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North Carolina Hospitals Honored for ‘Treating Their Neighbors’


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Seven rural North Carolina hospitals receive national recognition for excellence.

By Taylor Sisk

These are trying times for the state’s rural hospitals. Like their counterparts across the nation, they’re facing reduced reimbursements; aging, declining populations; and difficulties recruiting health care professionals.

But the news isn’t all bad.

On Monday, iVantage Health Analytics released its annual list of the nation’s Top 100 Critical Access Hospitals and Top 100 Rural & Community Hospitals. North Carolina was recognized with three hospitals on the critical access list and four in the rural and community category.

iVantage provides analytics and decision-support tools to health care providers. In compiling its Top 100 lists, it weighs more than 70 performance measures, including quality, outcomes, patient satisfaction, safety and cost.

The critical access hospitals honored are all in the western region of the state: Angel Medical Center in Franklin, Ashe Memorial Hospital in Jefferson and Transylvania Regional Hospital in Brevard.

Map courtesy NC Hospital Association

Map courtesy NC Hospital Association

The four rural and community hospitals selected are Carteret General Hospital in Morehead City and Sentara Albemarle Medical Center in Elizabeth City, both on the coast; Johnston Health in the Piedmont town of Clayton; and Northern Hospital of Surry County in Mount Airy, 45 minutes northwest of Winston-Salem.

North Carolina’s rural hospitals routinely ascend to “Best Of” status in national polls. But Jeff Spade, executive vice president of the North Carolina Hospital Association’s NC Center for Rural Health Innovation and Performance, cautioned in an interview with North Carolina Health News earlier this year that it’s not something that should be taken for granted.

Support from the federal and state governments is critical, Spade said. The payoff is neighbors caring for one another.

‘Time bomb’

The Top 100 ratings come three months after the release of iVantage’s “2016 Rural Relevance: Vulnerability to Value” report, which found 673 of 2,078 rural hospitals across the country are “vulnerable or at risk for closure.”

Of those 673, two-thirds are critical access hospitals. CAHs are hospitals with fewer than 25 beds and more than 35 miles from the next nearest hospital. They’re required to provide around-the-clock emergency care services.

“We’re in charge of the whole health care continuum,” says Cathy Landis, president and CNO of Transylvania Regional. Photo credit: Taylor Sisk

Cathy Landis is CEO and chief nursing officer of Transylvania Regional, selected a Top 100 Critical Access Hospital by iVantage Health Analytics. Photo credit: Taylor Sisk

There are 1,284 CAHs in the country. North Carolina has only 21 – three of which made that Top 100 list.

But CAHs are under particular duress.

Just prior to the release of the “Rural Relevance” report, federal Department of Health and Human Services Sec. Sylvia Burwell announced a plan calling for 85 percent of all hospital Medicare reimbursements to be tied to performance by 2016, and 90 percent by 2018.

Medicare is typically these hospitals’ largest payer, and CAHs now receive cost-based reimbursement from the program. That means CAHs receive payment based on 99 percent of allowable costs, whereas non-CAH hospitals are reimbursed based on a fixed rate – often lower than their costs – as determined by the federal Centers for Medicare and Medicaid Services.

iVantage’s “Rural Relevance” report called the shift to the value-based payment model a “financial time bomb” for these hospitals.

In the neighborhood

Spade believes the state’s critical access hospitals can compete in this value-based world. Health care costs are generally lower in rural areas, he pointed out, in part because of generally lower overhead. And small hospitals, he said, are well capable of delivering in quality of service and patient satisfaction.

“They can deliver in the new world of health care, the value that’s being sought,” Spade said, “but they won’t get there if they’re not resourced for it – and that would be a shame.”

When you work in a critical access hospital, he said, “you’re working and living with your neighbors, friends and colleagues.” The federal and state government should therefore provide resources “to ensure the value rural North Carolina [communities] can bring to their local low-income populations.”

These communities can succeed, Spade said, through the transformation to a focus on population health based on keeping people out of the hospital. But, he said, they’ll need assistance with, for example, implementing health IT and other support systems, and with recruiting health care professionals.

“It can be done, but we’ve got to be wise about it,” Spade said. “We’ve got to think about it and we’ve got to resource it.”

See you in church

Cathy Landis, CEO and chief nursing officer of Transylvania Regional, one of the three North Carolina critical access hospitals selected to this year’s Top 100, echoed Spade’s observation about the importance of a hospital to a small, rural community.

This year’s honor is nothing new for Transylvania Regional: The hospital has made it into iVantage’s Top 20 for three consecutive years, and Landis said the foundation of its success “is absolutely the passion and community commitment.”

One of the hospital’s orthopedic surgeons once told her that it was really quite simple: If he’s going to operate on your hip and then see you two weeks later in church, he’d darned well better feel a total commitment.

“It’s a heightened commitment, I think,” Landis said, “just because you’re treating your neighbor.”

This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina.

Occupational Therapists Advocate for Patient Choice and Access to Care


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By Rose Hoban

After Justin Richard sustained a spinal cord injury in 2003, he spent three months in a rehabilitation facility, re-learning how to do the basics.

