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Keeping the Mentally Ill Out of Hospitals


By Christine Vestal


It is a busy Friday afternoon. Staff members check in guests at the front desk. Other employees lead visitors on tours of the upstairs bedrooms or field calls from people considering future stays. Aromas of garlic and roasted chicken seep out of the kitchen.

Community Access is not a bed and breakfast, although it feels that way when you walk through its unmarked door off Second Avenue on Manhattan’s Lower East Side. Also known as Parachute NYC, this quiet seven-bedroom facility is one of four publicly funded mental health centers in New York City (located in Manhattan, Brooklyn, Queens and the Bronx) that provide an alternative to hospital stays for people on the verge of a mental health crisis.

Laurie Coker has spent years creating places to nurture and support people with mental health issues.

Laurie Coker has spent years creating places to nurture and support people with mental health issues. Her current goal is to create a respite center similar to Parachute here in N.C.. Photo credit: Taylor Sisk

Parachute’s respite centers have no medical staff, no medications, no locks or curfews and no mandatory activities. They are secure, welcoming places where people willingly go to escape pressure in their lives and talk to trained “peer professionals” who can relate to what guests are going through because they are recovering from mental illness themselves.

Without places like this, New Yorkers who suffer from serious mental illness would have little choice but to check into a hospital or a hospital-like crisis center when their lives spin out of control. Some people need to be hospitalized for severe psychosis and depression, but many others end up in the hospital because they have no other options.

Relatively rare in the U.S., respite centers like this one cost a fraction of the price of a hospital stay and can be far more effective at helping people avoid a psychotic break, severe mood swing or suicidal episode.

Community-based mental health services are particularly vital at a time when the number of beds in state psychiatric hospitals has declined sharply. Nationwide, psychiatric hospitals shed 3,222 beds from 2009 to 2012 amid recession-related budget cuts, and the number has continued to decline even as the economy has improved. According to the U.S. Substance Abuse and Mental Health Services Administration, 55 percent of U.S. counties have no practicing behavioral health workers and 77 percent have reported an unmet need.

Launched in 2013 by the city’s public health department, Parachute NYC includes mobile treatment units and phone counseling in addition to the four brick-and-mortar respite centers. A collaboration of city and state mental health agencies, the project received a three-year $17.6 million innovation grant from the U.S. Department of Health and Human Services. Its financial goal is to save $50 million in hospital expenses.

In addition, New York state’s Medicaid agency plans to use a federal waiver to pay for respite services and other community mental health services for 140,000 state residents under a managed care program for people with behavioral health needs. Separately, New York state’s mental health office has invested $60 million since last year on the creation and expansion of community-based services throughout the state, including child and adult respite programs.

“A hospital is the last place you want to be if your life is unraveling,” said Community Access CEO Steve Coe. “They put you in a room, check your blood pressure and walk away and leave you for hours. You need to put your life back together, not be held in a place where you can’t do anything or talk to anyone,” he said.

Nevertheless, there is broad agreement that nonmedical services such as Community Access are not for everyone.

“The caution is that while this approach is good for some people, others really need medication and structure, so it has to be a good match for the person who is coming into it,” said Sita Diehl, director of state policy at the National Alliance on Mental Illness. “The advantage is that you get an expert listener working with you, really delving into who you are, rather than someone slapping a diagnosis on you and handing you a prescription.”

Averting crisis

Parachute NYC provides a non-threatening environment where people who are coming undone can take a break from their turbulent lives and think through their problems before they reach a crisis point. Many who shun hospitals and crisis-stabilization units will voluntarily seek help at respite centers.

In fact, Community Access insists that all prospective guests check in on their own, without coercion from a doctor, friend or family member. They also screen applicants to ensure that respite is their best option. Some may need medication and more intensive treatment from medical professionals.

“We’re not against medication,” assistant director Keith Aguiar explained. “If they come in with their own medications and they want to take them, that’s fine. But we do not tell them they have to.”

Many guests have full-time jobs and continue working and seeing friends during their stay. They can come and go any time of day or night. Unlike a hospital, Coe stressed, respite centers allow people to maintain their lives and relationships instead of putting everything on hold. Guests can also continue seeing their regular mental health providers during their stay.

The maximum length of stay at Parachute NYC respite centers is 10 days, soon to be shortened to one week under new Medicaid rules. But guests can return up to three times per year as needed. They also can visit weekly and monthly as “alumni” and take part in group activities and talk to staff.

To qualify for any of Parachute’s respite centers, guests must be New York City residents who are 18 or older.  They must also have a clinical evaluation (within the last 48 hours) and a referral from a mental health provider stating they are not an imminent risk to themselves or others and would benefit from respite care. Guests also must have stable housing to go back to.

The guest list

“We have a wide diversity of guests, from a Columbia University professor and an art critic to people who have been chronically homeless much of their lives,” Aguiar said. “We see men and women of all ages and all walks of life.”

In the last month, the guest list at Community Access included a 28-year-old woman who was living in mental health support housing and believed her roommates were practicing witchcraft on her. She was referred by her housing counselor. A 24-year-old woman with a diagnosis of schizoaffective disorder needed to escape mounting conflicts at home with her brother, who had a diagnosis of schizophrenia. She was referred by a community psychiatric team.

A 70-year-old jazz musician who suffered from drug and alcohol addiction came to get away from his chaotic living situation. He talked to peers about his struggle with addiction, played his trumpet and napped a lot during his stay.

“It was the best sleep I’ve had in years,” he told the center’s director Lauren D’Isselt, who is a psychologist.

