In this Issue

In this Issue
Supporting our Pediatricians
2014 Measles Outbreak in MO
Bureaucracy Limits Health Care
Advocating for Child Nutrition
MOCARE
CATCH Grant Update
1
2
4
8
9
10
Legislative Updates
MO Advocacy Day
Young Physician’s Council
Postpartum Depression
Sr. Pediatrician’s Observation
Telluride, CO
13
13
14
16
17
20
Fall/Winter 2014
Supporting our Pediatricians
I am proud and
honored to take the
position as President
of your Chapter. I
ascended to the
role in May, as our
previous President,
Dr. Rob Steele, took a
position at Arkansas
Children’s Hospital in
Sandy McKay, MD FAAP
Little Rock. For those
Chapter President
who do not know
me, I am a general pediatrician, practicing in O’Fallon,
MO, which is in the suburbs of the St. Louis area. I have
been active with the Chapter in a variety of roles since
2008. I look forward to serving the Chapter and meeting
the needs of our members over the next year. I am a
staunch advocate for children, and I often advocate for
legislation to support children. I have a special area of
passion for vaccines and also to promote the support for
providers. Being a mother to 3 children (ages 10, 6 and
15 months), I also believe in finding the proper work-life
balance and am interested in exploring ways to help
people have their careers while enjoying their personal life.
Yes, I wear many hats, but being a multi-tasker at heart,
I would do nothing less.
We recently held our Annual Chapter meeting and
our bi-annual board meeting. As a chapter we are
very proud of all of our accomplishments, and proud
to support our members in their endeavors. We have
been successful in supporting our members for national
committee memberships and also supporting our
members who receive grant funding for projects to
support children in their region. We have been able to
serve as a fiscal agent for some of these and will work
to support the efforts of our members. We continue to
have a very successful and active Legislative Committee
which works to advocate for children. We have helped
to educate legislators on our roles in providing health
care for children and have become known as respected
child advocates in Jefferson City. For full updates on the
legislative activities, please see Dr. Sohl’s article in this
publication.
The focus of our Chapter will continue to be: support
for the pediatrician, broad member engagement, and
child advocacy. We will be focusing efforts on updating
and enhancing our communications with our members,
including updating the website, and improving our
use of Facebook and Twitter (yes MOAAP does tweet!).
We will also be examining the email and newsletter
communications in order to provide our members with
information that will be timely and concise. I certainly
Continued on pg. 18
PedsLines
| Fall/Winter
2014 1
PedsLines
| Spring/Summer
2014
2014 Measles Outbreak in Northwest
Missouri: Implications for the Future
The Kansas City regional
Kansas. Nearly 30% of children required
measles outbreak of 2014 was
hospitalization for pneumonia, hepatitis,
one of the largest measles
outbreaks since the United
States declared endemic
measles eliminated from the
U.S. in 2000. It occurred from
May 6 to June 28 of 2014 (See
Figure 1). The 29 confirmed
measles cases included
13 children from Clay and
Jackson County in Missouri
and from Johnson County in
The World Health
Organization
currently
recommends vitamin
A for all children
with acute measles,
regardless of their
country of origin.
or bone marrow dysfunction. At least 1
secondary case in Texas was linked to our
Missouri outbreak. The index case was
an unvaccinated child who had traveled
internationally from Micronesia. Not
surprisingly, the majority of cases were in
unvaccinated children, mostly among the
same community.
The health department declared the end
of this outbreak on August 4, 2014 after
Figure 1. Courtesy of the Kansas City Health Department
2 PedsLines | Fall/Winter 2014
2 incubation periods had passed
complications can occur,
without new cases. However,
especially in children. Those
clinicians should continue to
complications include acute otitis
consider measles in the differential
media, dehydration, pneumonia
diagnosis of any unvaccinated
and/or meningoencephalitis,
child with a generalized exanthem.
or even more rarely, a late
Measles typically begins with fever,
complication known as subacute
cough, coryza and conjunctivitis
sclerosing panencephalitis- SSPE.
“the famous 3 C’s”. After 4 -7 days
Preventing measles disease and
of illness, a rash emerges around
complications, particularly SSPE is
the face and neck, and then
dependent on preventing measles
spreads to the rest of the body but
infection by timely vaccination.
spares the palms and soles (See
Finally, the CDC recommends
Figure 2). Koplik spots are small,
that all health care workers be
red, irregularly shaped spots with
documented to be immune to
pale blue-white centers found
Measles, Mumps and Rubella. In
on the buccal mucosa of the oral
response to this outbreak, we
cavity. They are seen early in the
undertook aggressive record
febrile course and may be gone
reviews, plus serology and
by the time the rash is present. In
vaccination on Children’s Mercy
addition, children can appear quite
Hospital (CMH) personnel with
ill, are often very irritable. History
gaps in MMR documentation, so
of an unvaccinated child who has
we now have 97.6% of our workers
travelled outside the United States
at CMH documented as immune.
should put measles on top of the
differential diagnosis.
Suspected measles can be confirmed by serology (measles
IgM) but PCR of nasal or throat secretions is more specific.
Measles is one of the 3 most communicable diseases seen
in the U.S. that require airborne isolation precautions. In
hospitals/clinics, this includes a negative pressure room
and health care workers wearing protective respiratory
equipment. The World Health Organization currently
recommends vitamin A for all children with acute measles,
regardless of their country of origin (AAP Red Book 2012).
Duha Al-Zubeidi, MD
Duha Al-Zubeidi, MD is
an Attending Physician
in Infectious Diseases at
Children’s Mercy in Kansas City
and an Assistant Professor
of Pediatrics at University of
Missouri-Kansas City. She is
passionate about vaccinepreventable diseases and is
a leader in infection control
and prevention.
While most cases recover from the fever, rash, and other
symptoms associated with measles after a few days,
PedsLines | Fall/Winter 2014
3
Bureaucracy Limits Access to Health
Care for Missouri Children and Families
INTRODUCTION - Joel Ferber is currently the Director of Advocacy of Legal Services of Eastern Missouri (LSEM). He is
a graduate of John Hopkins University and New York University School of Law. He brings the unique perspective of an
attorney with extensive experience in policy analysis and advocacy regarding public benefits, Medicaid, managed care,
the Food Stamp Program, and low income health care issues. He is passionate about access to healthcare for Missouri
children and families and has been working with MOAAP and others to ensure that our most vulnerable citizens have
access to medical care through Medicaid and CHIP.