Occupational therapists Greg Smith, Anna George, Tony Leo and Lindsay Voorhees (back) and Justin Richard and Lauren Deisenroth (front) spent a day at the General Assembly last week, talking to Senators about passage of HB 683. Photo credit: Rose Hoban

Occupational therapists Greg Smith, Anna George, Tony Leo and Lindsay Voorhees (back) and Justin Richard and Lauren Deisenroth (front) spent a day at the General Assembly last week talking to senators about passage of HB 683. Photo credit: Rose Hoban

“Learning to reuse my arms and hands to perform everyday tasks, whether it was getting dressed in the morning or cooking in the kitchen or going grocery shopping,” said Richard.

“My main concern was getting back to school, getting back to work, getting back to the community … and being a productive member of society.”

During that process, Richard said occupational therapy was perhaps the most important part of his rehabilitation process.

Now, more than a decade after his injury, Richard plays quadriplegic rugby and uses a hand bicycle for exercise.

And he works as an occupational therapist.

Richard knows the value of having someone who understands his needs working as an occupational therapist. So he came with other therapists to the General Assembly last week to ask lawmakers to greenlight HB 683, which would give patients their choice of therapists.

The therapists were also asking lawmakers to give OT more consideration as they reform Medicaid.

Too few

If physical therapy is the process of teaching someone how to use their muscles, occupational therapy is the process of teaching someone with an injury what to do with those muscles: cooking, typing, dressing, toileting.

“It’s great that you can walk, it’s great that you can balance, and physical therapists work on those muscles,” said Amber Ward, the immediate past president of the North Carolina Occupational Therapy Association. “But are you going to walk around dirty and naked? You need to have those functional things to be able to help yourself.”

North Carolina’s Medicaid program limits the number of therapy visits a patient can receive once they leave the hospital: Someone like Richard, who has a spinal cord injury, only gets 24 visits combined from physical and occupational therapists. The occupational therapists said that’s not nearly enough.

“If a client needs a wheelchair or an assistive device, a lot of times OT clinics and referral sources won’t even do the evaluation,” because of the Medicaid restrictions, said Tony Leo, who was also visiting with lawmakers. Leo works with patients who have complex needs.

“We have to send the clients out of their home, we have to send them long distances to get the evaluations that they need – that are mandated by Medicaid – to provide the equipment, which is an access problem.”

And for people like Richard, Medicaid only provides a new wheelchair every five years. Waiting that long might mean a chair no longer fits right, creating pressure sores. Those pressure sores can quickly become serious, leading to hospitalization. An infected pressure sore can kill a patient, as happened to film star Christopher Reeve.

And Leo said doctors are not trained to do the assessments to fit a chair correctly.

“Doctors hate completing wheelchair evaluations; it’s hard, it’s confusing, it’s time consuming,” he said. “I do a lot of education for the physicians, how to navigate what’s needed documentation-wise … to actually qualify and get the equipment for the clients. That’s half the battle.”

Choices

The other thing the occupational therapists talked to legislators about is a bill that would allow patients to choose their occupational therapists.

Currently, patients can choose their doctors, physical therapists and other therapists within their insurance networks; HB 683 would add occupational therapists to that list. An analysis by the legislative Fiscal Research Division found the bill would have no cost to the state.

The bill made it through the House in 2015, but has been in the Committee on Rules and Operations of the Senate, a committee where many bills are sent to languish or die.

UNC-Chapel Hill OT student Anna George explained that many occupational therapists specialize, say, in working with brain-injury patients or patients who have orthopedic injuries or with kids with cerebral palsy.

“There’s different specialties,” Leo added. “You don’t want a pediatric OT treating an adult neurology patient.”

“The client should have the right to go to whoever they want and is most appropriate.”

 

HHS Acts To Help More Ex-Inmates Get Medicaid

In states that have expanded Medicaid under the Affordable Care Act, prisoners are eligible for the program once they’re released.

By Jay Hancock

Kaiser Health News

Administration officials moved last week to improve low Medicaid enrollment for emerging prisoners, urging states to start signups before release and expanding eligibility to thousands of former inmates in halfway houses near the end of their sentences.

Health coverage for ex-inmates “is critical to our goal of reducing recidivism and promoting the public health,” said Richard Frank, assistant secretary for planning for the federal Department of Health and Human Services.

Advocates praised the changes but cautioned that HHS and states are still far from ensuring that most people leaving prisons and jails are put on Medicaid and get access to treatment.

Photo courtesy Wikimedia Commons

Photo courtesy Wikimedia Commons

“It’s highly variable. Some states and jurisdictions are having a lot of success” enrolling ex-prisoners, said Kamala Mallik-Kane, a researcher at the Urban Institute who has studied the process. “Others of them have initiatives in place that aren’t reaching the kinds of numbers that are making a dent.”

The 2010 health law made nearly all ex-prisoners eligible for Medicaid in states that chose to expand the state and federal insurance program for the poor. Many welcomed the chance to cover a group with high rates of chronic disease, mental illness and substance abuse problems.

But prisons and jails, burdened with ineffective computers, understaffing and complicated Medicaid enrollment procedures, have been slow to sign up released inmates.

Federal and state prisons let out more than 600,000 people a year. Millions more cycle through jails. But a study published in Health Affairs found prisons and jails nationwide enrolled only 112,520 emerging inmates between late 2013 and January 2015.

In Maryland, often cited for progressive social policy, the prison system is enrolling fewer than one in 10 released inmates, Kaiser Health News reported this week.