Another woman, 25, applied to become a guest without a referral. (The center arranged for Parachute’s mobile unit of clinical professionals to provide an assessment.) She’d heard about Community Access from a friend. A native New Yorker who left college because of severe depression, Maggie (not her real name) spoke calmly about her history of mental illness while sitting on a bench on the center’s sunny back courtyard.

“I wanted to finish college,” she said, “but I kept ending up on the tops of buildings.”

Diagnosed with depression when she was seven, Maggie has been in psychiatric care most of her life.  She spent the better part of the last six months in hospitals.

Now that she’s back in New York temporarily living with her parents, she said she wants to find the right kind of treatment and get on her feet so she can return to school.

“Living at home is not very comfortable because my parents are the source of my problem. They abused me when I was a child,” Maggie said.  She said she could stay with friends, but they don’t understand what she’s going through.

Five days into her stay, Maggie said it’s been good for her. She’s been able to make plans for future treatment.

“It makes a lot of sense,” she said.  “At a typical hospital, they take depressed people and lock them up and away from everyone and expect them to get better. Here you can go out and have coffee with a friend and no one has to go through double-locked doors to see you.”

“When I feel really anxious or sad, I can talk to a peer. Places like this are rare,” Maggie said. “But they shouldn’t be.”

A national need

One in four adults, about 62 million Americans, experiences some form of mental illness during the course of a year. Of those, about 14 million live with a serious mental illness such as schizophrenia, major depression or bipolar disorder, according to data from the National Alliance on Mental Illness. More than half of them do not seek treatment, in many cases because they don’t know where to find help.

For those who do seek treatment, the direct medical costs total more than $100 billion per year, according to estimates from the National Institute of Mental Health. Community mental health services such as respite centers may make it possible to reduce those costs and relieve the demand for psychiatric hospital beds, which are in short supply in most communities.

Parachute NYC has so far served about 700 people at its respite centers, 600 through its mobile treatment teams and more than 20,000 through its peer-operated telephone support service. The city’s health department intends to analyze the program to determine whether it has resulted in a reduction in the city’s 100,000 annual psychiatric emergency room visits.

“We don’t perform miracles here,” D’Isselt said. “But we do help people find joy in their lives.” Most guests forge new friendships and leave with a new life plan, she said. “A lot can happen in a week.”

Stateline is a nonpartisan, nonprofit news service of the Pew Charitable Trusts that provides daily reporting and analysis on trends in state policy.

Big Changes for DHHS, Medicaid Leadership


By Rose Hoban

A big shuffle is coming to the top of the state’s Medicaid program, Sec. Aldona Wos announced today.

The current Medicaid head, Robin Cummings, will be leaving the department to become the new chancellor of UNC-Pembroke, and with his departure many other roles are shifting.

Robin Cummings headshot

Robin Cummings, MD

Dave Richard, deputy secretary of Behavioral Health and Developmental Disabilities Services, will move into Cummings’ seat, while Dale Armstrong, the current director of the Division of State Operated Healthcare Facilities, will move into Richards’ former position.

Courtney Cantrell, who has led the Division of Mental Health, Developmental Disabilities and Substance Abuse Services, will take on new responsibilities and also support Armstrong.

And the department will also get some new blood at the top, with the arrival of Raleigh OB/GYN Randall Williams, who will become deputy secretary of Health Services, managing the state’s rural health and public health offices.

The shuffle is typical of staff movement in recent years at DHHS, with Wos keeping people she knows and trusts close to her.

Big jump

Before coming to DHHS, Richard was head of The Arc of North Carolina, an organization that works with people with intellectual and developmental disabilities. During Richard’s last year at The Arc, his budget was about $20 million. Now he’ll be managing a budget that is in the neighborhood of $14 billion.

“He’s ready to take the leap,” said Julia Adams, governmental affairs liaison for The Arc, who worked for Richard for years and called him the “right man” for the job.

Ronnie Beale (left), president of the state Association of County Commissioners, and Dave Richard, assistant secretary for mental health, developmental disabilities and substance abuse services, confer after the Legislative Breakfast on Mental Health.

Ronnie Beale (left), president of the State Association of County Commissioners, and Dave Richard, assistant secretary for mental health, developmental disabilities and substance abuse services, at the Legislative Breakfast on Mental Health earlier this year. Photo credit: Taylor Sisk

“He has a lot of experience in Medicaid in the state of North Carolina,” Adams said. “The Arc is a Medicaid provider and he had to work closely with numerous Medicaid directors over the years.”

Adams said Richard has been pretty successful in working with mental health and disabilities advocates during his time as deputy secretary.

“He keeps all the stakeholders fully engaged, informed and has a place at the table for those of us with expertise,” she said. “That was critical in making sure that as we moved through the first two years, we didn’t see major adjustments that were negative.”

Adams also praised Richard’s honesty, a trait that sometimes could be disarming to legislators.

Richard also kept a line open to the media, who he had worked with as an advocate before coming to DHHS, at a time when other DHHS leaders were keeping the media at a distance.

When asked earlier this year what he’d learned about government since switching roles, Richard said he learned that government is far more complicated than he had ever imagined when he was an advocate.

Tasks left undone

In an interview with N.C. Health News last year, Cummings expressed confidence he would be able to get the department’s preferred Medicaid reform plan through the General Assembly.

The department’s plan features provider-led organizations that would share financial risk with the state, whereas Senate leaders prefer a plan that would use for-profit managed care companies to run the Medicaid program.

“I think we do our education, we respond to questions and we make ourselves open to explaining why we think this is the way to go,” he said at the time. “Hopefully, in the end, after good debate, we will come to a plan that will look a lot like what we have presented as our goal and we can move on.”

Though Cummings was well liked and respected by lawmakers, he was unable to get Medicaid reform across the finish line, as negotiations over the future of the program disintegrated at the end of a committee process last fall.