This article addresses problems with
Missouri’s administration of Medicaid
and other public benefits programs,
including the Family Support Division’s
implementation of a new eligibility and
enrollment system that has resulted in
delays and denials of coverage.1 These
problems have led to a significant
decline in Medicaid enrollment in
Missouri.
Perhaps the most glaring issue
identified by legal services (legal
aid) offices and a variety of other
stakeholders is the lengthy delay
in Medicaid application processing
for children, pregnant women, and
newborns. Applications are pending
for months beyond the time lines
established by the Family Support
Division as well as by state and federal
law. These delays result in newborns
lacking health insurance for the first
months of their lives and pregnant
women not receiving prenatal care
for most of their pregnancy. Cases
which formerly took 15 days to process
(Medicaid for Pregnant Women) or 30
days (children’s cases) under the old
system are now taking several months
to process.2
4 PedsLines | Fall/Winter 2014
Legal Services of Eastern Missouri (LSEM) has represented
children residing in the Neonatal Intensive Care Unit
(NICU) who were born without Medicaid coverage, even
though their mothers had applied months earlier for
Medicaid for Pregnant Women (MPW) coverage. Under
federal and state Medicaid requirements, MPW coverage
qualifies newborn children for coverage automatically
upon the child’s birth. Our clients have gone months
without prenatal care following the expiration of their
Temporary Medicaid coverage and the Agency’s failure to
transfer them to Medicaid for Pregnant Women coverage
as the law and state policy require. Another legal aid
office recently reported a pregnant women delivering at
28 weeks without coverage and hence no prenatal care,
with a child in the NICU and bills piling up. Still another
pregnant woman had applied four times for Medicaid,
delivered via C-section (without coverage), and the child
missed out on treatments. As of this writing, the family’s
medical bills are piling up for treatment that was received.
At a recent stakeholder meeting with state officials, a
pediatrician representing the Missouri chapter of the
American Academy of Pediatrics (AAP) reported newborns
going without medically necessary hearing screenings, a
child with a heart murmur going without an EKG because
she lacked coverage, while a 14-year old sexual assault
victim was unable to receive antibiotics to prevent sexually
transmitted disease.
Missouri’s legal services programs, the Missouri AAP
chapter, and other stakeholders are working hard to
address these problems. For example, Legal Services
of Eastern Missouri sends the Family Support Division a
spreadsheet of 60-70 cases each week showing children,
families, and pregnant women whose coverage is being
delayed. Often we find systemic problems that are causing
these cases to be held up in the system. Some of these are
discussed below.
Moreover, the State Agency has provided legal service
offices and other providers (federally qualified health
centers, hospitals, etc.) with “special contacts” that they
can use to assist their clients with processing delays on a
case-by-case basis. Such contacts were not necessary in
the past. Many of the cases we bring to the State Agency’s
attention through these contacts have been pending
for months before they get to our office, and these cases
still move very slowly, in part due to continuing systems
problems which we have brought to the State’s attention.
Many of those cases require manual interventions to push
through because the new state computer system (called
MEDES) is not equipped to perform the actions that are
needed. Legal aid offices have encountered a wide variety
of systems issues that are contributing to the delays. For
example, the new computer system was not allowing the
State to simply add newborn children to an existing “open”
case, thus requiring central office staff to obtain an entirely
new application and/or place the mother on Medicaid
for Pregnant Women coverage to open a newborn case
– even if the mother did not want or need such coverage
(e.g., because she already had private coverage). As noted
earlier, for women receiving Medicaid for pregnant women
coverage, the State is required to automatically cover the
newborn child. Yet the computer system would not allow
this automatic process to happen because it was requiring
eligibility information related to tax issues that is not even
needed for newborn coverage. Thus, a manual work-around
was developed whereby hospitals would send spreadsheets
to the Family Support Division for all newborn cases to be
manually entered into the system. As of this writing, the
system is still not set up to provide transitional Medicaid
coverage for parents/caretakers who become employed or to
transfer individuals from one Medicaid category to another
consistent with federal law. In other instances, “on-line”
applications were somehow not accessible to Family Support
Division staff, even though the system clearly showed that
an application was filed. Other problems include: frequent
system shutdowns that precluded input of information and
the new computer systems’ failure to transmit coverage from
the Family Support Division to the MO HealthNet Division
which pays the health care providers.
Closely related to these problems are denials and
terminations of benefits where clients, after receiving a
request for information from the Family Support Division,
have provided the requested information, sometimes multiple
times, but the agency cannot locate it. The causes of these
improper denials and terminations are the Family Support
Division misplacing the documents and/or the failure of
the agency’s electronic scanning system. Another critical
problem is clients’ lack of access to eligibility specialists
(caseworkers) or other agency staff. Clients are often unable
to reach a staff member either by calling the Family Support
Division or by visiting a local office. The state agency’s call
PedsLines | Fall/Winter 2014
5
center often has no information about the case, and clients
are not getting return calls from local offices after requesting
such a call from the call center. Typically, the call center
makes a referral (by e-mail) to a county office to call back the
client, but the return call does not occur.
In addition, our clients are subjected to improper and
excessive verification such as requests for verification (e.g.,
citizenship) for individuals not even applying for coverage
(which impedes coverage of eligible citizen children) and/or
not part of the household for Medicaid eligibility purposes
– e.g., income from an absent parent ¬– or requesting
information (e.g., identity verification) that an individual has
provided multiple times. Requiring individuals to verify a
negative – e.g., requiring a person to prove that he/she is
not working somewhere h/she has not worked for years is
another such problem. These practices create more work for
the Family Support Division as well as for the family.
Because of this array of issues, legal services clients are also
getting billed for “uncompensated care” that some of them
receive while they go without coverage -- bills they cannot
afford to pay when they have to put food on the table and
pay rent.
Why these problems are occurring:
These problems appear to result from a variety of factors,
including Missouri’s implementation of a new computer
system designed to meet new requirements in the Affordable
Care Act and the State’s own decision to reorganize the
offices of the Family Support Division at the same time other
major changes were taking effect. The new MEDES computer
system is supposed to be able to determine eligibility based
on new Medicaid eligibility rules, interact with the federal
data hub to verify various eligibility factors, and communicate
back and forth with the federal Marketplace (or Exchange).