Much of HHS’ guidance repeats existing policy, reminding states that those on probation or parole are eligible for Medicaid and urging states to keep prisoners’ names in the Medicaid computers while they’re locked up. (That eases re-enrollment.)

Inmates are generally ineligible for Medicaid while incarcerated. Prison and jail medical systems care for them.

HHS is “providing encouragement and a nudge” to states to improve sign-ups as well as money to upgrade enrollment computers, said Colleen Barry, a professor at the Johns Hopkins Bloomberg School of Public Health who has studied ex-inmate enrollment. “They understand that this is a technology issue.”

Making up to 96,000 halfway-house inmates eligible for Medicaid is new policy, designed to connect people with care before they’re fully released. Prisoners often move to halfway houses or home detention near the end of their terms, closely supervised but frequently allowed to shop, apply for jobs and see a doctor.

Under the new policy, “if you have a fair amount of freedom of movement” in a halfway house, “you’re not considered an inmate” for Medicaid purposes, said Sarah Somers, an attorney for the National Health Law Program, an advocacy group. “That will be very helpful for a lot of people who are trying to transition out of incarceration.”

Nathan Sharpe recently spent two months in a home detention program in West Baltimore between leaving prison and being fully released. He wanted to get a checkup to make sure there was no lasting damage from a stabbing he received last summer in Maryland’s Jessup Correctional Institution.

But he had to wait until home detention ended last week to be covered by Medicaid, he said.

“That helps a lot” if people like him could get on Medicaid after they first leave prison, he said. “People can get the health care they need sooner. I’ve been out a week now and I still haven’t been able to see a doctor because I don’t have my card.”

Ex-inmates have extremely high rates of HIV and hepatitis C infection, diabetes, mental illness and substance abuse problems. They are especially vulnerable after they leave the prison medical system and before they connect with community doctors.

One study in Washington state showed that ex-inmates were a dozen times more likely to die than the general population in the first two weeks after their release.

Immediate Medicaid coverage “can mean the difference between life in the community and recidivism and even life and death,” Michael Botticelli, the White House’s director of national drug-control policy, told reporters.

HHS has been urging states to enroll ex-inmates in Medicaid for years. But the Affordable Care Act’s Medicaid expansion made many more of them eligible for coverage, giving policymakers a new reason to promote sign-ups, advocates said.

So far, 31 states and the District of Columbia have expanded Medicaid under the law.

This story originally appeared in Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

NC Mental Health Agencies Announce Workforce-Development Collaborative


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By Taylor Sisk

Three of North Carolina’s Medicaid mental health organizations announced last week that they’ll be jointly launching a workforce-development initiative to offer training resources to frontline professionals who provide services to people with disabilities.

Cardinal Innovations sign

Photo courtesy Cardinal Innovations

The mental health agencies (known as local management entities/managed care organizations) collaborating in this initiative are Cardinal Innovations Healthcare, Smoky Mountain LME/MCO and Trillium Health Resources. They and the state’s five other LME/MCOs are responsible for public funds for mental health, substance use and intellectual and developmental disability services.

Cardinal is based in Kannapolis and serves 16 counties throughout the Piedmont and into the eastern part of the state. Asheville-based Smoky Mountain serves 23 Western North Carolina counties. And Greenville-based Trillium provides services for 24 eastern counties.

This initiative will offer access to training resources and evidence-based curricula from DirectCourse, an online training program for support and care professionals.

“Direct support professionals are critical to the success of our members,” Richard Topping, chief executive officer of Cardinal Innovations Healthcare, said in a press release.

“We welcome Trillium and Smoky’s partnership in the training that Cardinal Innovations Healthcare has piloted for three years,” Topping said. “Our results tell us that the use of this curriculum enhances the quality of the support services to our members and provides a valuable workforce development tool to our provider communities.”

According to the release, the Centers for Medicare and Medicaid Services has set new standards for direct-support professionals that focus on improving quality services for individuals with intellectual and developmental disabilities.

“The DirectCourse training curricula offered through this new workforce development collaborative are aligned with the CMS competencies that have been adopted in the NC Innovations waiver that will go into effect in North Carolina this July,” the press release states.

“Providers are absolutely critical to the success of North Carolina’s Medicaid system,” Trillium CEO Leza Wainwright said. “This new workforce development collaboration is focused on improving quality of care through improving provider engagement and support.”

Classes offered will include frontline supervision and management, employment services, personal assistance and caregiving and recovery community and inclusion.

“This on-line training program, when paired with effective mentoring, has been demonstrated to improve the quality of services provided by direct support workers – the folks that do the most to impact the lives of our members,” Smoky Mountain CEO Brian Ingraham said.

Health Officials Listen for the Buzz of Insects


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North Carolina’s weather is finally warming. That means health officials will watch for increased mosquito activity and monitor whether Zika virus infections appear in the state.

By Rose Hoban

Earlier this month, federal officials announced their findings from research into the cause of brain damage in babies born in areas with widespread presence of Zika virus: Something about the virus is causing the problem, although scientists are still not sure of the mechanism of the injury.

So far, the number of North Carolinians affected by the disease is small and limited to people who have traveled to the Caribbean and Central and South America, where mosquitoes carry the disease.

