North Carolina Health News
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Ending Solitary for Juveniles, Prison Commissioner Cites Use of Evidence-Based Alternatives


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By Rose Hoban

Juveniles under the age of 18 who are incarcerated in North Carolina prisons will no longer be subjected to solitary confinement starting this fall, prison commissioner David Guice announced last week.

In a statement accompanying a 16-page policy document, Guice wrote that “it is of paramount importance that, while these youth are in our care, their unique needs are accurately identified and addressed in the most effective way possible.”

Foothills Correctional Institution in Morganton from the air. Photo courtesy Irakli Rakeman, flickr creative commons

Foothills Correctional Institution in Morganton from the air. Photo courtesy Irakli Rakeman, flickr creative commons

The policy, which will be fully in place by Sept. 1, will apply to about 70 juvenile offenders currently housed at the Foothills Correctional Institution in Morganton. Those juveniles are the last 16- and 17-year-olds being held in “restrictive housing,” where inmates are confined to a cell for 22 or 23 hours a day.

According to the advocacy group Disability Rights NC, being segregated in solitary confinement can cause deterioration in mental health, producing paranoia, post-traumatic stress disorder, self-harm, and thoughts of suicide.

Guice said that a few more months are needed to get enough staff and get them trained for the new housing regimen that will address inmates with behavioral issues in a different way. And his department is working to create a similar facility in Pasquotank County that will open in the near future.

Positive reinforcement

“Although 16- and 17-year-olds are adjudicated as adults, they should not be treated the same as adults in the prison system,” Guice told NC Health News in an interview last week.

The new regimen at Foothills consists of creating smaller housing “pods” where inmates are given positive reinforcements to engage in good behavior. The policy document describes an evidence-based approach that emphasizes “rational thinking, appropriate communication and behaviors.”

Key to the approach are incentives ranging from receiving books, extra movies, popcorn or nachos, to participation in field days and access to music.

Inmates who do display behavior problems, instead of being confined in solitary, will be placed in “modified housing,” with more intense supervision and tiered losses of privileges.

There’s also the opportunity for inmates to learn trade skills and an increased emphasis on addressing the mental-health needs of teen inmates.

“We’ve actually set up programs where even those who have the worst behavioral issues in the system, we’re now placing those people in programs that we believe are going to be successful,” he said.

Prison commissioner David Guice told mental health advocates Photo credit: Rose Hoban

Prison commissioner David Guice. Photo credit: Rose Hoban

North Carolina is one of only two states in the country — the other is New York — that still charges 16- and 17-year-olds as adults, even when their crimes are for minor offenses such as littering.

For years, advocates have been pushing for legislation to “raise the age” of incarceration in the prison system. A bill passed the House in 2014, but the legislation has stalled in the Senate.

A cost-benefit analysis performed by the Vera Institute of Justice in 2009 found that raising the age of adult incarceration would cost $70.9 million but provide $123.1 million in benefits and savings per year.

Until the legislature acts, the new policies will make for more age-appropriate incarceration, Guice said.

Remissioning

Guice also said his department is in the process of “remissioning” all of the state’s correctional facilities, and an effort that includes getting adults out of solitary confinement as well.

“About six months ago we had about 5,500 inmates who fell into that category, and today we have less than 2,500,” he said.

For advocates, the changes can’t happen fast enough, especially because other young people in the correction system are still subject to solitary confinement.

“Today, for example, 20 percent of 18-year-olds in NC prisons are in segregation as well as hundreds of adults who have mental illness,” Vicki Smith, head of Disability Rights NC, said in a statement. The organization has long pushed for raising the age, and for ending solitary for all inmates.

“Commissioner Guice has identified solutions, but his progress will be stifled without adequate funding from the General Assembly,” she said.

Guice said he’s doing what he can with what he’s got. He has gotten some funding from the legislature over the past few years, a result of the Justice Reinvestment Act, which was signed in 2011.

He stressed the fact that more than 90 percent of people who end up in prison will eventually return to the community, and this is what’s driving his reform efforts.

“It is truly my goal to insure that the person who comes to us… that we provide them with a pathway that’s going to give them an opportunity to leave us better off than they came,” said Guice, who pointed out this means addressing mental-health needs and housing and work for newly released inmates.

“I know what we need to do and it’s creating a pathway to address those underlying issues,” he said. “I believe that the system fails if we release someone and we do not provide a pathway that that individual can be successful.”

Patient Advocates Push for Limits on Step-Therapy Prescription Practices


Patients, doctors and family members affected by the prescription practice called “step therapy” brought personal stories to the General Assembly Thursday in support of a bill that would prohibit it in some cases and limit it in others.

Pills

Photo credit: Rose Hoban

The bill, House Bill 1048, defines step therapy as an approach “under which patients are required to try one or more prescription drugs before coverage is provided for a drug selected by the patient’s health care provider.” The practice has been widely adopted by insurance companies, in part in response to demand for specific new drugs targeted to consumers by advertising.