Under the Agency’s “reorganization,” most clients will
generally no longer have an individual caseworker (now
called an eligibility specialist) handling their entire case;
instead, the various tasks performed by the worker will
be divided among a variety of offices and staff. The
Agency began implementing a plan to divide its office
into processing centers and resources centers. Generally
6 PedsLines | Fall/Winter 2014
speaking, resource centers would interact with clients,
while processing center would perform various “back room
functions” to do the processing of different types of cases
(although they would still have some “front-end” staff
available to see clients that come into the office). Meanwhile,
the responsibility to respond to client inquiries was to be
handled in many instances by new “call centers” staffed
largely with contract employees. For the most part, call
center employees are not equipped to take action on a case
but can only pass on information to a staff person in a county
office for further action to be taken. The process of returning
clients’ calls appears to break down during the handoff
from the call center to the county offices. In addition, many
recipients are not able to see a caseworker when they seek to
apply for benefits or provide requested documents. They are
often directed to a drop box to leave information (sometimes
original documents) which are supposed to be scanned
by Agency staff and ultimately forwarded to processing
centers to work up the case. The scanning system and the
transmission of scanned documents is another source of
delay.
These problems help explain a dramatic decline in Medicaid
coverage in Missouri. This decline is additionally reflected
in recent reports from CMS. 3 According to the latest report
from CMS, Missouri had the most significant decline in
Medicaid participation in the country. Missouri showed a
decrease of 37,260 people, or 4.4 percent compared with
average enrollment July-September 2013.4 While the most
pronounced increase in coverage is in states that have
adopted the Medicaid expansion, even non-expansion states
have increased enrollment by over 4 percent according to
the latest reports. This decline in Missouri has occurred
while unemployment has remained stagnant. 5 The State’s
own data shows a particularly dramatic decline in Medicaid
for Pregnant Women coverage during the last year, which is
especially troubling. LSEM’s review of the State’s Monthly
case load data indicated a nearly 30% decline in Medicaid
for Pregnant Women coverage from May 2013 to May 2014.6
Moreover, according to a November 2013 report published by
Georgetown University Health Policy Institute, Missouri is one
of only 2 states with an increase in the number of uninsured
children.7 That increase is likely to be aggravated by the
problems described above.8
Solutions
Recently, state officials have acknowledged and committed
to fixing these problems in their discussions with various
stakeholders, but the proof will be in improved performance.
The State indicates that it is in midst of a major effort to
resolve a number of the computer glitches and systems
problems. In addition to the computer fixes, the State
agency is reassigning 30 staff from other positions to process
Medicaid children and family cases. The State agency and
its management team are also focusing on the overall
client experience; including problems with the call center.
Furthermore, the Centers for Medicare and Medicaid Services
(CMS) is allowing states the flexibility to postpone and/or
simplify the Medicaid renewal process to accommodate the
transitions to new computers systems and other changes. The
Family Support Division is considering some of these new
options. The Agency also indicates that a new management
team is reviewing and addressing the above-described issues
with the scanning system, and clients’ lost documentation.
However, these changes are still in process. Finally, the
Agency has yet to produce transparent data that accurately
and clearly demonstrates its performance and its progress in
meeting federal time frames. The Agency has not published
timeliness reports since January 2014, the first month of the
new eligibility and enrollment system.
Whatever specific measures are adopted, correcting these
problems would help to ensure compliance with existing
law and enable low-income individuals to receive the health
coverage and other assistance to which they are entitled.
Otherwise, low-income individuals will continue to go
without medically necessary treatment or will incur medical
debt for services they are unable to afford
1
Medicaid is also called “MO HealthNet” in Missouri.
2
Under Missouri’s guidelines, all children, family, and pregnant women cases must be processed within 30 days, and pregnant women cases must be processed within 15 days.
3
See Timothy McBride, Ph.D., Washington University in St. Louis, Enrollment Dropping in
2014: A Cause for Significant Concern and What
Explains This Medicaid?, June 2, 2014, available
at: http://timothydmcbridephd.com/resources/
MOMedicaid2014June_v7.pdf
4
Joel has conducted extensive
policy analysis and advocacy
regarding public benefits,
Medicaid, managed care, the Food Stamp Program, and low income
health care issues. Joel has also litigated Medicaid and other public
benefits cases in the United States District Courts and the United States
Court of Appeals for the Eighth Circuit. He was also one of the lead
attorneys representing Missouri consumer groups in the settlement of
a lawsuit involving the reorganization of Blue Cross and Blue Shield
of Missouri: a settlement that established the Missouri Foundation for
Health, the largest health care foundation in the state of Missouri. Joel
has won numerous awards including the Alberta Slavin Award from
Consumers Council of Missouri (in 2012) and the Clarence Darrow
award from St. Louis University School of Law (in 2011).
Joel Ferber, JD
Joel has been a presenter at numerous state and national conferences
dealing with Medicaid, public benefits, low-income health and
legal services issues. He has written extensively on these subjects
in Clearinghouse Review, the St. Louis University Law Journal and
elsewhere. He has also been a trainer on Affirmative Litigation and
related advocacy for the Sargent Shriver National Center on Poverty
Law and the Center for Legal Education.
MO HealthNet Provider ‘Hot Tip of the Week’ for November 10,2014
Resources to Verify MO HealthNet Eligibility, has been posted to the
MO HealthNet web site at http://dss.mo.gov/mhd/providers/pages/
provtips.htm.
Centers for Medicare and Medicaid Services, “Medicaid & CHIP: June 2014 Monthly Applications, Eligibility Determinations and Enrollment Report,”
August 8, 2014, p. 11. available at: http://www.
medicaid.gov/AffordableCareAct/Medicaid-Moving-
Forward-2014/Downloads/June-2014-Enrollment-
Report.pdf
5
6
Joel Ferber is currently the
Director of Advocacy of Legal
Services of Eastern Missouri
(LSEM). He is a graduate of John
Hopkins University and New York
University School of Law. Since
1985, Joel has fostered LSEM’s
mission “providing high-quality
legal assistance and equal
access to justice” for low-income
Missourians in a variety of ways.
