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Bureau of Health Systems Development

Arizona Healthcare Connection - June 2012

Arizona Healthcare Connection

Empowering Providers for a Healthy Arizona
Volume 1, Issue 2

Want to read this publication offline? You can print a hard copy of this issue. To find previous issues, visit our newsletter archive. For newsletter editorial, suggestions, provider or site nominations, and feedback please contact Jane Jepson at 602-542-1208 or via email.

Story of Commitment

McWilliams Family
The McWilliams Family, Justin, Ryan, DeLoss and Thomas at home in False Pass, Alaska.

What does life in the Alaskan Bush and innovative medical education have in common? For Dr. Thomas E. McWilliams, D.O., FACOFP, it is his Public Health commitment to serve. As one of the first physicians to receive a Public Health Service Scholarship, Dr. McWilliams’ service connects the dots between childhood interests, future career direction, and the continuation of family tradition.

McWilliams was raised with the rigors and satisfaction of rural life. His father and grandfather, both rural Physicians, served farming communities in Iowa. As a boy, McWilliams was fascinated with Native American Populations and the varied cultural activities to which he was exposed.

However, like many National Health Service Corps (NHSC) scholars and clinicians, it was the increasing cost of medical education that initially inspired him to pursue Public Health Service. Dr. McWilliams applied and was awarded a Public Health Scholarship in exchange for a commitment to serve the Indian Health Services (IHS).

Following his favorite senior rotation with IHS in Fort Belknap, Montana and the completion of his postgraduate training, Dr. McWilliams transferred with his wife and young son to an IHS facility in South Central Alaska. One of just 10 physicians in a high volume practice, McWilliams served a vast geographical area, including the remote Kodiak and Aleutian Islands. A rapid introduction to the diverse medical need of the native people helped Dr. McWilliams crystalize his interests in the emergent discipline of Emergency Medicine.

Friendship and affinity with Alaskan Natives inspired Dr. McWilliams to participate in the development of a corps of Community Health Aides. As community elders and healers, Community Health Aides were revered by their villages, but often had little formal education. Equipped with satellite phones and intensive training, Community Health Aides assisted McWilliams and his associates in the diagnosis and delivery of simple care to those in the most inaccessible regions of Alaska. Alaska Natives in need of complex care, as identified by radio or (eventually) telephonic consultation between Doctor and Community Health Aide, were transported by bush plane into the IHS medical facility. The dedication of Dr. McWilliams and his associates and their novel practice of rural medicine, dramatically improved access to care and health outcomes for the Alaskan population.

Two years of Public Health obligation "exceeded all expectations" and quickly extended to seven years of total service with the IHS in the Alaskan frontier. The birth of his second son prompted the desire for a sabbatical, but did not return the family of four to the contiguous 48. Instead, the McWilliams family camped in sleeping bags and built a permanent home near False Pass, a tiny Aleutian Island village over 700 miles from a connected road. The pause in service gave the family much needed time together and their adventure continued with biking tours through New Zealand, Fiji, England, Spain and Portugal.

By the time the family returned to the mainland, McWilliams’ commitment to expanding the access to healthcare was driving his career choices. He went on to complete fellowships in Rural Medicine, National Health Policy, Leadership, and Teaching and Learning.

Today, McWilliams serves as Interim Dean and clinical professor of the A.T. Still University, School of Osteopathic Medicine in Arizona (ATSU/SOMA). Champions of innovative medical education and community service, ATSU/SOMA educates students to better meet the primary healthcare needs of our evolving society, especially in rural communities and among vulnerable populations.

In partnership with the National Association of Community Health Centers (NACHC), ATSU recruits students with the "heart to serve" and delivers medical education in clinical context. Educating medical students using the Clinical Presentation Curricular Model, SOMA emphasizes inductive reasoning and teaches students to think like expert learners. Student feedback on issues like the social determinants of health and health disparities are integrated into the curriculum, refining clinical schemes and preparing students to confront the dynamic medical needs of diverse communities.