Thursday’s event, put on by the National Patient Advocate Foundation, was part of an advocacy day designed to bring legislators’ attention to the bill, which is being called “Reduce Barriers to Improve NC Health and Safety.’ The bill has passed the House, but not the Senate.

Proponents of step therapy describe the practice as a necessary cost-saving measure. At an earlier legislative hearing this year, Tom Friedman, North Carolina State Health Plan policy liaison, said step therapy saves the plan for state employees about $10 million in its $700 million annual prescription-drug budget.

Panelists — including two physicians, a patient advocate who has rheumatoid arthritis and a state lobbyist for the American Cancer Society Cancer Action Network — resisted assertions that efforts to limit step-therapy represent a “mandate” that would harm providers.

“I suggest that they disregard the label of ‘mandate,’ when it is a word that is thrown around haphazardly when we are talking about lives at stake,” said rheumatologist Dr. Gwenesta Melton.

Protracted conflict with insurance companies and third-party vendors over step-therapy prescriptions has taken a toll on Melton’s practice, she said: “They are upset because they think that we are going to run amok and put all these people on these expensive drugs.”

Before some patients are approved for the most efficacious drug for their conditions, they can spend months or years taking the less expensive drugs that make up the first steps of the process, Melton said.

On the other hand, many patients may come into their doctors asking for a new, expensive, medication they saw in an advertisement, when an older, generic drug can suffice.

The legislation, sponsored by Rep. David Lewis (R-Dunn), would require insurers to allow exemptions from step therapy in cases where doctors find that the drug required by the insurer is not in the patient’s best interest.

A section of the bill specifically endorsed by Duke physician Dr. Steven Prakken prohibits step therapy when a doctor has prescribed abuse-deterrent opioids. These relatively new painkillers are designed to lose their potency if altered for potential abuse by crushing or cooking them.

“That’s a deterrent to abuse,” Prakken said. “Since they are more expensive, you can’t use them first” under step-therapy protocols, he said.

The federal Food and Drug Administration recently urged pharmaceutical companies to develop generic equivalents of abuse-deterrent drugs, while noting that some questions persist about how effectively the medications actually keep people from misusing them.

“Abuse-deterrent properties make certain types of abuse, such as crushing a tablet in order to snort the contents or dissolving a capsule in order to inject its contents, more difficult or less rewarding,” a March FDA statement said.

“It does not mean the product is impossible to abuse or that these properties necessarily prevent addiction, overdose or death – notably, the FDA has not approved an opioid product with properties that are expected to deter abuse if the product is swallowed whole.”

Firefighters Petition for More Health Care


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For firefighters, occupational exposures can lead to many types of cancer, with health care costs that currently aren’t covered under workers’ compensation insurance.

By Minali Nigam

A budget measure passed by the North Carolina House of Representatives last month adds language that would extend workers’ compensation for firefighters to include coverage for cancers related to fire exposure. But the budget passed earlier this month by the state Senate budget doesn’t.

Capt. Mark Stafford, from the City of Conover FD, Chief Andy Webster from the Statesville FD and Depty Chief Derik Martin from the Hickory FD came to the legislature to ask for, among other things, a death benefit for firefighters who die of certain cancers during their working lives.

Capt. Mark Stafford, from the City of Conover FD, Chief Andy Webster from the Statesville FD and Depty Chief Derik Martin from the Hickory FD came to the legislature to ask for, among other things, a death benefit for firefighters who die of certain cancers during their working lives. Photo credit: Rose Hoban

Almost 200 firefighters from all around North Carolina came Wednesday to the General Assembly, where they discussed many issues with lawmakers, including pension and health-care compensation. Cancer was also part of those conversations.

“We see a whole array of emergencies that we respond to that deal with medical maladies and long-term disease states of that nature,” said Kevin Gordon, president of the North Carolina State Firemen’s Association.

“Our biggest concern would be making sure that the firefighters have necessary health care for themselves and their families.”

Compensating Cancer

Currently, under workers’ compensation, firefighters can get medical costs covered for health problems including lead poisoning, carbon monoxide poisoning, and asbestosis, a chronic respiratory disease.

But constant exposure to chemicals and smoke has been linked to additional long-term health effects, such as cancer. In the House budget, representatives extended occupational diseases covered under workers’ compensation for firefighters to include testicular, brain and rectal cancers; mesothelioma; and esophageal cancers, among others.

“But it was taken out of the Senate budget,” said Anthony Penland, a firefighter in Buncombe County. “We’re hoping that the Senate will put that back in when the budget is finalized.”

An active firefighter’s death as a result of one of these cancers would be considered a “line of duty death” under this new measure, said Penland, who serves on the North Carolina Firemen’s Association Board of Directors. Families of deceased firefighters would be able to receive a $50,000 death benefit in the form of $20,000 at the time of death and three annual payments of $10,000.