Fewer Uninsured in N.C., But Fewer Still in Medicaid-expansion States


By Rose Hoban

New national numbers show that in states that have expanded Medicaid the rates of uninsurance have dropped at a faster rate than in states that didn’t expand the health care program for low-income people.

And North Carolina is among those states where, although the number of insured people is creeping up because of an improving economy, there are still a high rate of uninsured.

Data compiled by the National Center for Health Statistics show that the number of all people in the U.S. who are uninsured dropped from 14.4 percent in 2013 down to 11.3 percent in 2014.

MedicaidMoney_jpg_800x1000_q100But the difference in uninsured rates in so-called “expansion states” versus states that did not expand Medicaid are stark. Overall, states that expanded Medicaid, as allowed for under the Affordable Care Act, saw a drop in the ranks of the uninsured from 13 percent in 2013 to 9.3 percent in 2014.

North Carolina is one of the 22 states that have not considered expanding Medicaid, the program that serves low-income children, some of their parents, people with disabilities and low-income seniors. In states not expanding Medicaid, the number of uninsured dropped from 16 percent in 2013 to 13.5 percent in 2014.

The latest estimate of the number of people between 18 and 64 years old in North Carolina who remain uninsured is at about 17.2 percent, according to data from the National Health Interview Survey, the same source for the National Center for Health Statistics report.

“We are doing worse for uninsurance rates than the national average,” said Adam Zolotor, head of the North Carolina Institute of Medicine, who noted that was typical in non-expansion states.

But he did note some improvement in North Carolina’s numbers.

“People have been driven into the marketplace; that’s great news,” Zolotor said. About 463,000 people in North Carolina signed up for insurance in 2015 on the online health insurance marketplace created as a result of the Affordable Care Act.

”In addition, unemployment rates are down and my assumption is that employment-sponsored insurance is up,” he said.

Zolotor said more people have enrolled for Medicaid, in part because when they went to sign up for the health insurance marketplace they discovered they were eligible for Medicaid instead.

“We have seen an increase in Medicaid enrollment even without expansion,” noted Mark Holmes, a health economist at UNC-Chapel Hill’s Gillings School of Global Public Health. “Medicaid enrollment increased by about 300,000 in less than two years.”

The program had about 1.56 million beneficiaries in 2013, and has about 1.84 million beneficiaries now.

“Given that in general the economy is recovering, you’d be expecting Medicaid not to increase quite so fast,” Holmes said.

Percentage point decreases from 2013-2014 for persons 18-64 who were uninsured, by state Medicaid status and poverty status.

Percentage point decreases from 2013-14 for persons 18-64 who were uninsured, by state Medicaid status and poverty status. Data courtesy National Center for Health Statistics.

The NCHS report found the greatest gap in insurance came among people who earn below 138 percent of the federal poverty level ($15,836 for one person). People who fall into that income bracket would have benefitted most from expanding the program.

In states that expanded Medicaid, the rate of uninsurance dropped by 10.2 percent, whereas in states that did not expand the program the rate of uninsurance dropped by only 3.3 percent.

Health care advocates have been calling for North Carolina to expand the Medicaid program. While Gov. Pat McCrory and Department of Health and Human Services Sec. Aldona Wos have expressed interest, legislators have been cool to the idea.

UPDATED: Tanning Bed Bill Headed to Governor … Finally

On Wednesday, members of the Senate approved the measure by a 48-2 vote. It now goes to Gov. Pat McCrory for his signature.


By Rose Hoban

Legislative committee meetings usually aren’t emotional; they usually don’t involve standing ovations. But Tuesday morning’s meeting of the Senate Health Care Committee featured those things, along with passage of a bill that’s been held up in the Senate for several years.

With his widow in the room, the committee green-lighted a bill named for the late Rep. Jim Fulghum, who died in the summer of 2014 after a sudden, quick battle with late stage cancer.

The Jim Fulghum Teen Skin Cancer Prevention Act would keep teens under the age of 18 from using tanning beds ahead of proms and trips to the beach.

“I want to thank you for this vote of confidence,” said Mary Susan Fulghum, a retired obstetrician/gynecologist and Rep. Fulghum’s widow.

“Jim supported the bill before you today because he understood … the devastating impact skin cancer is having on young people, especially young women,” she said.

She noted the “overwhelming amount” of evidence linking even modest use of tanning beds to increased skin cancer incidence.

“He saw this bill as a way to build on the partnership between government and parents to make sure children have the best opportunity possible to become healthy, productive, responsible adults,” she said, before receiving a standing ovation from legislators and people in the audience.

Currently, anyone under the age of 18 has to have parental permission to use the devices, but many kids get around the restrictions. And research has revealed that some young women even go to tanning salons with their mothers.

After the meeting, Mary Sue Fulghum noted that as a gynecologist she treated many young women who used tanning beds and that she encouraged her late husband’s involvement in the bill.

Long history

Sen. Stan Bingham (R-Denton) noted during the committee meeting that former Sen. Bill Purcell (D-Laurinburg) first introduced bills to limit tanning bed use by young people in 2009. Similar bills have been introduced in each biennial session since.

In 2013, the bill was reintroduced and received enthusiastic support from Fulghum, who was a freshman representative at the time. Fulghum co-sponsored the bill and shepherded it through the House, only to see it languish in the Senate, which did not consider the bill for more than a year.

House members then inserted language forbidding tanning bed use by teens into an omnibus regulatory reform bill, which again saw no movement from the Senate.

Mary Susan Fulghum thanks members of the Senate Health Care Committee for approving the Jim Fulghum Teen Cancer Prevention Act on Tuesday.