Medical students are matched to one of 11 community campuses located across the USA (from Hawaii to New York) for second, third and fourth year education. The community campuses provide a team of physicians to train small groups of students (7-10) within a relevant clinical context. Based on this cognitive theory of learning, this approach improves the retention of material and keeps students connected to the communities most needing their service.

Three centers are available in Arizona through partnership with The National Association of Community Health Centers (NACHC) including North Country Community Health Center in Flagstaff; El Rio Health Center in Tucson, and Adelante Healthcare in Surprise. In 2011, the first class of ATSU/SOMA graduated and entered residency programs. Over 80% of the graduates are committed to practicing in Primary Care/NACHC needed specialties and 15 have gone on to residency programs here in Arizona.

The Healing Touch
"The Healing Touch" by DeLoss McWilliams, a depiction of A.T. Stills M.D.,D.O., which graces the entry to the ATSU/SOMA Mesa Campus.

Medical education and decisions about how and to whom education is delivered can inadvertently define and limit the recipients of medical care. Past emphasis on academic institutions as the centers of medical education has resulted in a healthcare workforce that is disproportionally distributed across sub specialties and urban locations. Dr. McWilliams and his colleagues at ATSU/SOMA have engineered an educational institution designed to "train compassionate family medicine and primary care physicians who are technologically adept, prevention oriented, and who are lifelong learners and teachers" through contemporary medical education and a social mission to serve the true medical needs of our society.

Research suggests that the best way to recruit and retain physiciansPDF in high-need communities is to select medical students from similar environments and provide competency and training within the community setting. Perhaps more by intuition, than strategic plan, the McWilliams family has a long-standing family tradition of community service that extends four generations. Both the McWilliams children are physicians and continue the legacy of service that began in the Iowa frontier so many years ago. Dr. Ryan McWilliams, their oldest son, was born six weeks before they moved to Alaska and has returned there to serve as a Family Medicine physician in the same system of care served by his father. Dr. Justin McWilliams is an Interventional Radiologist who is on the faculty at UCLA. Dr. McWilliams spouse for almost 42 years, DeLoss, is a professional artist. Her painting "The Healing Touch" graces the entry to the ATSU/SOMA Mesa campus. Thomas E. McWilliams, D.O., FACOFP may be reached at (480) 219-6053 or by email at tmcwilliams@atsu.edu.

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Arizona's Communities in Need

Medical and Administrative Support, North Country Healthcare,  Holbrook, AZ
Medical and Administrative Support, North Country Healthcare, Holbrook, AZ.

In the late 19th Century the gold rush drove an expanse of railway from points east all the way to the pacific coast. Transecting northern Arizona, the railroad transformed small communities into thriving boom towns. As a regular stop for water and supplies before massive steam engines rolled their cargo into California, Holbrook bustled with the business of the rail. Even in her glory days, Holbrook was lucky to have a single physician ministering to the needs of her residents.

Today, Holbrook has evolved into a quaint little town home to approximately 5,000 residents. While the town has modernized with the passing centuries, the struggle to meet the medical needs of the community continues. Local residents say Holbrook as one of those towns from which "you get what you put into it". Holbrook residents value uncongested commutes, clean air and water, and close community bonds above many urban conveniences.

Improving access to healthcare is a continuing challenge. Holbrook is designated as a Health Professional Shortage Area (HPSA) with a high need for primary care providers (Primary Care HPSA Score of 15). Currently, just three physicians practice in Holbrook with one planning retirement. The closest hospital is over 30 miles away. Last summer (2011) North Country HealthCare opened a 10,000 foot expansion which is the first new medical facility built in Holbrook in the last 50 years. North Country is a Federally Qualified Health Center and employs two of the town’s MDs and two additional Physician Assistants. Community leaders are working hard to recruit new doctors to the community. Providers site the brisk practice, diverse medical needs of the community, and eligibility for National and StatePDF loan repayment programs as reasons to come and stay. North Country Pediatrician, Dr. Hannah Rishel, M.D. says "when doctors decide against locating here" they often reference the lack of "shopping, Montessori or gymnastics, trees, mountains, and/or opera" as the reason.