See Tim McBride, Supra,
See Missouri Department of Social Services Research and Data Analysis. DSS Caseload Counter, updated September 15, 2014. Available at: http://dss.mo.gov/
mis/clcounter/history.htm
7
Tara Mancini and Joan Alker, Children’s Health
Coverage on the Eve of the Affordable Care Act, Georgetown University Health Policy
Institute, Center for Children and Families, November 2013, p. 7.
8
These issues are not restricted to Medicaid. There are significant problems with individuals receiving the interviews required for Food Stamp applications and recertifications; for example, clients often do not
receive calls at times designated by FSD and/or are unable to call in for interviews because they cannot
reach a caseworker or a supervisor, causing their
benefits to be denied or terminated.
PedsLines | Fall/Winter 2014
7
Advocating for Child Nutrition
by Kayce Morton, DO, FAAP, Pediatric Hospitalist at Cox Health in Springfield, MO
to get white potatoes included as a
vegetable that WIC participants can
choose from. The potato industry has
pushed again to get white potatoes
included in the amendment as a choice.
AAP and pediatricians point out that
WIC participants already consume
plenty of these in their daily diet.
In June of this year MOAAP Vice President Ken
Haller and I joined over 100 pediatricians who
made the trek to Washington, DC for the AAP’s 2014
Legislative Conference. This conference happens
every year and is meant to introduce or strengthen
advocacy in the pediatric world.
We went to Capitol Hill and met with our Missouri
Congress representatives to get support to oppose
an amendment to the bill FY 2015 Agriculture
Appropriations Bill so as to protect the funding
Kayce Morton, DO, FAAP
and integrity of child nutrition programs. We were
armed with information, handouts, lectures and
listened to amazing speakers including Senator Harkin, Dr.. John Lewy and Dr...
Robert Block. This conference shows how easy it is to be involved: it’s as easy as the
three A’s-Awareness, Advancement, and Action.
So without the boring details here is a little background on this bill to know what
we were advocating for. The Agriculture Appropriations bill FY2015 is a huge
bill and deep into it are recommendations on nutrition. These include WIC, child
nutrition programs and supplemental nutrition assistance program (SNAP).
WIC is in its 40th year of successfully serving more than half of all infants born
in the U.S. It provides a science-based food package based on a comprehensive
review by nutrition scientists and experts at IOM (Institute of Medicine) and USDA.
It is meant to provide foods that are missing from or are inadequately consumed
in daily diets. After multiple failed attempts, the potato industry has been unable
8 PedsLines | Fall/Winter 2014
Child nutrition programs are the
main supply of food for our school
systems nationally, as more than 32
million children in the U.S. are served
school lunch and more than 12 million
children are served school breakfast.
Every 5 years Congress reauthorizes
legislation to fund federal nutrition
programs. In 2010, the Healthy HungerFree Kids Act (HHFKA) directed the
USDA to make an effort to improve the
nutrition standards for all the foods and
beverages sold in schools. This initiative
started in 2012-2013 and added more
options of fruit, vegetables and whole
grains. This year the initiative requires
snack options to have less than 200
calories that are low in fat, sodium and
sugar was the next step. AAP endorsed
this legislation before Congress on
childhood obesity with USDA officials
and provided expert commentary at
the time of its implementation. If this
amendment passed, schools would
possibly get to opt out of the standards
if the school district shows a net loss in
its food service program for a 6-month
period. This would allow them to
not offer fruits and vegetables and to
allow any type of snack. This would
be a huge step backwards for our
children nationally, especially now that
90% of our schools are meeting the
highest nutritional standards since the
inception school nutrition.
What does this mean for pediatricians in Missouri? Our main goal in Pediatrics is preventative care, and nutrition is the
fundamental building block at maintaining a healthy life style. Good nutrition is important not only in growth and brain
development; it is also a first line defense in numerous childhood diseases. Every person deserves the opportunity to make a
good choice.
I urge all pediatricians to be more involved in advocacy, as it is fundamental in these children growing up healthier and
starting their families healthily as well. The first step is Awareness, just as stated in the three A’s of advocacy. Once you know
the topics that are affecting the children of this nation you can then move onto advancement. Go to a conference or just
become knowledgeable of your political climate and local representation use your knowledge and connections to voice your
opinion. You can go online to http://federal advocacy.aap.org/ or more locally http://moaap.org/index.php/legislation/. Then
take action, notify your local government, write letters and emails, get on list serves that send updates on pending issues. Visit
your local capitol yearly, and I recommend every pediatrician make it to Washington, DC, at some point in their career. It really
can change your outlook and make you a better physician.
MOCARE
Pediatricians are important and natural advocates for children,
but the knowledge, skills, and attitudes necessary to become a
pediatric advocate are not always innate. Recognizing this, the
ACGME requires that all pediatric residents receive training in
community pediatrics and advocacy. Training programs approach
this requirement in various ways, but often without the benefit of
advice or lessons learned from other programs. In 2007, a group
of 13 pediatric training programs in California led by Dr.. Lisa
Sarah Garwood, MD
Chamberlain decided to work together to change that experience
by forming a collaborative for education and advocacy. Based
on the successes in California and other states, pediatric residencies in Missouri decided to
follow suit by establishing MOCARE (Missouri Children’s Advocacy and Resident Education)
in 2013. Missouri has four training programs including St. Louis Children’s Hospital, Cardinal
Glennon Children’s Hospital, University of Missouri-Columbia Children’s Hospital, and
Children’s Mercy Hospital in Kansas City.
MOCARE has two main goals: to strengthen resident community pediatrics and advocacy
education and to improve outcomes for Missouri’s children through more effective
advocacy. Given that most Missouri pediatricians are trained in Missouri, we see the work
of this collaborative as an exciting strategy to engage future pediatrician advocates and
change the health and well-being trajectory for children.
Supported by a grant from the Deaconess Foundation in St. Louis, MOCARE brought a
project coordinator on board this fall to help us reach our goals. This year we will meet
quarterly to share program innovations and develop new curricular ideas. Our group
will also be closely involved in the planning and implementation of our state-wide AAP
Advocacy Day on March 11, 2015 in Jefferson City. We will continue to support pediatric
trainees in development of meaningful advocacy projects both at our institutions and
state-wide, and look forward to joining forces with other organizations working on behalf
of children’s health in Missouri.
Sarah Garwood, M.D.
Dr. Garwood is an Assistant Professor in Pediatrics at Washington University School of Medicine and
an Associate Program Director of the Pediatric Residency Program at St. Louis Children’s Hospital.