“We’re having more and more firefighters dying of cancer due to the types of materials that’s in the houses that’s burning now,” said Ryan Cole, a board director for the North Carolina Association of Fire Chiefs.

Some of these materials include asbestos found in pipes and flooring, along with combustion products from smoke that include carbon monoxide, benzene and cyanide.

Even with breathing equipment and protective gear, Cole said, today’s firefighters are actually at a greater risk for occupational diseases because of potential carcinogens found in burning houses.

“We’re starting to see more and more firefighters coming down with cancer,” he said. “And we feel like that’s going to be a growing trend that we’re going to have to address throughout our generation for firefighters.”

Researchers from the National Institute for Occupational Safety and Health found that the longer firefighters were exposed to fire and burning buildings, the more likely they were to die from lung cancer and leukemia. The study also found that firefighters had twice as many incidences of mesothelioma, a cancer resulting from asbestos exposure, as the rest of the U.S. population.

Right now, the family of a firefighter who dies can claim the benefit if the death was the result of a heart attack or stroke or injury within 24 hours of fighting a blaze.

Several senators involved in budget negotiations said they didn’t know enough about the firefighter death-benefit measure to have formed an opinion.

Mental Health

Fire chiefs (r to l, top row) Allen Wilson, Freddy Johnson Sr., TJ McLamb, John Grimes, and Chris Heath, sit in at the House hearing.

Fire chiefs (r to l, top row) Allen Wilson, Freddy Johnson Sr., TJ McLamb, John Grimes, and Chris Heath, sit in at the House hearing. Photo credit: Minali Nigam

Firefighters also watched a House session where representatives passed House Bill 451, which calls for a study on suicide prevention in minors, veterans, and emergency responders in North Carolina.

Cole said firefighters were hoping to be included as part of that study, especially to help those afflicted with post-traumatic stress disorder.

“Please allow me to also acknowledge the North Carolina Association of Firefighters, who reached out to me to be included in this piece of legislation,” Rep. Carla Cunningham (D-Charlotte) said from the floor of the chamber, motioning to the uniformed men and women sitting in the gallery above.

Cunningham had worked to add firefighters into the suicide study bill.

Passage of the measure was unanimous in the House. Now the study bill moves to the Senate.

New ASU Health Sciences Facility to Benefit Students, Region, Says Dean


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By Thomas Goldsmith

A new College of Health Sciences building for Appalachian State University in Boone will broaden students’ educational experience as well as the college’s reach into underserved Western North Carolina counties, the college dean said Monday.

When the 203,000-square-foot building breaks ground next week it will consolidate several fast-growing degree programs, Dean Fred Whitt said.

“We are trying to set up interprofessional delivery of services,” Whitt said. “We think we’ll be training the health-care leaders of tomorrow today.”

In anticipation of an increasingly team-oriented health-care environment, the new building will allow speech therapists, nurse practitioners, dieticians, physical therapists and other specialists to train side-by-side.

Gov. Pat McCrory’s office announced last week that contracts have been let for the facility, using $70 million in funding from the state’s Connect NC initiative. The Council of State approved $200 million June 7 in the first segment of the $2 billion bond program voters OK’ed in March.

Since 2008, the College of Health Sciences, with more than 3,300 students, has more than doubled its enrollment.

“We had just run out of room,” Whitt said.

nursing students listen to a heart

The new Health Sciences building at App State will provide room for several fast-growing degree programs, including a new masters program in nursing. Photo courtesy Appalachian State University

The new facility will offer “specialty laboratories, classrooms and support space centralizing several different health sciences degree programs under one roof,” according to a news release.

“New university facilities like the Health Sciences Building at Appalachian State will prepare students for high-demand medical careers to further enhance the health and quality of life in the region and state,” McCrory said in a statement.

The 16-county area around Boone has some of the state’s largest deficits in health-care professionals per 10,000 residents, Whitt said. Because professionals often remain in the area where they are educated, Western North Carolina should see ongoing benefit from the college’s growth.

“If you are trained in rural areas, you’ll want to go back and work in rural areas,” Whitt said. “When you get in the rural health area, it really means enhancing the quality of life in the region. In some counties up here, you may have only one physical therapist.”

In 2015, the college received funding for a Rural Health Care Services Outreach Program to provide services through partnerships with Wake Forest School of Medicine physician-assistant program and the High Country Council on Governments Area Agency on Aging.

How’s that arrangement working out?

“Awesome,” Whitt said. “They have a cohort of physician assistant students training here in our college.

“On the other hand, for our benefit, we are able to place some of our nursing students in clinical rotations in certain specialty areas at Wake Forest Baptist.”

Health-care jobs are represent one of the state’s strongest employment sectors, with about 400,000 people working as health-care practitioners, technicians or support employees, according to the commerce department’s Labor and Economic Analysis Division.

ASU offers undergraduate degrees in areas including athletic training, communication sciences and disorders, exercise science, health-care management, nursing, nutrition and recreation management, as well as masters programs in exercise science, nutrition, speech language pathology, social work and health administration.