Mary Susan Fulghum thanks members of the Senate Health Care Committee for approving the Jim Fulghum Teen Cancer Prevention Act on Tuesday. Photo credit: Rose Hoban

The bill was consistently opposed by trade associations representing tanning salons.

During the committee meeting Tuesday morning, Michael Hauser from the Indoor Tanning Association said the bill “would regulate a large number of these tanning salons out of business.”

In past years, arguments from the indoor-tanning industry seemed to carry some weight. But this year, the industry’s entreaties did not move legislators.

On Tuesday, Sen. Tommy Tucker (R-Waxhaw) noted that when his wife gave him a gift pedicure at a local salon, he witnessed girls getting into tanning beds and “literally come out of those tanning booths looking like lobsters.”

Tucker described himself as an “involved parent,” yet did not understand what tanning beds could do until learning about the bill at the legislature.

“I did not realize it was 14 times stronger than ultraviolet rays we have in the sun. I did not realize that teens and young adults who begin tanning before the age of 35 have a 59 percent higher chance of getting skin cancer,” said Tucker.

“I cannot tell you since this bill’s been introduced the number of young women who have come forward, even on the lobbyist staff here,” he said.

The bill passed the House last week, and on Tuesday the Senate Health Care Committee unanimously approved it. Now it’s on its way to the Senate floor.

Hundreds of Hospitals Struggle to Improve Patient Satisfaction

Kaiser Health News

Lillie Robinson came to Rowan Medical Center for surgery on her left foot. She expected to be in and out in a day, returning weeks later for her surgeon to operate on the other foot.

But that’s not how things turned out.

“When I got here, I found out he was doing both,” she said. “We didn’t realize that until they started medicating me for the procedure.” Robinson signed a consent form and the operation went fine, but she was told she would be in the hospital far longer than she had expected.

“I wasn’t prepared for that,” she said.

Disappointing patients such as Robinson is a persistent problem for Rowan, a hospital with some the lowest levels of patient satisfaction in the country. In surveys sent to patients after they leave, Rowan’s patients are less likely than those at most hospitals to say that they always received help promptly and that their pain was controlled well. Rowan’s patients say they would recommend the hospital far less often than patients do elsewhere.

Feedback from patients such as Robinson matters to Rowan and to hospitals across the country. Since Medicare began requiring hospitals to collect information about patient satisfaction and report it to the government in 2007, these patient surveys have grown in influence.  For the past three years, the federal government has considered survey results when setting pay levels for hospitals. Some private insurers do as well.

In April, the government will begin boiling down the patient feedback into a five-star rating for hospitals. Federal officials say they hope that will make it easier for consumers to digest the information now available on Medicare’s Hospital Compare website. Hospitals say judging them on a one-to-five scale is too simplistic.

Some hospitals improve as others stagnate 

Nationally, the hospital industry has improved in all the areas the surveys track, including how clean and quiet their rooms are and how well doctors and nurses communicate. But hundreds of hospitals have not made headway in boosting their ratings, federal records show.

“For the most part, the organizations that are doing really wonderfully now were doing well five years ago,” said Deirdre Mylod, an executive for Press Ganey, a company that conducts the surveys for many hospitals. “The high performers tend to continue to be the high performers and the low performers tend to be low performers.”

Some hospitals have made great gains. The University of Missouri Health System, for example, created a live simulation center at its medical school in Columbia to help doctors learn to communicate better with patients. The simulations use paid actors. Instead of having to diagnose the patient, doctors must respond to nonmedical issues, such as a feuding teenager and mother or a patient angry that he was not given information about his condition quickly enough.

“My scenario was I was late to the appointment and the patient’s husband was upset,” said Kristin Hahn-Cover, a physician at Missouri’s University Hospital. In 2013, the most recent year that the government has provided data for, 78 percent of patients at University Hospital said doctors always communicated well, a 10 percentage point jump from 2007. Other scores rose even more.

At Virginia Hospital Center in Arlington, executives credit improvements in patient satisfaction to their psychological screening methods in hiring and rigorous job reviews. Potential nurses and other staff must first pass a behavioral screening test and then be interviewed and endorsed by some of the staffers with whom they would be working. In the third element of the program, every six months managers rate employee performance as high, medium or low. Low performers are told to improve or find work elsewhere.

“Those are the three most defining things we did as an organization,” said Adrian Stanton, the hospital’s chief marketing officer. “Without that, I can guarantee you we wouldn’t have had the successes.”

Stubbornly low

Nudging up scores has been a frustrating endeavor elsewhere, like at Novant Health, a nonprofit hospital system that runs Rowan Medical Center and 13 other hospitals in North Carolina, South Carolina and Virginia. While some Novant hospitals have excellent patient reviews, Rowan’s scores have remained stubbornly low since Novant took over the hospital in 2008. The hospital is losing $29,000 this year because of the low scores.

Last fall, Rowan’s president, Dari Caldwell, replaced the physician group that ran the emergency room because the doctors had not reduced wait times. ER waits are down to half an hour, a spokeswoman said. Doctors and nurses also are being coached on their bedside manner, like being advised not to stare at their computer when a patient is talking.

Rowan’s nurses now spend 70 percent of their time with patients, swinging by every hour. Even the president makes rounds once a day. The hospital has made lots of small improvements to provide a warmer environment, such as putting white poster boards in each room where nurses can list a few personal details about their patients.

“I can go in there and say, ‘Oh, you have three dogs,’ or, ‘You have a grandchild; that’s great, great,’” said Jennifer Payne, a nurse manager. “And they can talk for hours about that.”

Payne said she pores over patient comments and surveys, passing around the good ones and tackling complaints. “We’re very driven by what these patients say,” she said. “Everything I do is based around how these patients come back [in comments in the surveys] and say, ‘Hey, is this working,’ or, ‘This isn’t working.’”