She received her M.D. from University of Missouri in Columbia. Following residency in Pediatrics at
Washington University, Dr. Garwood worked as a Pediatric Hospitalist at St. Louis Children’s Hospital
before joining the division of
Adolescent Medicine and the
leadership of the Pediatric
Residency Program at St. Louis
Children’s Hospital in 2008.
Dr. Garwood’s work through
the Adolescent Center in the
Department of Pediatrics
focuses on the unique health
care needs of adolescents,
including the physical, cognitive,
emotional, and social changes
that adolescents undergo, as
well as the disease processes
that occur during adolescence.
Dr. Garwood is also on staff at
the SPOT (Supporting Positive
Opportunities with Teens),
which is a one-stop, drop-in
center for youth, and provides
testing for HIV and sexually
transmitted diseases, health
care and counseling, social
support, prevention and case
management services at no cost.
She also sees teens in foster care
for comprehensive assessments
in the COACH (Creating
Opportunities and Choosing
Health) clinic.
Dr. Garwood serves the local
community as a Board Member
of Voices for Children, a program
that provides volunteers as Court
Appointed Special Advocates for
children in foster care. She has
been the AAP Chapter CATCH
grant co-facilitator since 2008.
PedsLines | Fall/Winter 2014
9
Parenting in the Context of Intimate
Partner Violence: a CATCH Grant Update
By Kimberly Randell, MD, MSc
Working with colleagues at Children’s Mercy Hospital and three community
intimate partner violence (IPV) agencies, I recently completed a CATCH planning
grant. Our long-term goal is to build resilience in children exposed to IPV through
safe, stable and nurturing relationships with their mothers. The goal of this
grant was to develop a plan for implementation of Child-Adult Relationship
Enhancement (CARE) workshops in the IPV agencies. We met with IPV agency staff
and focus groups of mothers who were IPV agency clients.
We learned about barriers to workshop attendance and means to decrease these
barriers, including childcare, refreshments, transportation assistance, incentives
(e.g. drawing for a gift card), and multiple scheduling options. Another barrier that
we must address is the hesitancy of some mothers to give up current parenting
practices such as corporal punishment.
We learned that we need to consider how parenting differs when IPV is involved.
Challenges faced by mothers experiencing IPV include co-parenting with an
abuser, loss of parenting authority and confidence, financial difficulties, and child
behavior problems resulting from toxic stress. Mothers living in shelters face
additional parenting challenges due to altered routines, scrutiny of parenting
practices and unsolicited advice from shelter staff and other residents, crowded
living quarters and differences between their parenting practices and those of
other shelter residents.
Mothers in general were very supportive of the idea of a positive parenting
class. They suggested we also address other parenting topics, including child
development, nutrition, co-parenting with an abuser, helping their children cope
with IPV exposure and caring for chronic illnesses. Mothers were adamant that the
class facilitator also have children; they felt this greatly enhances credibility. They
felt that having classes co-facilitated by a parenting expert and an IPV survivor
would be beneficial.
We heard from both focus group participants and IPV agency staff that mothers
enjoyed and appreciated the focus groups. Participants appreciated being able
to share feelings about parenting challenges in a supportive, non judgmental
environment. There was general agreement that parenting is rewarding, but it can
be extremely challenging too. As those of you who are parents will understand, it’s
always nice to hear that your children aren’t the only ones hitting their siblings or
having a meltdown at the grocery store! Participants also enjoyed time to interact
with other mothers without their children present.
We shared our findings with IPV agency staff. Staff felt that what we learned, in
particular the information about challenges of parenting while in a shelter, would
help them provide better services for clients regardless of the implementation of
CARE workshops.
This CATCH grant allowed us to gather information that resulted in a CARE
10 PedsLines | Fall/Winter 2014
workshop implementation plan
that will better address the needs of
mothers experiencing IPV. Additionally,
it identified other parenting needs in
this population. The result of this grant
will be improved access to parenting
support for a population of mothers
facing significant parenting challenges.
I strongly encourage any of you
thinking about implementing a new
community pediatrics program or
service to consider a CATCH planning
grant. Missouri’s CATCH facilitators,
Sarah Garwood [email protected]
edu and Emily Killough [email protected]
cmh.edu, can help with the application
process.
Acknowledgements:
This grant was possible because of
the assistance of my grant team at
Children’s Mercy (Lisa Spector, MD,
Sarah Evans PhD, Lisa Polka, LCSW and
Julie Gettings, LCSW), CATCH facilitator
Kristy Canty, and the staff and clients at
Hope House, Rose Brooks Center and
Synergy Services.
Kimberly Randell,
MD, MSc is
an attending
physician and
Co-Director
of Research in
the Division
of Emergency
and Urgent
Kimberly Randell, MD, MSc
Care Services
at in pediatric
emergency
medicine at Children’s Mercy and an assistant
professor of pediatrics at the University of
Missouri-Kansas City School of Medicine. Her
research and advocacy focuses on addressing
childhood adversity, including childhood
exposure to intimate partner violence and
adolescent relationship abuse.
Save the Date: Advocacy
Day is March 11, 2015!
Join us for the AAP statewide Advocacy Day on March 11,
2015. Previous experience or background knowledge about
the issues to be discussed is not needed. You may not realize
it, but as an expert in child health you are already equipped
with what you need to influence and educate lawmakers.
You will be briefed on the topics for the day and provided
with informational handouts for legislators. If you have not
been part of Advocacy Day before, you will also be paired
with an experienced advocate for your meetings with
legislators.
Come gain valuable hands-on experience in working with
our lawmakers, and be a voice for children in Missouri who
deserve the opportunity to grow up healthy and happy. They
are counting on us!
Contact [email protected] for more information or to RSVP for
the day.
New MOAAP
Membership Chair
Dr. Claudia Preuschoff, past
President of MOAAP and
a long time chair of the
membership committee
relinquished the position
to Dr. Sandeep Rohatgi. Dr.