A master’s program in nursing is slated to begin this fall.

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

Backyard Chickens At Center of Salmonella Outbreak


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By Catherine Clabby

Within the really-local food movement, setting up a backyard chicken coop is a hot hobby.

And for good reason. No fresher source of eggs can be found. Whether down-coated chicks or speckle-backed hens, the birds are good company. Keeping the birds can teach children about biology, ecology and the effort involved in putting fresh food on the table.

USDA_ChickenPhoto

Even when chickens look healthy, it’s best to assume that they are infected with Salmonella and take steps to protect all living nearby. Source: U.S. Department of Agriculture.

But disease risk, particularly Salmonella infection, lurks in backyard coops too. And it’s back.

The Centers for Disease Control and Prevention has confirmed Salmonella cases in 35 states linked to exposures in backyard poultry flocks. North Carolina, with 26 known cases reported, ranks among the five states with most infections during this outbreak.

Long illness

Salmonella is not to be trifled with. At best, multiple strains of the bug produce significant diarrhea, fever, and cramping that can last four days to a week. Most people recover completely but a fraction develop reactive arthritis, an inflammation in the joints that can disappear, but roar back as a chronic condition.

“It’s not just: ‘I’m going to be better in a couple of days.’ It can lead to long-term issues,” said Ben Chapman, a NC State University food-safety specialist. “You can have quite a long illness.”

Children younger than five, whose immune systems are still developing, are most vulnerable to getting infected. Those children, elderly people, and anyone with an impaired immune system are most likely to get very sick or, on occasion, die from it.

A Salmonella infection can turn fatal if it moves from a person’s intestines into the bloodstream.

As of May 26, 2016, the Centers for Disease Control and Prevention counted 324 people infected by Salmonella strains, infections linked to live poultry in backyard flocks. Source: CDC

As of May 26, 2016, the Centers for Disease Control and Prevention counted 324 people infected by Salmonella strains, infections linked to live poultry in backyard flocks. Map credit: CDC

This trouble can start in chicken coops because Salmonella bacteria thrive in the intestines of healthy-looking poultry. When the birds poop, the pathogen escapes the chicken gut and enters spaces that poultry share with us.

People easily come into contact with infected feces on the ground where chickens peck, inside a flock’s coop or cages, in feed dishes and on the birds themselves. It’s not at all difficult for some of that material to travel on a person’s clothes or shoes.

Infection can strike when even trace amounts of feces get close to a person’s mouth. Given that young children are most likely to put their fingers and almost anything else into their mouths, they are most likely to encounter the bug.

Careful with those birds

The good news is that infection is preventable. CDC officials recommend that children five and younger not be allowed to touch chickens at all. Cuddling with or kissing the birds should be verboten for all. And anyone who touches a chicken or duck, or even has contact with their living quarters, must wash their hands well immediately.

The North Carolina Department of Agriculture and Consumer Services is advising people not to be deterred from keeping backyard flocks. Instead, in the latest edition of the Poultry Safety Newsletter, agency officials urge people keeping chickens to take all known steps to protect themselves.

“Poultry owners must remember that birds inherently have a degree of risk, and even though they feel like members of the family, birds should be kept out of human living areas,” said Sarah Mason, a veterinarian and director of the agency’s poultry-health program.

Mason stressed that there is no reliable way to test flocks for Salmonella because infected birds don’t shed the bacteria constantly. The best thing, she said, is to assume the infection is present.

Families living with young children or with elderly people at home can also discuss vaccinations with a veterinarian to see if a vaccine exists for the types of chickens they keep.

The CDC has linked Salmonella outbreaks to backyard poultry every year since at least 2012. Investigations linked this most recent outbreak to chicks and ducklings obtained from multiple sources, including feed stores, co-ops, hatcheries, and friends in multiple states.

CDC officials are asking mail-order hatcheries specifically to help stop these outbreaks, in part by tutoring customers about how to protect themselves.

Chapman, the N.C. State associate professor and creator of barflblog.com, sees great value in everything that children can learn when a family keeps chickens. But he also knows from experience with his two children, ages 5 and 7, that it’s tough to keep kids away from chickens, particularly the youngest ones. But it must be done.

“Baby chicks are cute to look at,” Chapman said.

PountryBoxPoultryBoxThe sight of a child suffering with Salmonella is not.

Senators Eyeing Solutions for Optometrist Shortage


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By Minali Nigam

The eyes have it in this year’s Senate budget, which calls for $2.1 million to fund adult eye exams.

“We have reinstated [that] coverage so that we can continue to find glaucoma and diabetes and other vision issues that exist in the Medicaid population for adults,” said Senate Health and Human Services appropriations co-chair Ralph Hise (R-Spruce Pine).

photo of the eye measurement device at an optometrist's office

Photo courtesy Andrew Fresh, flickr creative commons

Sen. Gladys Robinson (D-Greensboro) asked during a Senate appropriations meeting Wednesday whether the coverage would extend to treatment for people who are diagnosed after the routine eye exam.

