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.
© Copyright 2019