Perceptions sometimes hard to change 

Rowan executives fear scores may not be going up because patients still harbor bad memories from previous hospitalizations.

“I was treated like a dog,” Carl Denham, 76, said about a stay two years ago. He said the hospital was doing loud construction work that kept him awake, and it took nurses all day to deliver an oxygen tank his doctor ordered.

Admitted again in Rowan in December, Denham said that visit was different.

“It is fantastic from what it used to be, if you want my opinion,” he said as he lay in his hospital bed a few days after he came back. “I’ve been both ways and the way it is now, it is great. No waiting and the doctors are all pleasant. I never thought I’d see it like this.”

He said he would give the hospital top marks.

His daughter Benicia said that in the last visit she had to nag the nurses to get her dad his medication. This time, it has not been an issue. “It’s like a totally different hospital,” she said. “I had to say, ‘Did I come to Rowan Regional?’”

Despite the unexpected operation on both feet, Robinson also said nurses have been attentive to her pain. “They do the best they can,” she said. “At times, it gets so bad I’m crying because it’s overwhelming to me.”

But “the best they can” is not good enough for Medicare. In determining how much to pay hospitals, the government only gives credit when patients say they “always” got the care they wanted during their stay, such as their pain was “always” well controlled. If a patient says that level of care was “usually” provided, it does not count at all. Likewise, the surveys ask patients to rank their stays on a scale of 0 to 10. Medicare only pays attention to how many patients award the hospital a 9 or 10.

“Sometimes what we see and hear from our patients doesn’t show up on their surveys,” Rowan’s president Caldwell said.

Too Few

Another challenge for hospitals is that Medicare does not take into account the inexact nature of these ratings, which can be based on as few as 100 patients over a year. Medicare recommends a minimum of 300 surveys, but even those have imprecisions that Medicare does not highlight when publishing ratings on Hospital Compare, or take into account when determining financial bonuses or penalties.

In its hospitals with lower ratings, Novant is trying to replicate some of its successes at its Medical Park Hospital in Winston-Salem, a surgical center, which has the best patient-satisfaction scores in the Novant system. Sean Keyser, Novant’s vice president for patient experience, interviewed the staff to figure out how it performed so well.

“The first thing they suggested was the relationship between the physician and the nurses,” he said. “They tend to round more together; they tend to huddle more together. It doesn’t matter how long we study health care organizations, personal relationships that caregivers have with each other translates into better relations with patients.”

Staff members from Medical Park now conduct the pre-surgical discussions for patients at several bigger Novant hospitals. Those preparatory talks, which take place a week or two before planned operations, give nurses the chance to allay fears and make sure that patients have realistic expectations of what will happen.

Scott Berger, a surgeon, said the smallness of the hospital – Medical Park has only 22 beds, while Rowan has 268 – gives Medical Park an advantage over other hospitals in pleasing patients.

“We also think that because we only do surgery here, that we’re really able to have kind of a sharp edge, if you will, of focus on good outcomes and good patient care,” he said. “And that really carries over to the nurses as well. Because all day every day, that’s all they see, is the same kind of surgical patients over and over again.”

Even patients who had not prepared to come to Medical Park are impressed. George Stilphen, who was admitted for emergency colon cancer surgery, said he planned to rate the hospital a 10.

“They said that they’d take great care of us,” he said as he recovered from surgery in the hospital. “They were very soothing, comforting, they weren’t condescending. It was a great experience.”

Michael Tomsic, a reporter for WFAE, contributed to this report.

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.

WNC Dairy Owner Sentenced For Dumping Cow Poop in French Broad River


Press release from the U.S. EPA

Dairy Company Owner Sentenced to Six Months of Home Detention and Ordered to Pay $15,000 Fine for Discharging 11,000 Gallons of Cow Feces into the French Broad River

ATLANTA – William “Billy” Franklin Johnston, the owner of one of North Carolina’s largest dairy farms located in Fletcher, N.C., was sentenced Thursday to four years of probation, six months of which he has to spend in home detention, for his role in the discharging of cow feces into the French Broad River, announced Jill Westmoreland Rose, Acting U.S. Attorney for the Western District of North Carolina. U.S. Magistrate Judge Dennis L. Howell also ordered Johnston to pay a $15,000 fine.

The dairy company, Tap Root Dairy, LLC (Tap Root), was also fined $80,000 and was placed on a four-year probationary term. The company is also required to abide by a comprehensive environmental compliance plan.

Image courtesy Ann Marie Michaels, flickr creative commons

Image courtesy Ann Marie Michaels, flickr creative commons

Acting U.S. Attorney Rose is joined in making the announcement by Special Agent in Charge Maureen O’Mara of the U.S. Environmental Protection Agency, Criminal Investigation Division (EPA-CID), Atlanta Area Office, and B. W. Collier, Acting Director of the North Carolina State Bureau of Investigation (SBI).

A criminal bill of information filed in U.S. District Court on November 11, 2013, charged Tap Root and Johnston, 62, of Mills River, N.C., with one count of violation of the Clean Water Act, in connection with the discharging of cow feces into the French Broad River.

Johnston, the owner of Tap Root, is also a Board Member of the North Carolina Department of Agriculture and currently serves as a Council member for the Town of Mills River.

According to filed documents and statements made in court, Tap Root maintains several hundred cows and manages hundreds of acres of crop fields in Fletcher. In the annual course of its operations, Tap Root disposes millions of pounds of solid and liquid animal waste, which are considered pollutants under the Clean Water Act.

Court documents indicate that beginning in 2009, Johnston let his certification lapse as Operator in Charge (OIC) of Tap Root’s animal waste management system.