Only the exams would be covered for adult eye issues, Hise conceded, adding that funding for follow-up services would be considered in the long run.

Even with the coverage, having all those eye exams performed could pose problems. According to 2014 health workforce data from UNC-Chapel Hill, twelve counties in North Carolina have few or no optometrists.

“Our ratio of optometrists to the population is low,” optometrist Dr. Hal Herring told legislators during a 2014 hearing.

That meeting brought lawmakers and optometrists together at the General Assembly to discuss provider practice, training, and the current state of optometry in North Carolina. Since Herring spoke at the legislature, there’s been little discussion about optometry training in North Carolina.

Until now.

The current Senate budget would also make moves to alleviate an optometrist shortage. Senators’ spending plan supports a study on creating a training school at Wingate University, in Union County.

“There are no schools for optometry in the state,” Sen. Tommy Tucker (R-Waxhaw) said during this week’s appropriations committee meeting. “Optometrists are aging out.”

The optometry program would be funded privately by Wingate, according to Tucker, but the state would put $900,000 towards establishing a free clinic so students could get experience while treating Medicaid patients.

Boy at phoropter; The phoropter is the most recognizable tool used by optometrists, used to determine a person's eyeglass prescription.

The phoropter is the most recognizable tool used by optometrists, used to determine a person’s eyeglass prescription.
Photo courtesy woodley wonderworks, flickr creative commons.

The plan encourages Wingate to assess the number of potential applicants and expenses for the program.

“No money has actually been appropriated; it’s just a study for the State to get the numbers,” Tucker said.

Herring told lawmakers in 2014 that national figures show roughly one optometrist per 7,000 persons. “In NC, it is closer to one optometrist for every 10,000 of the population,” he said.

Herring’s practice is in Robeson County, one of the shortage areas.

“If we had a school of optometry in North Carolina, we feel like that would be beneficial to our ratio of optometrists to population over the coming years,” he told lawmakers at the time.

Students from North Carolina who want to attend optometry training programs have to go out of state and pay out-of-state fees. Herring said that students who leave to be trained tend not to return to the state to establish their own practices.

How is North Carolina’s Medicaid Program Doing This Year?


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By Rose Hoban

As Gov. Pat McCrory introduced North Carolina’s Medicaid reform plan Wednesday, he praised this year’s “$300 million surplus in the Medicaid budget made possible by Republican-led reforms that have gotten the chronically troubled program back on track.”

When the budget numbers came in this spring, they showed the program was at least $313 million below it’s target budget.

And Republican leaders in the legislature have crowed over that number, most of which was returned to the state’s general fund this year.

However, it’s not clear that this year’s Medicaid surplus was a result of better management or legislative reforms, so much as better budgeting and some positive changes made possible by outside forces.

One of the biggest drivers for growth in the Medicaid program is enrollment. Last year, DHHS leaders projected that Medicaid enrollment would grow by 8.3 percent. That enrollment projection represented a higher growth rate than the level seen in most of the previous seven years. Even during the 2009 fiscal downturn, when many more people became eligible as people lost work, Medicaid grew by only 6.2 percent.

Blue lines show the predicted enrollment growth for Medicaid last year. The green lines show that actual growth was much lower.

Blue lines show the predicted enrollment growth for Medicaid last year. The green lines show that actual growth was much lower. Graph courtesy NC DHHS

[In 2014, enrollment growth for Medicaid alone was high at 9.2 percent, but that was in large part because kids in the state’s Health Choice program were moved into Medicaid as Health Choice was phased out. The total growth for the two programs overall was 6.6 percent.]

In a program as large as Medicaid, a small change makes a big difference. Last year’s actual growth in enrollment was only 3.3 percent. That seemingly small difference added up to more than $107 million in savings.

When asked about those over-estimates, Medicaid head Dave Richard said the forecast was a “reasonable projection.”

“We knew that we were conservative in that,” said Richard, citing uncertainty caused by an influx of Medicaid applicants into the system as a result of the Affordable Care Act, which added about 66,900 people in 2014, but only about half that amount in 2015.

“We didn’t know what it would be like,” he said.

All data courtesy NC DHHS.

All data courtesy NC DHHS.

The other big source of savings in last year’s Medicaid budget came from federal dollars paid into the program. More than $87 million of surplus arose from a more generous federal rate for matching the state dollars North Carolina puts into the program. In 2014, the federal government paid $1.93 for every dollar paid in by North Carolina. Last year that matching payment went up to $1.96 for every North Carolina dollar.

That change amounted to at least $100 million. And this year, that rate will tick up again, to more than $2.02 paid by the feds for every North Carolina dollar spent.

As DHHS officials told legislators in May, “over 60 percent of the reduction is due to lower than anticipated enrollment and a more favorable match.”