New map from the Centers for Disease Control and Prevention showing the estimated extent of Aedes egypti mosquitoes. They are the main type of mosquito that spread Zika, dengue, chikungunya, and other viruses. Because Aedes aegypti mosquitoes live near and prefer to feed on people, they are more likely to spread these viruses than other types of mosquitoes. Map courtesy CDC.

New map from the Centers for Disease Control and Prevention showing the estimated extent of Aedes egypti mosquitoes. They are the main type of mosquito that spread Zika, dengue, chikungunya, and other viruses.
Because Aedes aegypti mosquitoes live near and prefer to feed on people, they are more likely to spread these viruses than other types of mosquitoes. Map courtesy CDC.

But as the weather warms up, the prospect of Zika-carrying mosquitoes is becoming more real, state epidemiologist Megan Davies told lawmakers last week.

“We’ve developed a plan in partnership with Western Carolina University and NC State University and East Carolina University for doing mosquito surveillance and being able to really identify what mosquitoes are where and in what abundance,” she told lawmakers at the Joint Legislative Emergency Management Oversight Committee.

New territories

Davies showed lawmakers new maps developed this spring by the Centers for Disease Control and Prevention that indicate the presence of Aedes egypti mosquitoes, which most commonly carry Zika.

The map, she said, was developed by CDC experts “using a range of sources including more sort of informal communication with entomologists and academic partners, and they included any place that had ever detected one Aedes aegypti, and also people’s expert opinion about where they might be.”

New maps from the Centers for Disease Control and Prevention showing the extent of Aedes albopictus, or Asian tiger, mosquitoes. According to the CDC, because these mosquitoes feed on animals as well as people, they are less likely to spread viruses like Zika, dengue, chikungunya and other viruses. Map courtesy CDC.

New maps from the Centers for Disease Control and Prevention showing the extent of Aedes albopictus, or Asian tiger, mosquitoes. According to the CDC, because these mosquitoes feed on animals as well as people, they are less likely to spread viruses like Zika, dengue, chikungunya and other viruses. Map courtesy CDC.

On the old maps, areas reliably hosting Aedes egypti mosquitoes stopped short of North Carolina’s southern border. But the new maps show the state squarely within the range of possibility.

“We appreciate that it’s an estimated range and that this might be possible,” Davies said. ”But this makes it all the more important that we actually define what our risk is in North Carolina and not just go by an estimate.”

Another set of maps shows the extent of Aedes albopictus, or Asian tiger mosquitoes, which have been shown to carry Zika, but is a less efficient vector for the disease, according to state public health veterinarian Carl Williams.

“We’re all familiar with that,” he said. “You’ve all seen it in your backyards.”

Keeping track

Davies told legislators that when infected, the human body can quickly process the virus. There are exceptions, it seems, for the fetuses of pregnant women and in the semen of infected men, where it can persist for some time. CDC officials are suggesting that men who may have acquired Zika during travel to affected areas use condoms for at least six months if they and their partners are thinking about getting pregnant.

commonly known as the Asian Tiger mosquito, Aedes Albopictus is capable of transmitting chikungunya. Photo courtesy Wiki

Commonly known as the Asian Tiger mosquito, Aedes Albopictus is capable of transmitting dengue, Chikungunya and also Zika viruses. Photo courtesy Wikimedia creative commons

For women who contract Zika while pregnant, Davies said, North Carolina will participate in a national registry to track the women and their babies. The women will be followed while pregnant, and health officials will check in again at two and four months and one year to see what, if any, effects the babies have.

Not every baby born to a mother infected with Zika will have long-term effects, she said. “It’s not 100 percent, but it’s some percentage, and we need to know what that is.”

Early in the pregnancy is the most susceptible time for the most severe brain damage,” she said. “There is evidence that when infected later in pregnancy, there can be other kinds of bad outcomes, like miscarriage.”

Federal and state officials are also working with blood-collection centers to screen people donating blood and blood products.

“The FDA has provided blood establishments that collect whole blood and blood components recommendations for donor deferral and product management to reduce the risk of transmitted Zika,” Davies said.

She said her department is coordinating with blood suppliers throughout North Carolina to review the FDA guidance and make sure it’s consistent across the state.

“We were reaching out to them and they were reaching out to us simultaneously,” she said of many of the blood suppliers. “So I think that’s a good sign.”

Targeted spraying

Williams told lawmakers that the standard of preventing the spread of Zika-bearing mosquitoes will be to do targeted spraying, rather than using trucks to spray clouds of insecticide.

Aedes aegypti most likely originated in Africa; since then, the mosquito has been transported globally throughout the world, through global trade and shipping activities. It's a very good transmitter of Zika virus, along with dengue and Chikungunya virus.

Aedes aegypti most likely originated in Africa; since then, the mosquito has been transported globally throughout the world, through global trade and shipping activities. It’s a very good transmitter of Zika virus, along with dengue and Chikungunya virus. Photo courtesy, CDC

This aroused the ire of some lawmakers, who pushed for more aggressive mosquito control.

“We didn’t learn anything by letting the Anopheles come back and kill over a million people in Africa once we took a ban on DDT?” asked Sen. Ron Rabin (R-Spring Lake). “We’re now going to take the same sort of passive way to try to treat it.”

Williams explained that both species of Aedes mosquito breed not in swamps or ditches but in small water containers, such as birdbaths and buckets and other places close to where humans live. These mosquitoes also bite at all hours of the day, making them additionally difficult to control.