Rohatgi is a board certified
member of the American
Board of Pediatrics since
1996. He attended medical
school at the University of
Dr. Sandeep Rohatgi
Medicine and Dentistry of
New Jersey and completed
his internship and residency at the Cardinal Glennon
Children’s Hospital in Saint Louis. He currently practices with
Mercy Clinic in Saint Louis, Missouri where he has served
on many boards and committees. He is currently the Mercy
Clinic Pediatric Associate Medical Director, is a Joint Pediatric
Quality Committee-Co-Chair, and is on the Mercy Clinic
Pediatric Quality Improvement Committee. In his downtime,
he enjoys spending time with his wife and 6 children. Other
members of the committee include Drs. Tarantino, from CMH
and Dr. Peters from Mizzou. If you would like to serve on this
committee please email Johanna Derda [email protected]
There are two telephone conference a year and from time
to time conversations are conducted via email. Ideally the
committee has a member participating from each institution.
2014 CAPS
Front row from left to right: Drs. Molly Droge, (Sub Committee AAP Access to Care) Kristin Sohl, Ken Haller, Sandra McKay,
Bob Harris, Mark Eddy. Back row from left to right: Drs. Stuart Sweet, Pamela Shaw ( AAP District Chair) Thuylinh Pham, Beth
Simpson, Staff Johanna Derda, Drs. Laura Waters and Sarah Garwood. Not Pictured: Dr. Alan Grimes and Dr. Maya Moody
PedsLines | Fall/Winter 2014
11
Firearms, Medicaid and Tanning… Oh My!
2014 Legislative Session in Review
The 2014 Missouri Legislative Session was very busy for your Missouri AAP. The
legislative committee had a record number of requests to support particular
positions for bills being brought before the legislature.
As always, there were successes, and there were stalemates. We are very excited
about the Tanning Bill passing. This legislation requires parental consent for all
children under 17 years old to have parental consent prior to using a tanning
bed. We know this small victory will put a necessary barrier before children who
may not understand the risks of tanning.
Firearms and the physician right to counsel their patient was another major
topic. While there were many iterations for this bill and others like it, the take
home message is this: Physicians are protected in their ability to discuss firearm
ownership and safety with their patients and parents. We know the importance
of anticipatory guidance. Regardless of a person’s view on gun ownership,
we know it is imperative to protect kids and ensure parents know how to be
responsible gun owners.
Your MOAAP Legislative Committee also worked hard to educate and advocate
for improved Medicaid coverage through Medicaid Transformation, required
meningococcal vaccinations for college students, more timely weekend access
to newborn screening results, and
e-cigarette restrictions.
We continue to work diligently on
behalf of children in Missouri and the
Pediatricians who serve them.
We are looking ahead to hot topics
for the next legislative session. We
anticipate Medicaid Transformation to
be an important topic. We will continue
to keep a keen eye on issues for kids in
Missouri.
If you have any questions about
legislation in Missouri or are interested
in being more active, please let Johanna
Derda know at Jbder[email protected] The
more pediatricians engaged in being
a voice for children, the more we can
accomplish together.
PedsLines | Fall/Winter 2014
13
Federal Legislative Issues to watch
CHIP reauthorization is crucial for kids!
Children’s Health Insurance Program
was reauthorized through 2019, but
only funded through September 2015.
This means that children are in danger
of losing their health insurance when
they fall into the gap between 150%
FPL and 300% FPL. Without federal
funding for CHIP, Missouri has already
indicated it will only be able to support
those below 150% FPL. Families in the
gap will be faced with a decision to
attain health insurance through the
marketplace or go uncovered. Also of
note, ACA marketplace coverage is not
as strong as CHIP and may not provide
necessary services for special needs
children and other specific services.
Medicaid Parity Many providers across
Missouri have seen an increase in
Medicaid payments, which is currently
now at 100% of Medicare levels.
Children are just as important as adults
and thus payments for providing
primary care for our vulnerable
populations should be at a level
comparable to that of adult care. This
increase in payments has allowed many
providers to increase their Medicaid
panels and provide more opportunities
for access for children. This payment
increase is only authorized through
December 31, 2014! Action is needed
now to ensure that kids can continue
to enjoy improved access to care. Let
your legislator know how important it is
to your practice via phone call or email.
Click hear to find out how to reach your
federal Senators and Representative.
http://www.aap.org/en-us/advocacyand-policy/federal-advocacy/Pages/
Federal-Advocacy.aspx. Without your
input this will go away!
Kristin A. Sohl, MD, FAAP is the Director
of Clinical Services, Thompson Center for
Autism in Columbia, Missouri. She also
serves on the board of MOAAP and is the
chair of the legislative committee.
Young Physician Mentorship and Leadership Opportunities!
The Young Physician Council (YPC)
encourages young physicians to
take an active role within the AAP
and take advantage of leadership
and professional development
opportunities at both a Chapter and
National level. The Chapter is still
recruiting for the YPC Mentorship
program! The mentorship program
will pair young physicians with a
senior Chapter member within their
geographic region that have similar
career goals and professional interests.
Through the mentorship program, the
Chapter hopes to enhance membership
interaction, ease the transition from
residency to early career, help achieve
an adequate work-life balance, and
enable young physician professional
development. If you are either a young
physician interested in a mentor or a
senior Chapter member willing to be a
mentor, please contact Maya Moody at
[email protected] or Johanna
Derda at [email protected]
14 PedsLines | Fall/Winter 2014
The National AAP Section on Young
Physicians is offering a rotating 3 year
leadership development program at
the National Conference and Exhibition
– the Young Physician Leadership
Alliance. “This is an interactive forum
of young physician leaders with
demonstrated leadership potential
through their current involvement
in the AAP. The program will include
the sharing of leadership principles,
behaviors, and tools that can benefit
young physicians in achieving their
personal and professional objectives.
A small amount of preparatory work will
be required prior to the YPLA session.
Ongoing education and support will
be facilitated between each National
Conference and Exhibition/YPLA
session. Topics will rotate such that the
entire leadership curriculum will be
completed over the 3-year cycle.” The
Missouri Chapter is excited to have two
Young Physicians, Laura Waters and
Maya Moody, that will attend this year’s
program. Please contact Kimberly
VandenBrook [email protected]
for information regarding next year’s
Young Physician Leadership Alliance
program.
Dr. Maya Moody, D.O.
Dr. Maya Moody, D.O. is a pediatrician at
BJK People’s Health Center in St. Louis and
also serves as the Young Physicians Council
Co-Chair for the Missouri Chapter.
Postpartum Depression:
Everybody’s Problem
reported in children whose mothers suffered from psychiatric
illness.
It doesn’t take a doctorate in medicine to understand the
unique relationship that mothers have with their newborns.