Hospitals Partner with Community Programs to Improve Health Care


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By Minali Nigam

North Carolina hospitals say they are moving toward a new way of health care delivery: patient care beyond hospital walls.

Hospital officials and staff members came to the legislature last week, where they talked about how they’re partnering with community groups like food pantries and home-visiting programs to improve medical services and patient outcomes.

In one of the interior courtyards of the legislative building in Raleigh, a dozen hospitals and health care companies had tables displaying everything from new ways of measuring patient satisfaction to information about a community farmers’ market at a local hospital.

“We’re here to let the General Assembly know that we are working steadily on an innovational advancement to transform health care in North Carolina,” said Cody Hand, a lobbyist for the North Carolina Hospital Association.

Feeding patients

Melissa Lewis, a nurse at Ashe Memorial Hospital, said many of her patients have difficulty following through with their medical-treatment plan because they lack basic necessities, like food.

In Ashe County, one in six adults and one in three children have limited access to food, Lewis said.

Doctors and social workers at Ashe Memorial Hospital keep track of what kinds of patients need food and other help in order for them to be more successful when they are discharged from their hospital stay.

Doctors and social workers at Ashe Memorial Hospital keep track of what kinds of patients need food and other help in order for them to be more successful when they are discharged from their hospital stay. Photo credit: Minali Nigam

To combat their patients’ hunger, last December the Ashe County Sharing Center suggested making the hospital a food pantry for the community. Every patient admitted to Ashe Memorial Hospital is asked on an intake form about food insecurity. When they’re discharged, those patients in need are given a food box that lasts for about a week.

“I’ve had patients come back three months later, and when asked if they want a food box they say, ‘No, I don’t need it anymore. It was there when I needed it, and I have a job now, and I’m doing great,’” said Lewis, who’s also the hospital’s food pantry program director.

“It was a need at that moment. And that’s very humbling. I was able to help someone by roughly a $3 food box,” she said.

Hospital CEO Laura Lambeth said Ashe Memorial is the first hospital in the state with a food pantry program, and hopes for continued growth.

“Our philosophy is to help our community. But how can patients heal when they don’t have nutritious food?” she asked.

Supported through grant money, the Ashe Memorial Food Pantry Program has helped 176 patients get food boxes since its launch. In the fall, Lewis is adding a “Cooking Matters” class to the program, inviting patients who received food boxes to learn to grocery shop and cook on a budget.

“In a couple years, I hope to see readmissions rates go down,” Lewis said. “I’d like to see involvement in the community more, maybe even getting local farmers to do some produce, and cutting down our food insecure population in the county.”

Communications director Heather Monackey from WakeMed Hospital in Raleigh worked to bring a small once-weekly farmers market to the hospital grounds once the only grocery store in the area closed. She worked with Wake County farmer Roger Ball to get fresh fruits and vegetables to the neighborhood every year from April until Labor Day.

Communications director Heather Monackey from WakeMed Hospital in Southeast Raleigh worked to bring a small once-weekly farmers market to the hospital grounds once the only grocery store in the area closed. She worked with Wake County farmer Roger Ball to get fresh fruits and vegetables to the neighborhood every year from April until Labor Day. Photo credit: Rose Hoban

Managing meds

In Vance and Nash counties, hospitals have directed attention toward improving transitional care by partnering with the N.C. Mobile Medication Program, or MMP, a pilot initiative for visiting behavioral health patients in their home.

Staff members teach patients with severe mental health problems how to take their medications and build medication management into their daily routine.

“After psychiatric hospitalizations or an ED visit, patients are sometimes prescribed up to 10 to 12 different medications,” said Katelyn Chiang, a MMP assistant.

“A lot of times, it’s not that they want to be uncompliant with their meds, they’re just honestly confused. When you have 10 different pills, you don’t always know when to take them and what to take them with.”

Launched in early 2015, the MMP works with patients for six months, starting with daily home visits and transitioning to weekly phone calls, with the ultimate goal of patients taking medications routinely without any help. Chiang said that with the program still in its infancy, there’s uncertainty about whether it would include services for patients with issues other than mental health.

Participants in Nash and Vance counties are already more likely to take their prescribed medications on time and correctly, according to a case study done by the MMP. Patients have also had a 75 percent reduction in psychiatric hospitalization.

Chiang says these types of health outcomes make MMP expansion to other counties more promising.

Access to specialized pharmacies

It’s one thing to take your medications correctly; it’s another to be able to get them at all, especially if you’re uninsured. But a program in Durham is helping patients do just that.

Lynn Robbins, who heads pharmacy services at Lincoln Community Health Center, said a partnership with Duke Regional Hospital has eased the burden for uninsured patients to get specialty medications. Patients using the health center’s pharmacy can get discounts for medications and a face-to-face consultation with a pharmacist.

“In the hospital setting, we know about quality, we know how to do performance improvement,” Robbins said.

“Because of this partnership, we’re able to integrate those quality tools into our health safety net organizations and bring about transformational care,” she said.

