In May of 2015 the Pan American Health Organization issued an alert of confirmed Zika virus infections in Brazil. Continue reading →

This is just a friendly reminder to our referring providers who need to submit a new request on behalf of a PHC member for wheelchair related items or specialty items, that we have launched a new process to streamline these requests for members within our core counties for Solano, Napa, and Yolo.

Found on our website at www.partnershiphp.org you may download the In-Home Requisition Form and submit the completed form directly to PHC via fax at 707-863-4118, rather than submitting the request to a DME Provider.

Upon receipt Partnership HealthPlan will make arrangements for an in-home assessment to be completed. This process will help reduce the authorization wait time for both members and network providers, and overall improve member satisfaction!  We thank you for your continued support of our members and support of this new process.

Deborah McAllister RN BSN

Director of Utilization Management

Managing the acute pain that accompanies operative procedures is a challenging and risky process.  Studies suggest that opioid medications started for short term management of pain increase the risk of long-term use by up to 44%¹. To provide guidance on a more evidence-based set of pain management strategies post-operatively, the American Pain Society has recently issued an updated guideline. ²  Below are highlights of the 32 recommendations that they have made.

Multimodal therapy should be considered for all patients undergoing surgery. These options should be fully discussed with the patient and their families prior to surgery. These modalities include:

• Systemic pharmacotherapy including NSAIDS and/or acetaminophen, gabapentin or pregabalin, IV ketamine, or opioids (preferably oral)
• Local, intra-articular or topical therapies including local anesthetics at incision, or intra-articular anesthetic
• Regional anesthetic techniques- e.g. regional or paravertebral blocks
• Neuraxial anesthesia such as epidurals rather than general anesthesia
• Non-pharmacologic therapies including TENS and cognitive behavioral therapy (CBT)

Use of TENS and cognitive behavioral approaches may decrease the total need for opioid medications, and should be considered unless contraindicated.

If opioids are used, oral dosing is preferable over IV routes. Avoid long-acting opioids. Do not use opioids, long or short-acting, prophylactically pre-operatively. In addition, every patient started on opioid pain management therapy should be given a tapering plan prior to discharge. It is often adequate to discharge the patient on NSAIDs or acetaminophen rather than opioids. If discharged on opioids, tapering off within two weeks is appropriate. This can be done by decreasing the opioid dose by 20-25% of the discharge dose every day or two till off. Patients who were on opioids pre-operatively should be tapered back to the maintenance dose within two weeks.

NSAIDS and/or acetaminophen should be used along with or in place of opioids where possible and dosed therapeutically. Concerns about use of NSAIDs and the risk of non-union of bone or anastomotic leakage is not supported by the literature.

Use of gabapentin and pregabalin should strongly be considered as part of multimodal pain management post-operatively. Both reduce opioid requirements. IV ketamine also has moderate evidence to suggest it is effective and lowers opioid requirement.

For thoracic and abdominal surgery, consider use of epidural anesthesia rather than general anesthesia. Epidurals are associated with improved pain management scores post-operatively and have fewer complications than general anesthesia

¹ Alam A. et al, “Long-term Analgesic Use after Low Risk Surgery”. Archives of Internal Medicine, 2012, 172(5): 425

² Chou R. et al “Guidelines on the Management of Post-Operative Pain” Journal of Pain, 2016 17(2): 131

Scott Endsley MD, Associate Medical Director, Quality

As we start to ease (sneeze?) into another cold and flu season we also start to deal with requests for cold and flu medications. In the pediatric realm the recommendations have been clear for many years Continue reading →

Last July, Joe Cruz (his name has been changed) was diagnosed with metastatic lung cancer, which carries a very poor prognosis.  Continue reading →

Is there a link between global climate change and health?  Yes, and it is not just that rising sea levels inundating low-lying areas and warmer temperatures leading to new infectious conditions.  It turns out that the two most impactful actions we can take as individuals to reduce carbon dioxide production improve the health of us as individuals, as well as the planet.  What actions are these?  Read on to find out. Continue reading →

Definition of Motivational Interviewing (MI): Patient-centered communication style for eliciting behavior change by helping patients explore and resolve ambivalence. Continue reading →

The Substance Abuse and Mental Health Services Administration (SAMHSA^{1 )}defines the concept of a Trauma-Informed Approach as one that:

• Realizesthe widespread impact of trauma and understands potential paths for recovery;
• Recognizesthe signs and symptoms of trauma in clients, families, staff, and others involved with the system;
• Respondsby fully integrating knowledge about trauma into policies, procedures, and practices; and
• Seeks to actively resist re-traumatization.”

