highest level within the Hierarchy, self-actualization, where the much needed creativity resides, requires that bigger picture perspective, as well as practice (dreaming with action).  Why did I go into medicine in the first place?  Why primary care?  Isn’t a Community Health Center an ideal resource to improve healthcare options for a community or population?  If not, what’s needed?  I do not think these are musings of a Medical Director alone.

One of the most interesting examples of a community approach toward remedying childhood obesity in San Marcos, CA, that began with a lunch table discussion (dream to goal) between the staff pediatrician, an FNP, and some WIC/CPSP staff.  The initial funding for their projects came from recognizing they could recoup more from CPSP nutrition counseling visits and leverage that for services and efforts off-site, collaborations.  The conference highlighted story after story like these.

Extended Access to Primary Care Program. As we heard about last week the EAPC program is out of funds for FY 2007-08.  As it exists now, this under funded state program is clearly in need of management or re-evaluation.  The management changes involve more eligibility screenings, collections etc., but clearly there is a pressure for case management as well.  As we found out at the meeting last week, some data does exist, mostly coming from Quest and Medical Manager, yet Central Coast Alliance forHealth did send us some lab utilization data from last year.  Unfortunately, Quest data for our EAPC patients does not include diagnosis codes.  So to stratify cost per patient per provider cannot be further examined by diagnosis codes.  I admit this is a frustration, but I do see some useful recommendations forthcoming, regarding limiting certain high cost laboratory studies.

For example recommending the Comp. panel over the individual tests, requiring prior authorizations for HPV, H. Pylori testing and urine microalbumin, may be initial recommendations, although no process has been developed yet on how to effect these changes.  Be assured that any of my individual discussion with providers will be with the intention of education/clarification not punitive.  

            On a related note, I have submitted a list of combination antihypertensive drugs, to our consultant pharmacist for consideration.  Additionally remember to continue using the Walmart, Costco, Target formulary programs as much as possible.  Keep in touch with your PSM’s about any changes in these programs and remember that EAPC meds are now subject to a $5 copay.

Call providers. Pedro Moreno is working with CSVS and others to try to get help with his call obligations for next year.  For a while he is looking to step away from call, that would leave a large number of calls open for the rest of this year.  Reimbursement is available for those call for any substitutes.  The drawback at this moment is investigating our malpractice coverage for those calls as they involve covering the Internal Medicine service as well.  I will keep informed as things reveal.

Diabetes Collaborative Health Fair Reminder. Once again CSVS will be offering a Diabetes Collaborative Health Fair on March 27th, 2008 at El Sausal Middle School, beginning at 6:30PM.  Committed participants so far are, Dr. Alan Smith, Jeanette Cisneros M.D., Chesney Hoagland-Fuchs, Lupe Covarrubias from WIC, Ruth Ramirez and more.  We plan on an organizational meeting Tuesday night 3/11/08, so contact me prior with any ideas, desires to volunteer, etc.  It’s exciting and hopefully foundational for future community collaborations around obesity prevention and chronic disease.

Recruitment. I hope to have some good recruitment news next Pulse.  We have on the line a very experienced clinician relocating from Hawai’i.  He’s previously worked with Jimmy there.  If he were to sign on, there may be some related CSVS shifting that could benefit all sites, at least during the summertime PTO crunch.  I hope to get a provider PTO August and Holiday season survey out this week, which you can return to me by interoffice.  This will help plan better for “crunch time recommendations.

Hasta Luego, next Pulse will be 03.24.08, as next week I’ll be celebrating my 23rd anniversary with a day off.


Health Disparities Collaborative  http://healthdisparities.net

Monday Pulse 02.11.08 -Redux 02.11 Teamwork efficiency through Kaizen principles and effective communication

Monday Pulse

02.11.08 (Redux 2011)

Random Acts of Kindness Week 2011 begins on 02.14.11 and info can be found at this web url  http://www.randomactsofkindness.org/  One of the hospitals I where I work has just begun a team building campaign where employees are encouraged to do an unexpected favor for a workmate, a random act of kindness.

    Additionally this edition of my newsletter is from 3 years ago when I was actively medical directing in my previous position.  I was involved in a process of seeking and teaching efficiency in our clinic “gembas” or workplaces, to use a Japanese Kaizen term.  It’s clear that the transition to highly effective teams is a project and I was trying to teach the elements of teamwork to staff.  I had great help, including an intuitive Director of Nursing who got it and a motivated Psych D. who I often collaborated with.

Mostly the three of us were trying to coach up the future team leaders.  As we move towards Patient Centered Medical Home models, it’s clear that licensed practitioners will have to learn to share and delegate responsibilities to others of lesser training.  Confidence in each other will be a requirement, and this will necessitate a commitment to ongoing training (and remediation) and accountable supervision.  Two skills physicians, in my estimations, often lack the patience and a desire for when it comes to unlicensed staff. My Desktop updates below were an effort to breakdown teamwork into its foundational components and encourage staff to develop them.

     The focus here is on workplace Kaizen’s initial steps environmental management and that all important piece of teamwork: effective communication.

            Greetings! This week marks the 13th annual Random Acts of Kindness Week, sponsored by the Random Acts of Kindness Foundation.  This foundation is a non profit, that represents the US at the World Kindness Council.  The words “Random Acts of Kindness” are a response to the all-too-commonly heard phrase “random acts of violence”.  The other emphasis here is on the word random. Ideally its emphasis will encourage us to look beyond our circle of friend and family, as recipients of kindness.  The foundation believes “these completely unexpected gestures to or from total strangers have the most impact on our lives”.  Sample ideas: invite someone new to lunch; get to know new hires;  leave a treat on the desk of a co-worker you may not get along with; write, draw or make an encouraging card for someone experiencing difficulties; give a compliment.  In this vein I am totally inspired by a patient of mine, Deborah Aguilar.  I saw her in Saturday’s paper planting a tree in Closter Park to honor victims of violence.  After her son was killed in a drive-by shooting in 2002, she started meeting with other families who had lost loved ones to violence, and this effort evolved into the community support group “A Time for Grieving”.  The group meets regularly, at Sunrise House in Salinas, and their contact # is 443-0480, in case you know of a family in such need, or if you want to contribute time or funds for a plaque on the site nearby the bench and lighting the city is providing.