Specialty services are available through Summit Healthcare, which provides outpatient service for orthopedics, oncology, pulmonology, cardiology, urology, Ob-Gyn, physical therapy, and radiology. Public education initiatives include county health department coordination with a child development specialist at North Country to do fluoride tooth varnishes for children birth to five. Diabetes education classes are offered intermittently though-out the year. Navajo County Public Health District offers flu shots and provides required immunizations to all children 18 and under at no charge at a local Holbrook Clinic Office. Behavioral healthcare is provided at the Community Counseling Center. Though North Country Healthcare offers a sliding fee scale for services, healthcare access continues to be limited by high unemployment, lack of insurance, and the exclusion of providers from third party payers.

While behavioral healthcare is available in Holbrook, providers frequently don’t meet the third party payer requirements for private insurance which limits care to AHCCCS recipients. Behavioral healthcare for private pay or commercially insured clients is 90 minutes away. According to Kristi Hillebert, Domestic Violence Program Coordinator, healthcare outcomes for residents could improve with additional mental health services and the practice of trauma informed care. Kristi goes on to say "many times I have to refer patients to Flagstaff for any mental health related to trauma; this is a certain hardship on a family already traumatized".

In an effort to combat violence and sexual assaults, North Country HealthCare has partnered with Navajo County judicial and law enforcement professionals to integrate the investigation and treatment of victims of violent crime. The clinic dedicates one of its 18 exam rooms exclusively to forensic examination. The only two pediatric forensic examiners in Navajo and Apache Counties are employed at North Country of Holbrook.

North Country Healthcare Expansion
North Country Healthcare Expansion, the first new medical facility built in Holbrook, AZ in the last 50 years.

Holbrook schools offer diversity, state of the art technology, excellent sports programs, and a brand new auditorium and theatre for the arts. There are two elementary schools, a middle school and a high school in the Holbrook District. According to the Holbrook District website, Holbrook has a graduation rate (79%) that is higher than the state’s average. Holbrook parents praise the "interaction between school staff and students" and say in Holbrook schools "the child has a name, a face, and is an important part of the school community."

Northland Pioneer College (NPC) is Holbrook’s local community college. The college offers exceptional and highly affordable education. Accredited by the Higher Learning Commission (HLC) of the North Central Association (NCA) States, college credits transfer to Northern Arizona University (NAU), Arizona State University (ASU), University of Arizona (U of A) and most major four year colleges and universities.

Located on the famous Route 66, Holbrook is a hub city with State Highways 377, 77, 180 and Interstate 40 all intersecting within the town. The gateway to the Painted Desert and Petrified Forest, Holbrook is a destination from which day trips and week-end outings may be easily organized. Many of Arizona’s outstanding destinations like the White Mountains, Mogollon Rim, San Francisco Peaks, Sedona, Flagstaff, Oak Creek Canyon, and Hopi & Navajo Reservations are within easy reach. City life in Phoenix (three hours south) and Albuquerque (four hours east) are within driving distance.

Whether coming for a visit or establishing a rural practice, Holbrook is a community you can enjoy… and if you choose to stay, one in which your service will truly make a difference.

Contributors: Kristi Hillebert, Domestic Violence/Sexual Assault Victim Advocate and Hannah Rishel, MD Pediatrician North Country Health Center, Holbrook

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Arizona Department of Health Services – Programs in Profile

The Arizona Department of Health Services (ADHS), Empower Program has received national recognition for outstanding work to promote children’s health and prevent childhood obesity. William H. Dietz, M.D., Ph.D., Director of the Division of Nutrition, Physical Activity, and Obesity for the Centers for Disease Control and Prevention (CDC) praised the ADHS program for implementing "creative strategies to get children moving and encourage healthy eating".