“There’s the logistical aspect of it being very difficult to control those mosquitoes with the traditional methods,” Williams said in response.

He said that much of the available data indicates that traditional methods of mosquito control are “not as effective or are unproven with regards to these peri-domestic container-breeding mosquitoes.”

Williams said that in Brazil, where the widespread appearance of Zika first aroused attention, people with backpacks are going throughout the neighborhoods of people with diagnosed disease spraying for mosquitoes and draining small containers of water.

“It’s really difficult to get at them,” he said.

The Dark Side of Recycling


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Recycling may make you feel better about the garbage you generate, but workers in the recycling industry often experience a darker side.

By Brian Joseph

Fair Warning

Darkness had enveloped the Newell Recycling yard by the time Erik Hilario climbed into a front-end loader on a cold evening in January 2011. Hilario, a 19-year-old undocumented immigrant from Mexico, earned $8 an hour at the industrial park in East Point, Ga., working amid jagged piles of scrap metal eventually bound for the smelter.

forklift moving recycled cardboard

Heavy equipment is necessary to move the large amounts of recycled trash. But many workers are poorly trained, if at all, in how to manage the machines used to process recycled goods. Photo courtesy US Army

On this day, Hilario was driving a loader in a paved section of the nine-acre yard known as the defueler or car-processing area. Here, according to witness testimony, gasoline was drained from junked cars through a crude process employing a 30-foot crane and an 11-foot-tall structure topped with a spike known as The Puncher.

A claw attached to the crane would pick up cars and smash them, gas tank first, onto the spike, spilling gasoline into a trough. The crane then would swing the cars onto a pile, dripping gas along the way.

As Hilario used the loader to slowly push metal scraps, a spark ignited the gasoline on the ground. An intense fire suddenly engulfed him. “Help me!” he screamed, his co-workers later testified.

When the fire was finally extinguished, Hilario’s severely burned body was found 10 feet from the charred loader. A doctor reviewing Hilario’s autopsy later determined that he was probably conscious for as long as five minutes before he died.

Not feel-good

Recycling may be good for the environment, but working conditions in the industry can be woeful. The recycling economy encompasses a wide range of businesses, from tiny drop-off centers in strip malls to sprawling scrap yards and cavernous sorting plants. The industry also includes collection services, composting plants and e-waste and oil recovery centers.

Some of the jobs at these facilities are among the most dangerous in America. Others offer meager pay, and wage violations are widespread. Experts say much of the work is carried out by immigrants or temporary workers who are poorly trained and unaware of their rights.

Recycling111“These are not good jobs,” said Jackie Cornejo, former director of Don’t Waste LA, a campaign to improve working conditions for waste and recycling workers in Los Angeles. “People only hear about the feel-good aspects of recycling and zero waste, and rarely do they hear about the other side.”

The last comprehensive analysis of the American recycling industry, commissioned in 2001 by the National Recycling Coalition, estimated that it employed more than 1 million people. Private scrap yards alone generated more than an estimated $80 billion in revenue in 2015.

The nation’s largest trash haulers, Waste Management and Republic Services, are also the largest recycling firms. In 2014, recycling generated a combined $1.7 billion in revenue for the two corporations, or about 7.5 percent of total sales.

But many of the companies that do this work are small and may lack the knowledge and resources to establish effective safety procedures. Recycling workers, by virtue of their immigration status or status as temps, often hesitate to speak up when they see hazards on the job or are victimized by the outright illegal behavior of their supervisors.

Dirty, labor-intensive

Scrap yards, one of the largest sectors in recycling, have long had high fatality and injury rates. In 2014, their fatality rate was 20.8 deaths per 100,000 full-time workers, more than nine times higher than manufacturing workers overall. The same year, garbage and recycling collectors had the fifth-highest fatality rate among the dozens of occupations analyzed by the Bureau of Labor Statistics.

No one tracks how many workers die across all recycling sectors. But at scrap yards and sorting facilities, at least 313 recycling workers were killed on the job from 2003 to 2014, according to the BLS.

Christopher Webb with his daughter Lillian in May 2012. He was killed at a recycling plant in Reidsville two months later.

Christopher Webb with his daughter Lillian in May 2012. He was killed at a recycling plant in Reidsville two months later.
Photo courtesy: Allison Hildebrand

A FairWarning analysis of Occupational Safety and Health Administration records found that inspections conducted from 2005 to 2014 resulted in scrap yards and sorting facilities receiving about 80 percent more citations per inspection than the average inspected worksite.

Recycling is dirty, labor-intensive work. It involves heavy machinery, including conveyor belts, shredders and grinders that can pose a serious risk of injury or death, especially if they’re not properly serviced or lack basic safety features.

Unlike many industrial processes, recycling cannot be completely systematized because it deals with an ever-changing flow of materials in all manner of shapes and sizes. Workers may have to personally handle most of the scrap passing through recycling facilities, potentially exposing them to sharp objects, toxins, carcinogens or explosives.

“I did not realize the danger,” recalled Alice Pulliam of Reidsville, whose 32-year-old son, Christopher Webb, was killed at the Southern Investments plastic recycling plant in July 2012. The plant purchased loads of milk jugs, detergent bottles and other recyclable plastics and ground them into bits for resale to businesses that would further process the material.