A mother’s physical and psychological health is oftentimes
interwoven with that of her baby. Thus, the importance of
screening for postpartum depression (depression occurring
within 12 months of delivery,) is critical. Though in many
regions, diagnosing and treating postpartum depression
(PPD) falls on the woman’s obstetrician, it is actually the
pediatrician who is uniquely situated to screen for PPD. The
OBGYN may only see a mother once after delivery, but the
pediatrician will see her every time she brings her newborn
in for evaluation within the first 12 months of life.
The effects of PPD cannot be understated. All women
need to be directly asked about thoughts of suicide or
infanticide. While actual completion of suicide or infanticide
is more likely with postpartum psychosis than postpartum
depression, women with such thoughts warrant closer
evaluation. PPD is also associated with poor maternal-infant
bonding. Of particular concern to the pediatrician, child
development may subsequently suffer – attention deficits,
conduct disorders, and inappropriate aggression have been
16 PedsLines | Fall/Winter 2014
Bringing home a new bundle of joy is naturally associated
with some new stresses – fatigue, insomnia, low libido.
Unfortunately, PPD often goes overlooked due to an overlap
with these symptoms and women need to be evaluated in
the context of normal expectations. For example, fatigue
is normal for new mothers but being unable to get out of
bed for hours may be indicative of PPD. Women should
be screened for feelings of irritability, anger, guilt, and
inadequacy. Clinicians should also be cognizant of risk
factors for PPD, the greatest of which is a personal history of
depression. Other risk factors include poor social support,
unplanned pregnancy, and stressful life events. An excellent
screening tool is the Edinburgh Postnatal Depression Scale,
a 10-point questionnaire. [Where do people get it? Is there a
link where they can download it?]
Diagnosing and treating postpartum depression needs to
be one of our chief concerns in the immediate postpartum
period. It’s important for all members of the health care
team to get involved with this problem, which is too often
overlooked. With just a little effort, we can stop postpartum
depression in its tracks. Healthy and happy moms mean
healthy and happy children.
Jason Phillips MD, OBGYN
PGY-2
Jason Phillips MD, OBGYN
PGY-2 at Mercy Hospital St.
Louis. Jason Phillips is from
the great state of Texas. He
attended Texas Tech University
medical school. Jason is
currently a resident at Mercy
St. Louis in Obstetrics and
Gynecology. He lives in St.
Louis, MO with his beautiful
wife Diana.
Observations by a Senior Pediatrician
Here are some more notes from the Senior (AKA “experienced, “old”, etc.) Pediatric perspective.
Blaine Sayer, MD
Our annual legislative day went well on
March 5, and there was the predictable
positive reception for our positive message—
they key to our long history of “success”.
The big exception remains the expansion
of Medicaid under the Affordable Care Act.
Resistance remains strong for the similar
reason that the legislative majority feels that
“Obamacare” must be revisited in any way
possible. Senator Bond’s lobbying efforts
were visible, and the general message of
“Be part of the solution and not part of the
problem” should always be encouraged.
Recently released data from Oregon is
discouraging to some since it clearly shows
that with an increase in Medicaid coverage, there is a corresponding rise in
inappropriate E.R. utilization. Please allow me to explain why this should have
been anticipated and should not be viewed as discouraging. Remember that my
perspective is from that of understanding the dynamic interface between poverty
and ignorance.
Many of us who were ambivalent about the Affordable Care Act see this as an
unintended but predictable consequence of increasing health care coverage
without correcting fundamental structural issues with our health care system.
Individuals cannot be expected to fix the system by initiating more responsible,
appropriate utilization of access, testing and treatment. Rather, individuals in this
setting will almost certainly take advantage of the somewhat dysfunctional system
that becomes available to them. I can imagine the family finally getting health
care coverage (Medicaid) after some likely extended period without. How do you
celebrate? “Let’s all go to the E.R.,” voiced, of course, in more familiar terms. The
last thing one would be likely to hear is: “Let’s all became part of a comprehensive
primary care prevention-focused system.”
It is up to professionals (us) to initiate health system changes that result in more
appropriate utilization. National attention is being focused on an analogous
over-utilization of our Social Security Disability System, where the response of
economically-compromised families is likewise quite predictable. A significant
percentage of parents I see respond to a diagnosis of asthma with the question:
“Does that make my child eligible for disability?” Early in economics, this way
of thinking received attention as: The Law of the Commons. When there was a
common grazing section for a village, it was always overgrazed, i.e., no individual
would choose responsible grazing, and as a result, it would be grazed until there
was a crisis. There had to be STRUCTURE so that grazing could be controlled to
achieve maximum benefit for all. In an analogous way, opening up the health
care pasture to a multitude of new users will yield predictable but unintended
consequences.
I studied Health Planning at Berkeley
under the father of modern Health
Planning, Dr. Henrik Blum. He described
our present health care system as being
that of “disjointed incrementalism”,
meaning that we “solve” one problem
at a time without relationship to all
the other aspects of care that may
be affected, directly or indirectly. The
Affordable Care Act would be a great
teaching example.
When I served as the Pediatric
Consultant to the Missouri Division of
Health (yes, it was once just a division
yet to grow into a department), my boss
and mentor, Dr.. Herbert Domke, would
point out that I should not use such
“MPH” terms, that health professionals
would be turned off. Yet I simply cannot
think of a better descriptor to accurately
define the state of our present system
of health delivery. It may seem far afield,
but when I previously attempted to
teach about our health care system, I
would start with a lesson from Adam
Smith to understand the intrinsic role of
capitalism, followed up by a lesson from
de Tocqueville to explain the uniquely
American method of problem solving.
When will it change? I predict that when
our cost of Health Care exceeds 50%
of GNP, we will be motivated to make
fundamental structural changes, but
not before. What do you think?
Dr. Blaine Sayre is a frequent contributor
to Pedslines. After many years developing
“Healthcare for Kids” he has undertaken a
new endeavor, “Pediatric Care for Kids” is
a new praxis, cutting across all ethnic and
social boundaries. He is most proud of and is
privileged to provide health care for special
needs children. His new practice will be
organized in a manner that promotes the
most positive attributes of a Medical Home
for all.
PedsLines | Fall/Winter 2014
17
continued from page 1
appreciate all the hard work the Communications
Committee has performed to help make this a reality.