Despite receiving repeated warnings and notices, court records show that as of December 4, 2012, Tap Root still had not designated a valid OIC to oversee its waste management system. Furthermore, according to filed documents, from September 3, 2012 to December 4, 2012, for a total of 93 days, Johnston and the Tap Root employees had failed to check and maintain the levels of cow waste in their on-site waste containment lagoons.

According to court records, this resulted in the spillover and discharge of 11,000 gallons of cow feces and other waste into the French Broad River on December 4, 2012.

Fletcher-based Tap Root Dairy sits aside the French Broad River upriver from Asheville.

Fletcher-based Tap Root Dairy sits aside the French Broad River upriver from Asheville. Image courtesy googlemaps

Testing by the North Carolina Department of Environment and Natural Resources concluded that the fecal coliform level where the waste stream meets the river was 99,000 parts per million, whereas anything above 800 parts per million is indicative of a release. Even downstream, testing found that the fecal coliform level was 2,200 parts per million.

“Agriculture is an important sector of Western North Carolina’s economy but it should not thrive at the expense of public health. Environmental protection laws are in place to ensure appropriate land use and safeguard our communities from potentially harmful pollutants,” said Acting U.S. Attorney Rose.

“As one of North Carolina’s largest dairies, Tap Root Dairy Farm has an obligation to protect the surrounding community from pollution,” said Maureen O’Mara, Special Agent in Charge of EPA’s criminal enforcement program in North Carolina. “Animal wastes are considered pollutants under the Clean Water Act because when discharged illegally, they can cause serious damage to the environment and put human health at risk. Today’s sentencing shows that those who violate our nation’s environmental laws will be held accountable for their crimes.”

The Clean Water Act is a federal law enacted to prevent, reduce and eliminate pollution, and to restore and maintain the chemical, physical, and biological quality, of the Nation’s waters for the protection and propagation of fish and aquatic life and wildlife, for recreational purposes, and for the use of such waters for public drinking water, agricultural, and industrial purposes.

The French Broad River supplies drinking water to more than one million people and is frequently used for recreational water activities, such as swimming and kayaking.

In 2012, North Carolina listed the French Broad River from Mud Creek to NC Highway 146 as “impaired” for fecal coliform bacteria. Tap Root is located on this impaired section of the French Broad River.

The investigation of this case was conducted by special agents of the EPA’s Criminal Investigation Division, and SBI’s Diversion and Environmental Crimes Unit. The prosecution is being handled by Assistant United States Attorney Steven R. Kaufman of the U.S. Attorney’s Office in Charlotte.

United States v. Tap Root Dairy et al; 1:13-mj-61-MR-DLH

Reporter’s Notebook: Of Sausage Making and Sleep Deprivation


Editor Rose Hoban contemplates the practice of making laws late in the evening.

By Rose Hoban

My mom says I’m a lot like my late dad: I have his heavy eyebrows (boo), his intellectual curiosity (yay) and, like Jack Hoban, I can sleep on a picket fence (double yay).

Also like my dad, I’m a mess if I can’t get enough sleep. And this week, I haven’t gotten enough sleep.

I blame the legislature.

This week was “crossover.” If your non-spending-related bill isn’t through one chamber by Thursday at midnight, there’s a good chance it’s dead for the next two years. So lawmakers end up piling the work and getting everything in just under the deadline – a little bit like reporters.

But the catch is, they’re not writing a story. They’re making our laws.

Legislators (and the reporters who cover them) were all in the General Assembly building late for three days this week, and back early each day following. On Wednesday, many of them started their days with committee meetings at 8 and 9., and then were in the floor session from early afternoon until after midnight.

The NC House of Representatives met late into the evening last night, debating the budget bill.

The N.C. House of Representatives met late into the evening Wednesday night to beat the “crossover” deadline. N.C. Health News file photo

House Speaker Tim Moore (R-Kings Mountain) said he wanted to finish up during the Wednesday overnight session. So lawmakers were passing bills until well after 2 on Thursday morning.

In the press room, around midnight on Wednesday, we were punchy and a little cranky. I joked about using a blowgun with sedative darts to put the more long-winded legislators to sleep.

And if I, at 51, was tired this week, I don’t want to imagine the state of some of our legislators, many of whom are retirees in their 60s, 70s and some in their 80s.

So, after I woke up on Thursday, I put in a call to Brad Vaughn, who researches and treats sleep disorders at UNC-Chapel Hill. (Disclaimer: Vaughn wired me up and studied my sleep a few years ago. He called my sleep “beautiful.” Thanks, Dad.)

I asked Vaughn what happens to people who are sleep deprived.

“When we are deprived of sleep, we tend to be more irritable and remember more negative events,” said Vaughn, who also said sleep is key to peak performance.

We know sleep deprivation can be used as a form of torture. Research shows that if you keep people up long enough, healthy individuals show symptoms of psychosis similar to those observed in schizophrenia.

According to the Centers for Disease Control and Prevention, insufficient sleep has been linked to poor management of a number of chronic diseases and conditions, including diabetes, cardiovascular disease, obesity and depression.

On the less extreme end, the National Institutes of Health says that “poor nighttime sleep contributes to depressed mood and attention and memory problems.”

Hey, wait a minute! Did they say “attention and memory problems”?

We sure witnessed it this week. Some lawmakers rambled. Many, many lawmakers pushed the wrong button (there are only two: one’s red, one’s green) when they went to vote. The number of requests to change votes increased as Wednesday evening wore on. You don’t think fatigue was part of that?

“When we pass bills like that, we get to the point where we’re not watching carefully, not reading carefully,” said Rep. Verla Insko (D-Chapel Hill). “We’re answering emails, multitasking, people are getting up and talking to others, and then they’re needing to change their votes on bills.