One day, just a couple of months after joining the 13-employee company, Webb was feeding giant bales of compacted bottles and jugs into an auger with 14 spinning blades. More than a foot long and sharpened to a point, these blades broke up the bales before they were ground into finer pieces.

Following the plant’s standard procedure, Webb used a forklift to place the roughly three-foot-high bales on an elevated platform next to the mouth of the auger, according to a report by the North Carolina Department of Labor’s Division of Occupational Safety and Health. While the blades spun below him, Webb climbed onto the bales to cut the wires holding them together. Then he used the forklift to push the bales into the auger.

Webb was on top of a bale when he fell into the spinning blades below, crushing his head. A subsequent investigation by the state department of labor found that plant employees weren’t instructed to shut down the auger while climbing on the bales, and that the machine did not have the proper guarding to prevent the blades from hitting workers.

The state cited Southern Investments with 35 safety violations, including 16 “willful violations,” and fined the company the unusually high sum of $441,000. The plant’s owner, Donald Southern, said he could not pay and agreed to close Southern Investments and not manage another plastic recycling business in North Carolina. He declined to comment for this story.

Safety procedures ignored

Generally, the hazards at scrap yards and sorting facilities are typical of any major industrial operation. Safety measures to make these workplaces less dangerous are well known and widely implemented in other industries.

“This is not rocket science,” said Susan Eppes, a Houston-based safety consultant to the recycling industry.

Although OSHA says five of its 10 regions have special enforcement programs covering sectors of the recycling industry, safety advocates said that isn’t enough.

“Systematically, across the country, they haven’t given the industry the attention it’s due,” said Eric Frumin, the health and safety director for Change to Win, a partnership of four national unions. Advocates are lobbying the agency to create a national program aimed at sorting plants, where metal, paper and plastic are separated. The Institute of Scrap Recycling Industries, a trade association, recently announced it is partnering with OSHA to try to reduce injury and fatality rates.

Yet basic safety procedures are often ignored in recycling plants, experts say. Consider the case of Robert Santos, a 46-year-old line supervisor at a Republic Services plant in North Las Vegas, where he helped dump mounds of recyclables onto a conveyor belt.

Using radios, workers would direct front-end loaders to push paper from a holding bay onto the belt, which rolled toward a baler. State safety inspectors later learned that it was common for employees to stand on the moving belt to pull material from the holding bay or to sweep up material along its sides.

On the morning of June 8, 2012, work at the sorting facility was delayed two hours because a mass of paper had clogged the holding bay. Once the jam was cleared, Santos stood on the conveyor belt, yanking paper from the bay, when two to three tons of paper suddenly collapsed on top of him. A co-worker would later remember him shouting, “Stop the belt! Stop the belt!” before he was enveloped in a pile of paper eight feet high.

After the paper was lifted off him, Santos was found to have minimal brain activity. He was taken off life support six days later and died. The Nevada Occupational Safety and Health Administration fined Republic Services $5,390 for the incident. Asked to justify such a small fine for a fatal accident, Nevada OSHA’s chief administrative officer said it was in line with agency policy, and that investigators did not find “clear indifference to employee safety and health.”

Republic Services did not respond to requests for comment.

After his fatal accident, Erik Hilario’s family moved quickly to file a wrongful death lawsuit. Newell Recycling of Atlanta and the Hilario family declined to comment for this story.

Last September, a jury in Fulton County, Ga. awarded $29.2 million to the Hilario family. Newell and the family subsequently settled out of court. But the pain of a life cut short lingers among Hilario’s family, who were described by their lawyer as still reeling from Erik’s death five years later.

“He wanted to be somebody,” Erik’s older brother, Efrain, recalled in his tearful testimony during the trial. “He had many dreams.”

Bridget Huber contributed to this report. The Courtroom View Network provided access to its archive of video trial testimony.

FairWarning, which reported this story, is a nonprofit news organization that focuses on public health, safety and environmental issues. A longer version of the story appears at fairwarning.org.

Fraudulent Cancer Charities Will Repay North Carolinians More than $1 Million


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By Rose Hoban

North Carolinians who thought they were giving money to help cancer patients are about to get refunds, courtesy of a class action lawsuit.

The offices of Attorney General Roy Cooper and Secretary of State Elaine Marshall announced Wednesday that North Carolina is part of a nationwide settlement against two “sham cancer charities,” the Cancer Fund of America and Cancer Support Services.

Image courtesy College-Guide, flickr creative commons

Image courtesy College-Guide, flickr creative commons

The lawsuit alleged the two groups raised more than $75 million between 2008 and 2012 purportedly to help cancer patients and support research, but kept about 85 percent of the gifts for themselves.

The suit was filed by officials from all 50 states, the District of Columbia and the Federal Trade Commission, which also sued the Breast Cancer Financial Assistance Fund, the Breast Cancer Society of America and James Reynolds Sr., who ran the charities.

Reynolds is also permanently barred from charity work.

The other defendants in the case settled their portion of the suit in 2015.

North Carolinians donated about $1.03 million to the charities during the four-year period and, according to Cooper’s office, more than 80 percent of the money went to the fundraisers.