            February Clinicians’ Meeting Desktop Updates (leftovers).  # IV Kaizen/Pursuit of Flow.  In tracking the holy grail of flow through Kaizen, it’s clear that there are foundational undergirdings that are necessary before the other disciplines can take hold.  I believe two crucial ones are sound communication and management of the workspace (remember the 5S’s, sort, set in order, shine, standardize, start over).  A personal goal is to 5S my desk, then with those benefits in place, hopefully export with a 5S office wide initiative.  In terms of communication, the staff development here continues.  During our meeting Thursday morning, Vicki and Linnea were continuing their effective communication skills building practicum with MA staff. They learned about the relationship between the intended message and how it can be nuanced by tone and other non-verbal cues like body language, emotionality and contexts.  The presentation was very similar to the first chapter in my Intro to Org. Communication textbook.  This describes the process of communication involving a sender and a receiver, and a properly encoded message being sent through the correct channel.  Unfortunately confounders exist and are referred to as noise (interference), either external, physiologic or psychologic.  In my experience a major cause of workplace noise is psychologic (stress, emotions).  When you get a chance touch base with staff about how the last communication workshop went; consider sharing what you’ve learned over the years about reading patients’ body language.

            In terms of our (providers/leaders) own communication my Kaizen guru, Daniel Goleman says “…star teams can use intellectual battle to upgrade the quality of decisions, provided they keep the debates free of the emotionality that might alienate or sabotage commitment to the decision by some team members.  The key lies in emotional competencies such as self-awareness, empathy and communication–that is, how well team members argue”…  Food for thought.  Hasta la proxima vez!

Cultural Competency: US Apologizes for Syphilis Study in Guatemala, 1946-1947

I totally missed this report from the NYT during the fall of 2010.  Apparently former Tuskegee Study researchers were in their waning days in the States and they still had many unanswered questions.  Some remaining Public Health Service work apparently had to be outsourced.  This report must give us insights into what the situation must have been like for the Tuskegee patients, as the cheif investigator, Dr. John Cutler, was a Tuskegee Study researcher.  Interestingly as these studies were getting started in Guatemala, the Helsinki Declarations were being honed down in Europe, ultimately recommending the Nuremburg Code of ethics for prisoner and POW (and really human) medical care.

See the whole archived article at:  http://www.nytimes.com/2010/10/02/health/research/02infect.html?_r=1&ref=donaldgjrmcneil

Cultural Competency, Self awareness: What up with our white coats?

From medical blogger Ellen Schattner, M.D. Consider a physician’s attire as a mode of non-verbal communication.

We physi­cians might make assump­tions about what patients want us to look like, but what does the evi­dence say?

A cross-sectional survey in Tennessee a few years ago found that patients prefer family physi­cians who wear white coats (1). Another study in a South Carolina internal med­icine office found that patients “over­whelm­ingly” pre­ferred physi­cians in white coats (2). A Northeast Ohio OB res­i­dency found sim­i­larly; patients pre­ferred a white coat and pro­fes­sional dress to scrubs (3). A quick PubMed search pulls up the same theme over and over: the patients studied have more trust in, and comfort with, physi­cians who wear white coats…


Code for compassion?

This link comes from Paul Levy, a NEJM blogger and former hospital administrator, who wonders why not compassion anymore? This url leads to blogentry that attempts to explain why not and is followed by a robust comments section.


Culture of Medicine: Compassion

In this post, Wendy Harpham, a medical blogger, physician, cancer survivor and mother of three speaks to doctors’ socialization to sometimes be dispassionate. I have wondered often why we physicians are not required to undergo counselling as part of out training, as psychologic counsellors do. If we did, I believe a lot less harm would be done.


FDA may ease access to lap-band surgery – SF Chronicle 01.26.11

     I read the below attached article in today’s SF Chronicle.  Apparently the FDA is poised to lower the BMI threshold recommendations for the obesity surgery known as “lap-banding” to BMI of 35 for obese individuals and 30 for obese individuals with diabetes, hypertension or other heart disease. This represents a significant change. The article points out that the panel’s request for the change came from “one of the main manufacturer’s of a lap band device.”  A surgeon/medical director at California Pacific Medical Center who states the recommendations might seem aggressive but “it’s quite low risk for surgery.”  Not one source in the article describes any studies supporting the new recommendation.  Although the American Society of Bariatric Physicians questions the proposed changes, suggesting that the new guidelines would encourage people to “jump directly to surgery”.  Foregoing or bypassing (excuse the pun), the educational requirements that often lead to enlightened wellness.  The co-founder of the Center of Weight and Wellness at UCB frankly states, “It’s not an appropriate solution”.
     The article offers ths website to check your BMI: www.nhlbisupport.com/bmi
As a practitioner trying to teach wellness, I find the whole FDA process in this regard, very frustrating.  Additionally irritating in that one of the tenets of health care reform going forward, as proposed by the Administration, is evidence- based medicine. That is healthcare decisions should be based on review of the best available research studies, ideally not derived from partial industry reports.  The procedure presently cost between $15,ooo and $20,000, and insurers usually covers based on FDA guidelines.

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