“That was because we weren’t really focusing or concentrating on what we were doing.”

Insko, who’s 79, said the adrenaline kicks in and she can run on five hours of sleep for a couple of days, but it generally catches up with her.

And it caught up with some other lawmakers, some of whom Insko said were “slap happy” by the wee hours of Thursday.

“It’s not a good way to make public policy,” she said. “And we make mistakes. Some are bigger than others.”

The example several people pointed to was that of Rep. Pat Hurley (R-Asheboro), who stood up sometime after 1 a.m. to offer an amendment on a bill to regulate the keeping of wild animals. She proceeded to break  into giggles.

“Everyone seemed to find it fabulously ridiculous,” said WRAL’s Mark Binker, who was in the building on something like his 16th hour of work. “We were roaring about small monkeys at 1 a.m.”

Binker was tired enough that his original story, posted at 1:48 a.m., included a description of the bill that “would include large cats like lions as well as lions.”

“Believe me, we didn’t have any copy editors up at that hour either,” he said on Thursday afternoon.

Many of the dozens of bills passed on Wednesday evening alone will need to have problems ironed out of them when they go to the Senate, where the pace will likely slow down.

That’s all well and good. But when I ponder that old trope comparing lawmaking to sausage making, I keep thinking: If I were that tired while making sausage, I’d cut off one of my fingers.

Helmet Bill Crashes at the Starting Line


By Rose Hoban

Legislative committee members heard a bill Wednesday to remove North Carolina’s requirement that motorcycle riders over the age of 21 wear a helmet.

And once again, lawmakers decided that it was a bad idea to eliminate the safety measure.

Rep. John Torbett (R-Stanley) introduced a bill similar to one he proposed in 2013 that would have required riders to carry $10,000 more in insurance coverage along with lifting the helmet restriction.

“Sixty percent of states already allow freedom of choice,” Torbett said. “It’s estimated it’ll bring in tourism dollars from neighboring states, keeping local money from going to South Carolina, which does not have a mandatory helmet law.”

He also argued that in states with “freedom to choose,” insurance rates were lower.

But Torbett’s proposal found little support, even among his fellow Republicans.

“I’ve been here a long time. This bill has come up and come up and come up, and we’ve had debates about what would be the right thing to do and we’ve had doctors come up here, and all of them say it is the worst idea in the world not to wear a helmet when you ride a motorcycle,” said Rep. Leo Daughtry (R-Smithfield). “We make people wear seat belts. I think it’s the least thing we can do to require people to wear helmets when they ride motorcycles.”

In the past, public health advocates and emergency doctors have shown up to present data to support North Carolina’s helmet bill. But this time, the bill was heard at almost 8 p.m., with little notice. So it was left to Torbett’s fellow legislators to bring up arguments against his proposal.

Rep. Darren Jackson (D-Raleigh) said he was in the process of reading an article in the North Carolina Medical Journal about motorcycle helmets when he received notice of the bill being sent to the Committee on Rules, Calendar, and Operations of the House.

Rep. Darren Jackson holds up a photo of his childhood friend who died as the result of a motorcycle accident. His friend was not wearing a helmet.

Rep. Darren Jackson (D-Raleigh) holds up a photo of his childhood friend who died as the result of a motorcycle accident. His friend was not wearing a helmet. Photo credit: Rose Hoban

“The conclusion of the study was that North Carolina’s universal motorcycle helmet law provides key benefits in terms of reduced traumatic brain injury, hospitalization in North Carolina and averted hospital charges,” he read. “We can argue how much money helmet laws save the citizens of this state, but it is a figure.”

Jackson sat at the committee table with a helmet in front of him. He explained it came from the head of someone who was hit by a car, flew 20 feet and had substantial injuries, but no head injury.

Then Jackson held up a photograph.

“This is a picture of my friend from elementary school,” he said. “He got killed in South Carolina where they don’t have a helmet law. He wasn’t wearing a helmet.”

Jackson admitted he didn’t know if the helmet would have saved his friend, but that “he would not have had a closed casket at his funeral if he’d had a helmet on.”

Torbett attempted to argue that more people wearing helmets die in motorcycle accidents than those who don’t, as reported by the Centers for Disease Control and Prevention.

But a closer look at the numbers finds that the rate of death among riders wearing helmets is much lower than that of riders not wearing helmets.

“On average, states with a universal helmet law save 8 times more riders’ lives per 100,000 motorcycle registrations each year, compared to states without a helmet law, and save 3 times more riders’ lives per 100,000 motorcycle registrations each year, compared to states with a partial helmet law,” reads the main page on motorcycle safety on the CDC website.

In North Carolina, the CDC estimates about 80 lives saved for each 100,000 licensed motorcycle drivers.

Even though the CDC notes more people wearing helmets died, that’s because more people ride with helmets than without. Overall, the rate of death was higher for people not wearing the helmets.

The bill failed on a voice vote, but not before Rep. James Boles (R-Southern Pines) quipped that the bill was the “only jobs bill for my profession.”

Boles is a funeral director.

Needle Disposal Bill Moves Forward


A pilot project would make it easier to dispose of needles used for drug injection without fear of penalty.

By Rose Hoban

The North Carolina House of Representatives approved a bill Monday that would create a pilot project in several counties to make it easier to dispose of needles that have been used to inject illegal drugs.

“Once the needle is used, then either the person is so dependent on that needle that they put it in their pocket and keep it or they throw it aside,” said bill sponsor Rep. John Faircloth (R-High Point) during the House Health Committee meeting Monday afternoon. “They turn up in parks, they turn up in trash cans, they turn up in the pockets of addicts.”