The ADHS Empower Program is a voluntary nutrition, physical activity, and tobacco prevention program for licensed childcare providers. The initiative "Empowers" childcare providers, as well as the children and families they serve, to enjoy healthy eating and active living. Childcare providers can become an Empower provider by agreeing to follow 10 best practices to empower children to lead healthier lives in exchange for a 50% reduction in licensure fees. This approach supports the ADHS Division of Public Health Prevention commitment to addressing the priority issues around obesity and tobacco prevention, while leveraging the reach that childcare licensing has into this population.

The ten elements are:
  1. Provide at least 60 minutes of structured activity and at least 60 minutes (and up to several hours) of unstructured physical activity each day.
  2. Limit screen time to less than one hour a day.
  3. Avoid more than 60 minutes of sedentary activity at a time, except while the child is sleeping.
  4. Serve meals family style and let the child decide how much to eat. Avoid using food to reward behavior.
  5. Provide families with education and referrals regarding tobacco prevention, cessation and second hand smoke.
  6. Serve 1% low fat or fat free milk for all children over two years.
  7. Offer water at least four times during the day (water is not to be served during lunch).
  8. Limit juice to 100 percent fruit juice (with no added sugars) and to no more than four to six ounces per day.
  9. Enforce 24 hour smoke-free campuses (no smoking 20 feet from any entrance).
  10. If eligible, participate in the USDA Child and Adult Care Food Program.

Almost 90% of licensed childcare providers in Arizona are participating in the ADHS Empower Program reaching over 220,000 children statewide. For more information, visit the ADHS Empower Program website.

Contributor: Adrienne Z. Udarbe, MS, RD, Community Programs Manager, Bureau of Nutrition and Physical Activity, Public Health Services

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Data and Statistics

Federally designated Health Professional Shortage Areas (HPSAs) are reviewed every three years. Updates and changes to designation statusesPDF are made by Health Resources and Services Administration (HRSA) on a continuous, rolling basis. This update includes all designations with a status change (new, updated or withdrawn) within the past quarter. Review update to determine changes in status that may affect loan repayment qualification, Conrad 30 service, and/or Medicare/Medicaid bonus payments. Current federal designation information can always be found online. For questions, contact Tracy Lenartz, Designations Coordinator, at tracy.lenartz@azdhs.gov.

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Community Resources

New Interactive Mapping Tool

The Designation Mapper is a new interactive web-based mapping tool recently launched by Arizona Department of Health Services (ADHS). This valuable tool can assist primary care administrators or clinicians who are preparing a grant application, conducting a community health needs assessment, researching potential locations for future service sites, or searching for areas of the State that meet the Loan Repayment or Visa Waiver HPSA designation requirements.

The map is available to the public and includes demographic, primary care provider, and shortage designation data. Data can be viewed at the county, Primary Care Area, or census tract level. Users also have the ability to zoom into a specific address, compare various data indicators to state-level data, and download PDF maps. HSD is planning to conduct a demonstration of the Designation Mapper via webinar in the near future for statewide partners. Please contact Tracy Lenartz at tracy.lenartz@azdhs.gov with any questions or to request an invitation to the upcoming webinar.

What is the best screening method for colorectal cancer? The one that gets done!

Colorectal cancer is the second leading cause of cancer death in the U.S. after lung cancer. There are 80 million Americans age 50 and over and screening rates for this group are less than 50%.

The American Cancer Society’s Recommendations for Screening and Surveillance for the Early Detection of Adenomatous Polyps and Colorectal Cancer for 2003 acknowledge that there is enough evidence to recommend fecal immunochemical testing for routine colon cancer screening. In recognition of the importance of colorectal cancer, the National Committee for Quality Assurance added colorectal cancer screening as a HEDIS measure since 2004. This new FDA cleared testing is designed to detect human hemoglobin from the lower GI in fecal samples in an easier, more patient-friendly screening technology for early detection of colorectal cancer in the average-risk population. It is found to be more accurate than traditional guaiac-based fecal occult blood testing and eliminates false positive results from certain foods and medications. Specimen collection is easy and requires no fecal handling or special diet. Practices have seen an increase of better than 66% in patient compliance with InSure FIT.