The news irked Leslie Boyd, of WNC Health Advocates in Asheville. Boyd lost her 33-year-old son to colon cancer and started her organization to provide support and advocacy around access to care and helping people get their wills and powers of attorney papers in order.

The Federal Trade Commission has an educational page about avoiding charity scams. “Everyone is scared of cancer. You hear that word and someone calls and asks you to give to cancer, it’s like asking to support apple pie,” Boyd said.

But she said donors should ask what the charity is doing: whether it’s helping people, doing actual research, paying for chemotherapy for someone who can’t afford it or other activities. She said the answers should be specific.

“There are so many ways to find out what a charity is doing and how much money is being spent on services and collaborating with other charities doing real work,” Boyd said.

Good sources are Guidestar and Charity Navigator, both of which make charities’ federal financial documents available. Another source is a charity’s website, which should include links to similar financial documents.

“It is extremely important for people to do thorough research before giving to a charity,” said Mallory Wojciechowski, president and CEO of Better Business Bureau Serving Eastern North Carolina.

She said Better Business Bureau has a resource, the Wise Giving Alliance, for checking out a charity, along with a “scam tracker.”

In a press release, Marshall said it’s important to ask questions of the folks who are soliciting money for their health-related charities.

“Do your homework before you give so that your contributions can do the most good,” she said.

That struck home with Boyd, who said, “If a charity calls me and there’s no way to volunteer, if there’s no way for you to be involved, I’ve got to wonder if they’re legit.”

Study: Primary Care Doctors Often Don’t Help Patients Manage Depression


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By Michelle Andrews

Kaiser Health News

Although primary care doctors frequently see patients with depression, they typically do less to help those patients manage it than they do for patients with other chronic conditions such as diabetes, asthma or congestive heart failure, a recent study found.

depressionThat is important because research has found that it can be good for patients’ health when physician practices have procedures in place to identify and provide targeted services to patients with chronic conditions and to encourage patients to get involved in actively managing their own care.

But physicians were less likely to use those “care-management processes” with patients who have depression than with those who had other chronic conditions, according to the study in the March edition of the journal Health Affairs.

The study analyzed data from the three largest national surveys of physician practices to determine the extent to which they employed five care-management processes between 2006 and 2013. The five processes studied were patient education; patient reminders about preventive care; nurse care managers to coordinate care; feedback on care quality to providers; and disease registries that identify patients with chronic conditions, enabling practices to be proactive about their care.

The results were particularly dismal for depression. In the 2012 to 2013 time frame, physician groups on average used fewer than one (0.8) of the care-management processes for their patients with depression, and that level of use hadn’t changed since the 2006 to 2007 period, according to the study. In contrast, practices used 1.7 diabetes care-management processes on average overall with their patients between 2012 and 2013.

Among only large practices, the use of diabetes care-management processes grew significantly over time, to 3.2 in 2012-2013.

The use of care-management processes for patients with congestive heart failure and asthma was 1.1, a statistically significant difference compared with their use in patients with depression. Still, Tara F. Bishop, the lead author of the study and an associate professor in the department of health care policy and research at Weill Cornell Medical College in New York City, said those measures were also considered low.

The depression results were not surprising, said Bishop.

“There’s a growing understanding that depression and mental illness generally are being undermanaged [in primary care settings] and we’re not using the tools that are available,” she said.

It may be that physicians are less comfortable managing psychological illnesses than they are physical ones, but size may also matter, she said. Primary care practices that are part of academic medical centers or integrated health care systems may be better equipped to adopt care-management processes, while smaller, independent practices have trouble marshaling the staff and other resources necessary to put comprehensive care-management techniques to use.

This story originally appeared in Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Disability Advocates Worry About Transgender Bathroom Bill


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By Rose Hoban

People with profound physical and developmental disabilities often need help while going to the bathroom.

And for those people who have caregivers of the opposite gender, the legislative language being bandied about ahead of this week’s special session to overturn Charlotte’s ordinance forbidding discrimination for transgendered people looking to use the bathroom may have lots of unintended consequences.

photo of a disabled accessible bathroom

Photo credit: Lee Brimelow/ flickr creative commons

“When you go to hire someone as a caregiver, you’re looking for the most qualified person to assist you and that may not be a person who shares your gender,” said Julia Adams-Scheurich, head of governmental affairs for The Arc of North Carolina.

She said it’s all too common that someone, say, a mother with a son in a wheelchair, needs to enter the bathroom of the opposite sex.

“You may have an individual with cerebral palsy or muscular dystrophy or spina bifida or some other profound disability who does not share the same sex with their husband, caregiver, mother, father,” Adams-Scheurich said. “We’re afraid that legislation created by the General Assembly would have the unintended consequence of possibly prohibiting that assistance.”

This concern was echoed by Corye Dunn, who represents Disability Rights North Carolina at the legislature. She noted that having a disability often makes using a traditional public restroom less practical.

“Many of the practices that make bathrooms more accessible for gender non-conforming people also make them more accessible for people with disabilities,” she said.

Dunn said the Charlotte ordinance would probably result in the creation of more “single stall” restrooms in the city.

“And that’s a good thing for our clients,” she said. “It’s a good thing for a lot more people than you think, people with  colostomies and urostomies, who have complicated medical issues that make a restroom stall without a sink in it difficult to manage.”

Dunn said she hadn’t seen any draft language, but she’s holding her breath.