The majority of patients who receive their primary care services at Lincoln are uninsured. Robbins said the collaboration with Duke Regional enables patients to receive good health care by making sure their medications are affordable and accessible.

“A premier partnership of hospital and community can decrease health care cost and improve population health,” she said.

Funds for Food Desert Initiative Move Forward


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Three years after the legislature started hearing about food deserts, legislators are poised to address North Carolina’s obesity problem.

By Rose Hoban

Walk into Carolina Country Fresh on the edge of the Pitt County town of Bethel this week and you’ll be surrounded by fresh lettuce, onions and peas.

And strawberries – for another week or so. You drive past where they grew to get to the store, the only place for miles where you can find something fresh to eat.

Strawberries on display at Carolina Country Fresh.

Strawberries on display at Carolina Country Fresh. Photo courtesy CCF Facebook page, with permission

Bethel is a blinking red stoplight where Main St. crosses Business 64, a couple of churches, a school, some pretty little houses and a lot of run-down ones.

If you don’t farm, there’s really not much else, said Josh Roberson, who owns Carolina Country Fresh. Even with the farms, the area used to be a food desert before he opened. You had to drive more than 10 miles to find some produce.

“A Piggly Wiggly was in town, and that grocery store closed up,” he said. “Dollar General started carrying some groceries and they’re not carrying much of anything fresh; it’s just a lot of canned and boxed stuff. There’s no immediate source of really fresh produce.“

Until Roberson and his dad opened their business.

Carolina Country Fresh was one of the original pilot sites for the so-called “corner store initiative” being discussed in the budget at the General Assembly this month. Roberson and his dad received a grant to get equipment to keep the produce fresh, especially in the summer.

A display case at Carolina Country Fresh.

A display case at Carolina Country Fresh. Photo courtesy CCF Facebook page, with permission.

“There’s one of the open front coolers; I think the technical term is like an air dam. It’s like a fan that blows air straight down to keep the cool air in,” he said. “It’s so accessible, it’s so nice and so open and has a mirrored background, so the produce you put in there looks really nice.”

Health advocates are asking for a million dollars to help small store owners around the state do what the Robersons have done.

“It definitely helps the aesthetics of the business,” Roberson said. “We’re all drawn to something shiny, something that looks nice, right?”

Berries vs. honey buns

During the 2015 legislative session, House lawmakers passed a bill allowing for small retailers such as Roberson’s to receive small grants up to $5,000 to cover the costs of buying or renting refrigerators, display shelving and other equipment that would allow for the stores to stock nutritious foods.

Peas shelled fresh at Carolina Country Fresh market in Pitt County.

Peas shelled fresh at Carolina Country Fresh market in Pitt County. Photo courtesy CCF Facebook page, with permission.

According to the U.S. Department of Agriculture, there are 349 food deserts in urban areas in North Carolina. That means there’s no place to buy healthy food for more than a mile. In rural areas, that distance stretches to 10 miles.

Since passing the House in 2015, the bill has been sitting in a Senate committee. Peg O’Connell, a long-time lobbyist for public health interests, has been working both chambers to get the bill passed and the million dollars in seed money for the initiative into the state budget.

Even though many House members have been supportive, there’s been resistance.

“People don’t go to convenience stores to buy fruits and vegetables,” argued Rep. Michael Speciale (R-New Bern) during budget hearings. “We go there to buy honey buns – honey buns and Cokes.”

He moved an amendment that would have stricken the appropriation, which would have come from a community development block grant, and put it elsewhere.

But even the town of Oriental, in Speciale’s district, nearly became a food desert last year when the local Walmart Express closed. Local leaders scrambled to get fruits and vegetables into the local provision company that usually serves the waterfront.

Many folks were forced to drive up to two hours, to New Bern or Vanceboro, several times a month to grocery shop, said Town Manager Diane Miller.

A Piggly Wiggly will be moving into the old Walmart building soon, she said. But that was only because some high-powered retirees in town organized and made it happen.

“If you have a poor community with little resources and they’re trying to get through the same situation, then what do you do?” Miller asked.

Communications director Heather Monackey from WakeMed Hospital in Raleigh worked to bring a small once-weekly farmers market to the hospital grounds once the only grocery store in the area closed. She worked with Wake County farmer Roger Ball to get fresh fruits and vegetables to the neighborhood every year from April until Labor Day.

Communications director Heather Monackey from WakeMed Hospital in Southeast Raleigh worked to bring a small once-weekly farmers market to the hospital grounds once the only grocery store in the area closed. She worked with Wake County farmer Roger Ball to get fresh fruits and vegetables to the neighborhood every year from April until Labor Day. Photo credit: Rose Hoban

In the end, Speciale’s amendment failed, and $300,000 of the money stayed in the final House budget.

“We’re starting to hear that if it comes over from the House in the budget, that the Senate might not take it out,” O’Connell said.