Due to the slow progression from polyp to cancer, colorectal cancer is a disease for which screening can be particularly effective. The American Cancer Society (ACS) has established guidelines for colorectal cancer screening. These guidelines apply to all men and women 50 years of age and older, as well as younger people at increased risk due to personal or family history of polyps, cancer, or inflammatory bowel disease, or due to a familial syndrome, such as familial adenomatous polyposis (FAP), or hereditary non-polyposis colon cancer (HNPCC). In a clinical trial of 240 high-risk subjects, the InSure FIT showed an 87% sensitivity for colorectal cancer and a 47% sensitivity for large adenomas (>10mm) with 98% specificity. InSure FIT can detect as little as 50 micrograms of hemoglobin per gram of feces with 100% sensitivity. Colorectal cancer is the third most common cancer in both men and women (in men – 3rd after prostate and lung, and in women – third after breast and lung).

This inexpensive, non-invasive, high positive predictive value testing is available through your local laboratory, Sonora Quest Laboratories. You can also request a free sample box of test kits. For more information on InSure FIT or other value added testing available through Sonora Quest Laboratories email the account manager through the Sonoran Quest Laboratories’ Marketing Department.

For additional guidelines on Colorectal Cancer, see the American College of Gastroenterology Guidelines for Colorectal Cancer Screening.PDF

Contributor: Lynn Pierson, Account Manager Sonora Quest Laboratories/Laboratory Sciences of Arizona

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Emergency Preparedness

Wildfires and Other Natural Disasters Test Healthcare System

National and global disasters set new records in 2011 and tested the resilience of our healthcare system. In Missouri, tornados devastated the town of Joplin and made a direct hit on the St. John’s Regional Medical Center. Closer to home, the Wallow Wildfire forced many licensed healthcare facilities to evacuate according to the ADHS Wildfire Plan.

In both communities, displaced patients were safely transported and absorbed into surrounding facilities. The healthcare system, though tested, was able to respond and recover quickly. The perseverance of the system was due to the increase in preparedness planning that has taken place since 2001.

The Arizona Department of Health Services Bureau of Public Health Emergency Preparedness plays a significant role in the response to disaster and wildfires, like Wallow and more recently, the Sunflower and Crown King fires. Environmental health functions surrounding community health risks from smoke, maintenance of sanitary conditions, and food safety in shelters are primary concerns. The ADHS Wildfire Smoke and Your Health brochure is available to assist community members in safeguarding health during the wildfire season.

In general, one of the greatest risks to the healthcare system and public safety during a disaster is the lack of available healthcare personnel. In an emergency or disaster, the healthcare workforce sustains the same worker shortages experienced by other community sectors, but with a dramatically increased need for service. The services provided by doctors, advanced practice nurses, physician assistants, registered nurses, licensed practical nurse and respiratory therapists are critical to an effective emergency response and resilient healthcare system. All healthcare providers should register with the Emergency System for Advanced Registration of Volunteer Health Professionals (ESAR-VHP) before services are required:

ESAR-VHP pre-verifies credentials and organizes volunteers into categories by medical specialty. During an emergency when healthcare workers are needed, the ESAR-VHP system will poll volunteers for availability and direct them to the healthcare facilities that most need assistance. One of the biggest barriers to people volunteering in this manner has been the question of legal liability for the healthcare worker. This has been addressed in Arizona Revised Statutes (A.R.S.) 26-302 (7) and A.R.S. 26-314 (C) so that when a volunteer is requested by a hospital, the request pathway includes local emergency management. This classifies the healthcare volunteer as an "emergency worker" and liability protection is then provided by the County. Once the volunteer arrives at the facility liability is covered by the facility as part of their malpractice and worker’s compensation insurance. Medical professionals registering with ESAR-VHP will only be called upon during a declared emergency by the Governor.

Contributors: Joel Bunis, MBA, Office Chief Bureau and Antonio Hernandez, State Volunteer Coordinator, Arizona Department of Health Services, Bureau of Public Health Emergency Preparedness

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Trauma Informed Care

Not everyone who experiences a traumatic event will be traumatized. People can experience trauma and go on to live healthy and productive lives. However, for many others, traumatic events occur during a critical developmental phase of life or are repeated over time. For these people, life may be encumbered by emotional upset and behavioral turmoil. Traumatized individuals intersecting with healthcare and public services may react with unanticipated volatility which can impede health and safety outcomes.