“Anyone who has young kids knows that a family restroom isn’t always an option,” said Mike Meno, from the ACLU of North Carolina, who pointed out there was some legislative language floated last year that would have created similar problems, but that version of the bill didn’t make it into law.

Both Adams-Scheurich and Dunn said the current trend of “family restrooms” has been a huge boon for people with disabilities. But many locations don’t have the space for such bathrooms, or their current physical configurations don’t support having an extra bathroom.

Adams-Scheurich noted that until the 2007-08 session, Raleigh’s legislative complex did not have a disability-accessible bathroom, and there’s still no family-designated restroom that is accessible in either the Legislative Building or the Legislative Office Building.

So, depending on how legislators craft this week’s bill, folks with disabilities might also have to learn how to hold it.

Rural Health Care’s Broadband Gap Widens


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Health care institutions in non-metro counties have significantly slower broadband than metropolitan institutions do, a new study shows. And the gap is getting bigger.

By Brian Whitacre, Denna Wheeler and Chad Landgraf

The Daily Yonder

A new study suggests that health care facilities in non-metropolitan counties connect with relatively slow speeds when compared to their metro counterparts. More importantly, it also indicates that this connectivity gap is growing.

The finding comes at a time when the health care field has changed dramatically, with technologies such as electronic health records and health information exchanges becoming commonplace. These technologies require Internet connections – and, as more and more data is being transferred, those connections need to be fast.

The study takes advantage of the fact that the National Broadband Map gathered data on connectivity speeds for a variety of “community anchor institutions” – including health care facilities – during its run from 2010 to 2014. Each state surveyed its own facilities, and the resulting database included over 35,000 health care entities in 2010 and increased to over 62,000 in 2014. The location of each facility was also recorded, allowing for analysis of whether the connection speeds varied across metro/non-metro designations.

High-speed connections (>50 Megabits per second) for healthcare facilities increased dramatically in metropolitan areas between 2010 and 2014, but only slightly in non-metropolitan areas. The purple portion of the bars represents the percentage of facilities with 50 Megabits or more connection speeds. From 2010 to 2014, the gap between metro and non-metro healthcare facilities at that connection speed grew by 34 points.

High-speed connections (> 50 megabits per second) for health care facilities increased dramatically in metropolitan areas between 2010 and 2014, but only slightly in non-metropolitan areas. The purple portion of the bars represents the percentage of facilities with 50 megabits or more connection speeds. From 2010 to 2014, the gap between metro and non-metro health care facilities at that connection speed grew by 34 points. Graph courtesy Daily Yonder.

(Note: This story uses metropolitan and non-metropolitan counties to compare urban and rural trends. In rough terms, metro counties have a city of 50,000 residents or more at the center of their economic activity; non-metro counties don’t. But it’s more complicated than that. Read more about different ways to define “rural” here.)

The results (as depicted in the chart above) show a significant difference in the speeds at which health care facilities connect between metro and non-metro areas.  In 2010, 14 percent of all health care facilities in metropolitan areas had the fastest category of connections (at least 50 megabits per second).  Comparatively, only about 5 percent of health care facilities in non-metro counties had connections of that speed. Non-metro facilities also had higher rates of the lowest category of speeds (less than 3 mbps), with 38 percent (vs. 33 percent in metro areas).

More striking, however, is how those rates changed between 2010 and 2014.  Health care facilities in metro areas saw their rates of “very fast” connections shoot up from 14 to 55 percent, while facilities in non-metro areas saw a much smaller increase (from 5 to 12 percent). Similarly, the percentage of metro facilities with “very slow” connections decreased from 33 to 11 percent, but non-metro connections of this type had a much slower decline (from 38 to 28 percent).

The result is that the health care connectivity gap was much worse as of 2014 than it was in 2010. Similar gaps exist for upload speeds (which are important for technologies like EHRs and HIEs).

The remainder of the study goes on to show that this gap is primarily driven by non-hospital facilities. The rate of growth for hospital connections between 2010 and 2014 is actually quite similar between metro and non-metro areas. However, when the analysis is done for non-hospital facilities (private practices, health departments, pharmacies, clinics, etc.), it becomes clear that the gap is dramatically increasing for these types of health care services.

Additionally, the Federal Communications Commission has recommended that solo primary care practices have speeds of at least 4 mbps and that small primary care practices, nursing homes and rural health clinics have speeds of at least 10 mbps. The latest data (from 2014) indicates that a significant portion of rural health care facilities are not meeting these requirements.

Vintage computer image

Vintage computer image courtesy of Alan Light, flickr creative commons

This increasing connectivity gap happened despite the existence of a pilot (and resulting full-time) program called the Healthcare Connect Fund. This program had funds available to support broadband connectivity for public or not-for-profit health care providers including hospitals, rural health clinics and local health departments.

However, the fund is dramatically underused, perhaps due to overly stringent requirements. This research suggests that changes to this program should be considered to encourage participation by non-hospital facilities.

Brian Whitacre is associate professor and extension economist at Oklahoma State University. The study is forthcoming in the Journal of Rural Health and is entitled “What Can the National Broadband Map Tell Us About the Healthcare Connectivity Gap?

This story originally appeared here and is shared by North Carolina Health News through a content-sharing agreement with the Daily Yonder, a not-for-profit news agency dedicated to covering rural policy.
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