With each use, needles develop more holes and crevices in them that can contain traces of blood. Photo: NC Harm Reduction Coalition

With each use, needles develop more holes and crevices in them that can contain traces of blood. Photo courtesy N.C. Harm Reduction Coalition

According to Faircloth, the idea behind House Bill 712 is that members of the North Carolina Harm Reduction Coalition would work with the State Bureau of Investigation to find places where addicted people can dispose of needles without fear of being prosecuted. There they would jointly set up a mechanism for people to surrender their needles without penalty.

The yearlong pilot project would be launched in two selected counties, and if it is successful would be expanded to other counties and eventually statewide.

Faircloth, who is a former sheriff, has said he supports the bill because it protects law enforcement officers.

“This [bill] goes a step further to not only protect the officers, but it will protect the general public from exposure to these needles,” he said, “Particularly in parks where children gather.”

The bill also has the support of the public health community that seeks to reduce the harm to addicts by the use of injection drugs.

For years, public health advocates have pushed for people who use illegal drugs to have safer ways to use them. So-called harm reduction measures, such as this bill, are intended to help drug users stay alive and healthy long enough that when they eventually are ready to quit using injection drugs, they won’t be too sick to benefit from quitting.

“If we go to them and ask for their syringes, they give them to us,” said Tessie Castillo from the North Carolina Harm Reduction Coalition.

Castillo told the committee that volunteers from her organization have also gone into areas where there is frequent drug use and picked up needles off the street and from places where people gather to use injection drugs.

“It’s basically a trust relationship,” Castillo said.

Mark Ezzell from Addiction Professionals of North Carolina said his group supports the bill.

“These needle programs help keep people safe and mitigate the impact of communicable disease,” Ezzell said. “We think it’ll make a substantial impact in the communities where it’ll be done and on public health.

“We know they work.”

The bill is a companion to a measure passed during the last legislative session that makes it possible for addicts to hand over needles to a police officer while they’re being searched without fear of penalty or prosecution.

Faircloth told the House Health Committee Monday afternoon that the bill also ties into the SBI’s existing program that allows for easier disposal of prescription drugs at many of the state’s sheriffs’ offices.

The bill now goes to the Senate for final approval.


Coalition Hopes to Amp Up Push for Health Care Transparency

Kaiser Health News

As consumers increasingly are being asked to pay a larger share of their health bills, a coalition of insurers, pharmaceutical companies and provider and consumer advocacy groups launched Thursday a new push for greater transparency regarding the actual costs of services.

The group includes AARP, Novo Nordisk, the National Consumers League, the Ambulatory Surgery Center Association, the National Council for Behavioral Health and Aetna.

Health care transparency, long a buzz word, means all consumers – whether they are covered by Medicare, work-based insurance or without coverage at all – have access to information enabling them to estimate accurately the cost of health services and compare physician quality rankings and outcomes.


New laws increase scrutiny of hospital spending and income. A coalition of health care organizations would like to see more. Photo courtesy Christine Schmidt, flickr creative commons

The initiative, “Clear Choices,”  will add to private and government efforts already underway to get more such information to patients, including Medicare’s Physician Compare, and the Health Care Cost Institute’s “Guroo,” which culls data from private insurers to provide average prices regionally.

The group’s first priority is advancing the Medicare doctor-payment legislation pending in the Senate, because it includes a provision requiring Medicare to release for broader use a substantial amount of data on claims at the provider level.

“We have data, but it’s a random sample across the entire nation. So you can’t use it to do what Clear Choices and other organizations want to do – to analyze the cost and quality of individual providers within the Medicare program,” said Francois de Brantes, executive director of the Health Care Incentives Improvement Institute, a nonprofit group that studies and promotes payment reform. It is not affiliated with the initiative.

Another priority is to push states and the federal government to enforce the part of the health care law that requires exchange plans to give consumers very specific information about provider networks and covered drugs.

“Insurance company rates are negotiated, so each patient would be subject to a different rate,” said Caroline Steinberg, vice president of trends analysis at the American Hospital Association, which is not involved in the campaign. That negotiated rate means a consumer will likely pay less money for an in-network doctor or hospital. But they need a way to find out that information.

Some states already have moved in this direction.

For example, Connect for Health Colorado, Colorado’s state exchange, provides a tool for shoppers to compare insurers based on what drugs are covered and what providers are in network.

The coalition’s most lofty goal is to change the health system so that patients can know upfront the cost of a medical procedure. This is a complicated proposition because so many components – among them facility-use fees, physician charges, deductibles and co-payments – are factored into the bill a patient eventually receives.

Wanda Filer, a physician based in York, Penn., says even health care providers are often confused by pricing.

“Physicians don’t even know where to refer people and they don’t know what to tell them,” said Filer, who is on the board of directors of  the American Academy of Family Physicians, which is part of the coalition.

Representatives of Clear Choices have framed the campaign as being simple: If a consumer can get a sticker price for a television, so should they for health care. But others say this is much harder than it might appear.

“It’s like asking what the price [will be] for the repair of a leaky roof before the roofer has figured out the cause of the leak,” said Mark Pauly, professor of health care management at the University of Pennsylvania. “It’s harder for the insurer to tell you what you will end up paying until you have precise information on what services you will be using – which patients, and, for that matter, doctors, do not always know in advance.”

The group’s other objectives include:

– improving quality measures for doctors and hospitals so that patients will be armed with more comparative information;

– requiring hospitals to be clearer regarding what may or may not be included in their cost estimates for care; and

– creating better tools for consumers to make medical decisions based on price, quality and safety of medical services.

Kaiser Health News (KHN) is a nonprofit national health policy news service. 



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