Military readiness

One strategy O’Connell’s taken for selling the initiative in the Senate has been to point out that obesity has become a national security problem of sorts.

In 2010, dozens of retired generals, admirals and civilian military leaders published a manifesto, “Too Fat to Fight,” calling on the U.S. to address its weight problem.

The group cited Department of Defense data showing that more than a quarter of young Americans are too physically unfit to be recruited into the military. The same report showed obesity was the leading medical reason for being rejected from service.

“Since 1995, the proportion of recruits who failed their physical exams because they were overweight has risen by nearly 70 percent,” retired Army General John M. Shalikashvili, the former head of the Joint Chiefs of Staff, wrote in the report.

In North Carolina, about 28 percent of high school students are overweight or obese, according to a 2015 report card compiled by Prevention Partners, and only 12.3 percent of people eat five or more servings of fruits and vegetables per day.

“We won’t be able to defend ourselves,” said Rep. Grier Martin (D-Raleigh), who served two years in the Army in Afghanistan. “Of course, it’s a health care issue, but it’s important to realize the truly important national security aspect of the issue.”

Sen. Louis Pate (R-Mt Olive), who served in the Air Force in Vietnam, said O’Connell has a compelling argument.

“I think it would be very helpful if we could get something like that into food deserts,” he said, noting that he went over to Roberson’s store last year and liked what he saw.

But he remained noncommittal when asked about the appropriation’s chances.

“I think it’s probably something that we’re taking a hard look at,” he said. “It could have a big payoff.”

Study Finds Encouraging Surgical Outcomes at Critical Access Hospitals


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By Taylor Sisk

On the heels of a report warning that more than a third of the nation’s critical access hospitals are in danger of closure comes some encouraging news. A new study indicates certain procedures are being performed in these small hospitals more safely and at a lower cost than in larger institutions.

A University of Michigan team of researchers looked at four common surgeries – appendectomy, gall bladder removal, hernia repair and removal of all or part of the colon – and found no statistically significant difference in 30-day mortality rates between critical access and other hospitals.

Further, critical access hospitals experienced serious complications in performing these procedures 6.4 percent of the time as compared with 13.9 percent of the time in other hospitals.

CAHs also billed Medicare an average of $1,400 less for the procedures.

CAHs serve many of the nation’s remotest regions. By definition, they have fewer than 25 beds and are more than 35 miles from the next nearest hospital. They must maintain an average length of stay of 96 hours or less for acute-care patients and provide 24-hour emergency-care services. In return, they receive preferential reimbursement from Medicare, which covers more of their costs.

North Carolina had 20 critical access hospitals as of Nov. 2014. Since that time, Yadkin Valley TKTK Hospital has closed. Blue areas on the map indicate non-metropolitan counties.

North Carolina had 20 critical access hospitals as of Nov. 2014. Since that time, Yadkin Valley Community Hospital has closed. Blue areas on the map indicate non-metropolitan counties. Map courtesy UNC Sheps Center for Health Services Research

There are 1,284 CAHs throughout the country; North Carolina has 20.

Two CAHs in the state have shut down in just over two years: Vidant Pungo Hospital in Belhaven in February 2014 and Yadkin Valley Community Hospital in Yadkinville in May of last year.

Doing what they should

The Michigan researchers examined more than 1.6 million Medicare-beneficiary admissions to 828 CAHs and 3,676 other hospitals. Their results were published last week in the Journal of the American Medical Association.

Transylvania Regional Hospital. Photo credit: John Warner

Transylvania Regional Hospital. Photo credit: John Warner

The researchers found that patients who had any of the four types of operations at CAHS tended to be healthier upon admission than patients treated for the same procedures at other hospitals. They said this indicated CAH surgeons appropriately selected patients who they felt would be most likely to have positive outcomes, while sending higher-risk patients to larger hospitals.

“From a surgical standpoint, these hospitals appear to be doing exactly what we would want them to be doing: common operations on appropriately selected patients who are safe to stay locally for their care,” lead author Andrew Ibrahim said in a release.

That said, even after correcting for differences in health status at the time of the operations, the CAHs had equal or better outcomes.

‘On the firing line’

In rural communities throughout the country, small hospitals in general, and critical access hospitals in particular, are facing mounting challenges including reduced reimbursements; aging, declining populations; and difficulties recruiting health care professionals.

“Critical access hospitals are on the firing line. They’re in the middle of the target,” Alvin Hoover, past chairman of the American Hospital Association’s Small or Rural Governing Council and current board chair of the Mississippi Hospital Association, said in a recent interview. “It’s hard for me to understand why you want to target those guys, because if you look at the cost of care, they do it cheaper than anybody else.

“If you can keep that person home, right there in that local community, your cost of treatment of that pneumonia patient, [for example], is going to be way less than it is if you have to send them to the big university.”

The outcomes found in this research, the study’s authors write, should “inform legislators about the valuable role critical access hospitals provide in the U.S. health care system.”

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