In my therapy practice, I found it more useful to assume that nearly every patient had a trauma history. The statistics bear this out². More than 1 in 3 women and more than 1 in 4 men in the United States have experienced rape, physical violence and/or stalking by an intimate partner. The majority of clients served by public mental health and substance abuse service systems are survivors of trauma.

Trauma also affects physical health. The CDC Adverse Childhood Experiences (ACEs)³ study (with 17,000 participants) revealed that 67% of the population has at least one ACE, and one in eight have four or more ACEs, a rate which correlates with worsened health outcomes: 2.5 times the risk of COPD or hepatitis, 4.5 times the risk of depression, 12 times the risk of suicidality. A person with 7 or more ACEs has triple the risk of lung cancer and 3.5 times the risk of ischemic heart disease.

It seems reasonable, therefore, for all health care providers to assume that their patients have experienced trauma and treat them accordingly, starting with understanding why medical offices can be so distressing for victims of trauma³.

1. Invasive procedures:

Problem: Much abuse involves sudden and unavoidable penetration (sexual or breaking of the skin). All ob-gyn procedures followed closely by shots and blood draws are guaranteed to be re-traumatizing.

Principle of a Trauma Informed Practice: Taking time. Allow the patient to control the timing (even as to whether a procedure is done during the current visit or the next visit). Provide a running verbal explanation of exactly what is happening, inquiring how the patient is tolerating the procedure, and maintain a total willingness to pause or stop based on the patient’s tolerance.

2. Removal of clothing and lack or loss of privacy:

Problem: The shame that accompanies forced nakedness in children or adults is often the most distressful part of the trauma. We tend to think that leaving a patient alone to disrobe and then knocking politely will do the trick. This can make the experience worse for victims who were forced to disrobe while their perpetrator lurked in the shadows.

Principles of a Trauma Informed Practice: Demonstrating awareness and knowledge of trauma and respecting boundaries. Remain client-centered by asking what would make them comfortable plus provide better gowns and coverings, especially blankets that provide heavier protection and warmth.

3. Physical touch and vulnerable physical positions:

Problem: One of the prime symptoms of chronic PTSD due to trauma is an exaggerated startle response when touched on most any part of one’s body. Unannounced and sudden touching is the worst.

Principle of a Trauma Informed Practice: Sharing information and control. Give patients the choice of having a trustworthy supportive person in the room with them. Signal every move and continually ask if it is hurtful or distressing. If possible, help the patient find a less vulnerable position.

4. Power dynamics of the relationship, gender of the health care provider, and personal questions that may be embarrassing or distressing:

Problem: Remember that trauma occurs when the child or adult is either physically or emotionally restrained by a more powerful person who uses their physical and mental power to overwhelm the victim and keep her/him silent.

Principal of a Trauma Informed Practice: Developing rapport and respect. The patient is THE expert on herself/himself. Your expertise is in the area of medical knowledge. Ask if the patient would be more comfortable with a person of another gender present in the room or doing the procedure. Never insist that any patient reveal the details of their trauma, but do provide a referral to counseling if desired.

References:

1. SAMHSA site: http://www.samhsa.gov/nctic/trauma-interventions
2. Shelly Virva, LMSW, Center for Integrative Medicine/Network 180, Trauma Informed Care Presentation, Integrated Clinics for High Utilizers Conference hosted by the California HealthCare Foundation, September 28, 2015 Documents Downloads available at http://www.chcf.org/events/2015/clinics-high-utilizers
3. Centers for Disease Control and Prevention (CDC). Adverse Childhood Experiences (ACE) Study. Available at http://www.cdc.gov/ace/

By: Karen Stephen, Ph.D., Mental Health Clinical Director

As we begin the New Year, Partnership HealthPlan would like to hear from you. Take this survey (link below) and tell us what you think of the Primary Care Blog. What do you like about it, how we can improve it? Also we are very interested to find new authors. If you would like to author a blog, let us know and we’ll put you into the schedule. The blog topic is yours to choose. The length is usually ~500 words or less. Click on the link below and give us your opinion!

https://www.surveymonkey.com/r/phcprimarycareblog

Falls are every provider’s responsibility to prevent in every venue of practice. One out of every three older persons fall every year. Continue reading →