Traumatic experiences can be dehumanizing, shocking, and terrifying. Traumatic events often include an element of betrayal by a trusted person or institution, and leads to a loss of safety. Trauma can result from experiences that include physical, domestic or sexual violence, institutional abuse, neglect, inter-generational trauma, and disasters. These events induce a sense of powerlessness, fear, recurrent hopelessness, and a constant state of alert. Trauma impacts an individual’s spirituality and sense of self, along with ones relationships to others, community and environment and can escalate to serious mental illness. Recurring feelings of shame, guilt, rage, isolation, and disconnection from others and society are common. Healing is possible.

Although exact prevalence estimates vary, there is a consensus in the field that most consumers of mental health services are trauma survivors and that their trauma experiences help shape their responses to outreach and services.

What is Trauma-Informed Care?

Trauma-Informed Care (TIC) is an approach of engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives. The Arizona Department of Health Services and Division of Behavioral Health Services (DBHS) support the adoption of a trauma-informed approach in the delivery of a broad range of services including mental health, substance use, and peerPDF/family support. Led by Kathy Bashor, Manager, Office of Individual and Family Affairs and Dr. Nitika Singh, Senior Clinical Advisor, DBHS wants to change the paradigm from a question of "what is wrong with you?" to "what has happened to you?"

Most individuals seeking public behavioral health services and other public services have histories of trauma-inducing experiences. These experiences often lead to mental health and co-occurring disorders such as chronic health conditions, substance abuse,PDF eating disorders, HIV/AIDS, and contact with the criminal justice system.

Developing a Trauma-Informed System of Care

Kathy Bashor recommends using a "systematic approach"PDF to the delivery of TIC. The problems engendered by violence cut across multiple service systems. Frequently, trauma survivors cycle in and out of these various systems without ever receiving appropriate services. In a trauma-informed system, services are survivor-driven, strength-based, recovery-oriented, culturally relevant, gender-specific, hospitable, engaging, collaborative, sensitive, respectful, and empowering. Systems recognize the developmental impact of trauma across physical, emotional, cognitive, social, occupational, and spiritual domains. It appreciates the value of numerous behavioral health manifestations (dissociation, substance use, overeating, acting out, and self-injury) that many trauma survivors use as attempts to cope and survive. According to Dr. Singh, our systems must ensure a relational and safety oriented environment to minimize inadvertent clinical re-traumatization. We also have to make sure that trauma-sensitive services are delivered regardless of which "door" a survivor enters or whether they ever find their way to a trauma-specific treatment program.

The Division of Behavioral Health Service publishes the Midweek-TIC-Communiqué a weekly communication focused on providing information about happenings in the field of TIC. Our goal with the Midweek TIC Communiqué is to build on the momentum and create awareness about trauma and TIC by sharing articles and information on upcoming webinars, trainings and conferences related to TIC as well as to provide updates from Arizona’s Trauma-Informed Care Taskforce. To subscribe to the communiqué, please contact Anne Rock.

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Continuing Medical Education

ADHS seeks input on CME activities from a wide variety of CME providers in Arizona. Below is a sample of the Continuing Medical Education (CME) meetings for the coming quarter or you can download a full list of the upcoming CME meetings.PDF

Continuing Education and Events
Course Date Sponsor Course Name CEs Location
06/05/2012 The University of North Carolina at Chapel Hill 18th National Health Equity Research Webcast   Live, interactive broadcast via Internet webcast
06/08/2012 Gillings School of Global Public Health Emerging Diseases & Infection Control 6 Scottsdale
06/13/2012 The Arizona Partnership for Immunization Seven Secrets to Streamlining Immunization Delivery   Navajo County Government Complex

If you are a CME provider and wish to have your information added to this page, please contact us.

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