Our beloved Executive Director, Johanna Derda, who
has been working diligently over the last several years
to help the Chapter achieve its goals, will be retiring.
We will greatly miss her dedication and her voice for
the children in Missouri. She has agreed to stay to help
with the transition to the new executive director once
that position is filled. Currently we are undergoing the
recruitment process for this position and will be happy
to announce the new director in the near future. I will
personally miss Johanna, as she has been so integral to
many of the projects with MOAAP, and she has become
part of the MOAAP family. She will continue to help out
the chapter on an as needed basis and will focus on time
with her grandchildren.
MOAAP will continue to advocate for your needs on a
local and national level. Two areas of focus continue
to be Medicaid parity and CHIP reauthorization. We
want to continue to reinforce the importance of
CHIP to our legislators, and the importance of having
coverage for vulnerable children. We are also working
to continue the increased Medicaid payments to that
of the Medicare levels, as this is set to expire at the end
of this year. Children deserve access to high quality
health care. When we had surveyed you, our members,
Thank you for
paying your dues
Your support helps us
help Missouri’s children.
18 PedsLines | Fall/Winter 2014
the responses were that approximately 70% of those
who answered the survey were receiving the increased
payment rate. We also learned that of those receiving
increased payments, approximately 60% were able
to increase their Medicaid panels. This is increasing
access to care. MOAAP will continue to work for you,
but we also need your help. We need your stories and
your experiences to share with our lawmakers to help
reinforce our belief that children deserve access to high
quality health care. If you have a story, please send it to
me!
Thank you for the privilege of being your President.
I will do my very best to meet the needs of the
membership, and I look forward to hearing from you
with your concerns. With your support we can continue
the work of support for Missouri’s pediatric providers
and advocate for the children entrusted in our care.
Sandy McKay, MD FAAP
President Missouri Chapter
American Academy of Pediatrics
Mercy Clinic Pediatrics | 2223 Technology Dr.. Suite 10
O’Fallon MO 63368 | 636-240-9896
[email protected]
Kids grow up fast.
And we’re growing
along with them.
We offer:
• Dedicated pediatric hospitals in St. Louis and
Springfield, Missouri
• Pediatric specialty clinics in Joplin and Rolla, Missouri
• Teams of experts in more than 20 different pediatric
specialties
• Coordinated care through our electronic health record
• Telemedicine consults to bring specialty care to
hometown physician offices
• Family-centered care that recognizes parents as
partners with caregivers
See our specialties and meet our physicians
at mercy.net/MercyKidsDocs.
More pediatricians. More family
doctors. More pediatric specialists.
Mercy Kids is expanding to connect
more children with top-tier pediatric
care – everywhere we serve.
Every child. Every need. Every day.
Telluride, CO: More than a ski town.
Nestled deep within the Rockies, Telluride, Colorado offers breath-taking views
and prime opportunities for camping, skiing, hiking, and biking. One could lose a
week exploring its historic Colorado Avenue shops, endless mountain trails, or even
sitting by the babbling brooks of San Miguel River while catching up on a good
book. In early June, the exact opposite happened for thirty residents from across
the nation who descended upon this mountain town. They had one goal in mind:
discover ways to make healthcare safer and more effective for their patients. This is
exactly what they accomplished!
several improvement projects on the
books including a resident second
victim program. Being the first resident
from my program to attend, this has
been an experience I will never forget
and will always be grateful for! Telluride
isn’t just sunshine and scenic views, it’s a
place that has forever shaped my career.
This summer, I had the opportunity to spend a five days in beautiful Telluride with
these residents who I can now confidently call my peers. They are not ‘my peers’
because they, too, are physicians, but they, like me, have an innate drive to make
their hospitals a better and safer place for their staff and patients. After having
witnessed the Telluride Patient Safety Resident Summer Camp founder, Dr. David
Mayer, gave a Grand Rounds presentation at my home institution, Children’s Mercy
Hospital of Kansas City, I had the fortunate opportunity to be selected to attend
Telluride (www.telluridesummercamp.com). This summer was the camp’s ten year
anniversary and did they put on a show!
(Now, what trip to Telluride would
be complete without a hike?!
Unfortunately, it rained the day of
our trek, so not everyone was able to
ascend to Bear Creek Falls.)
The five day program included experts from around the world (Yes, even safety
experts from overseas) educating on a variety of topics ranging from high reliability
and patient safety principles to transparency and patient/family communication.
Not only did my fellow residents and I get to learn from some of the nation and
world’s foremost experts in these fields, but we had the opportunity to hear what
other residents are facing at their home institutions. Although each of us was from
a different region of the country and from a diverse range of specialties, we faced
very similar problems.
How do we prevent patient harm? How do we keep our safety programs going?
How can we be more open and honest with our patients and families when there
is pressure not to disclose? How do we support our staff and the most vulnerable
physicians in our hospital (the residents) from experiencing the second victim
phenomenon? These were a few of the hundreds of questions that arose from our
breakout sessions with each being as hotly debated as the next. Conversations
would start on the gondola ride to the morning’s first lecture, and many would
last into the wee hours of the night over a pint at the local pub well after the day’s
sessions had ended.
Regardless of the individual reasons why each resident attended, one thing is clear:
Telluride Patient Safety Resident Summer Camp is doing it right! Even though, each
day was jam packed with about 10 hours of engaging material, the residents kept
coming back wanting more, so much so, it sparked additional resident experiences
of Telluride East in Washington, DC and now Telluride West in Napa, CA.
Telluride Safety Camp provided the foundation and building blocks for a career in
improving patient care. Since attending, I have found new and better ways within
my own residency program to advance our patient safety program and resident
curriculum. It has only been a handful of weeks since attending and I already have
20 PedsLines | Fall/Winter 2014
Nicholas A. Clark, MD
Nick is a native of the St. Louis area who
travelled across the state to attend the
University of Missouri- Kansas City School
of Medicine’s Combined 6-Year Medical
Program. After graduating in 2011, he
continued his medical education in the
field of Pediatrics at Children’s Mercy
Hospital in Kansas City. He currently
serves as a Chief Resident where he will
go on to pursue a career in Pediatric
Hospital Medicine upon completion of this
academic year. His role as a Hospitalist will
focus not only on providing exceptional
inpatient care but will have an emphasis
in patient safety, quality improvement,
medical education, and leadership
development.