July 16, 2019

Hospice House & Support Care of Williamsburg

James E. Lesnick, MD, Neurosurgery; Past Senior Vice President of Riverside Medical Group and Riverside Business & Venture Development (retired)

 

In 1982, professional hospice services didn’t exist in Hampton Roads. That year, Hospice Support Care of Williamsburg began to change the lives of terminal patients and their families, ultimately building a unique residential program and ushering a new type of care into the region.  

As a neurosurgeon, Dr. James Lesnick saw firsthand how hospice eased the burden on his patients and their loved ones. Now retired from practice and his prominent leadership and business roles at Riverside, Dr. Lesnick has been a member of Hospice’s Board of Directors for six years and will serve as President for the next two. 

“This program has always been about a community rallying together to take care of its own families,” he says. “We are blessed to have it, so it’s an honor to be part of it and help continue its history.” 

Hospice House & Support Care of Williamsburg, or HHSCW, is a nonprofit social model hospice, picking up where medical hospice leaves off to cover service gaps. The overarching goal is to keep people out of hospitals during their final days, and to let family caregivers simply be loved ones again.   

“With expert help, a wife can just be a wife in those last precious days – not the person struggling to provide care,” he says. “A husband can be a husband, a child can be a child, and so forth. That is immensely important and comforting.”

The four-bedroom Hospice House in James City County, which opened in 2002, provides 24-hour care in a homelike setting. Surrounded by gardens and woods, it features a kitchen, family room, sunroom and fireplace. 

HHSCW also offers in-home respite care, loaned medical equipment, bereavement support groups, and online and print resources on the dying process and responsibilities such as planning for funerals and tending to legal and financial matters. Programs are free to residents of Williamsburg, James City County and upper York County, with occasional reach outside those areas if possible.  

More than 700 people a year participate in HHSCW’s educational and support groups, which include general grief management sessions and targeted options such as surviving suicide loss; coping with the death of a child, grandchild, sibling, spouse or parent; and navigating cancer care. HHSCW also organizes memorial ceremonies and hosts a walking club and social group.

HHSCW is constantly forming new community partnerships. One more recent program, “Final Gifts Vigil”, aims to ensure that no person ever dies alone at Sentara Williamsburg Regional Medical Center. Instead, trained volunteers sit with dying patients who don’t have loved ones nearby, a model that HHSCW would like to expand to other hospitals. 

“One of the worst things for nurses is knowing someone has passed when they’re not in the room,” Dr. Lesnick notes. “This is a great relief for them, and it’s simply the right thing to do.”

Dr. Lesnick is a longtime leader and innovator in the local medical community. After moving to Williamsburg in 1986, he opened a neurosurgery practice there in 1991 and helped bring the Chesapeake Regional, Riverside and University of Virginia Radiosurgery Center to Newport News. He led Riverside Medical Group for eight years and spent another three at the helm of Riverside Business & Venture Development, presiding over periods of rapid growth. He retired this past January.    

Financial donations and volunteer efforts are crucial to HHSCW; each year, more than 300 volunteers provide about 15,000 hours of time. As a Board member, Dr. Lesnick has served as Secretary-Treasurer and Chair of the Finance Committee and is looking forward to his term as President.  

“Families don’t have to feel alone and overwhelmed in these difficult days,” he says. “We have so many resources here, and we want to reach as many people as possible.” <

To learn more, visit williamsburghospice.org, call (757) 253-1220 or send email to info@williamsburghospice.org.

Progress in Sight-Saving Research

By Kapil G. Kapoor, MD

“Am I going to do this forever, or is there going to be a different way of treating this in the future? Don’t you have a pill, or an eye drop you can give me instead?” 

Frequently just before I administer treatment for macular degeneration by placing a needle in someone’s eye, patients launch existential questions, presumably stemming from their anxiety of what’s imminent. While I often start speculating with them on how their potentially blinding condition may be treated in the future, recent progress in research now allows me to offer these patients a more concrete visual of their future treatment regimen.

To this end, I recently went to San Francisco for a surgical update course. It reviewed advances in an implantable intraocular device we brought to the Mid-Atlantic region two years ago as part of a clinical trial. As an aside, microsurgical courses for ophthalmology have typically utilized pig eyes, and this course instead used a virtual reality simulator. The haptic feedback the VR simulator provided – down to the degree of hand rotation, angle of device insertion, and accuracy of placement – was phenomenal. The uniqueness of the experience resulted in a feature article in The Wall Street Journal (https://blogs.wsj.com/cio/2019/02/07/the-morning-download-genentechs-vr-effort-focuses-on-training-eye-surgeons ).

But I digress – back to saving sight. Even more remarkable than the progress in surgical training is the progress in innovative research for novel sight-saving treatments. We have known for a while that diabetic retinopathy and macular degeneration are potentially blinding diseases that have a chronic course, but they often require an enormous treatment burden with consistent intravitreal anti-VEGF injections every 1-2 months for years. Now that we’ve moved beyond demonstrating how to treat these conditions effectively, research is focusing on durability of anti-VEGF, minimizing treatment burden and our practice’s magnified research focus: reducing treatment cost.

This surgical device involves implanting a small port about the size of a grain of rice into the eye that continually releases anti-VEGF drug for sustained treatment of a blinding condition such as neovascular macular degeneration. Instead of getting consistent injections and office visits every 1-2 months, these patients are getting refills of their ports perhaps 1-2 times a year! While this remains part of a clinical trial at this point, the transformative potential in clinical efficacy and reduced treatment burden and cost is immediately apparent. 

The future of anti-VEGF administration will likely utilize more durable anti-VEGF molecules as well, and we are participating in some clinical trials that utilize a medication potentially durable for 12-16 weeks instead of current molecules that last 4-8 weeks on average. Circling back to reducing costs further, we launched the very first randomized prospective trial in the world in wet AMD utilizing ziv-aflibercept, a low-cost analogue to aflibercept (Eylea). So far, it has shown non-inferiority to other anti-VEGF agents with respect to anatomy and function, and it may save patients in the United States billions of dollars each year! 

As you can see, the future is here, and it’s accessible to our patients and family members right in Hampton Roads! If you or one of your patients may benefit from participation in one of our clinical trials, please reach out to our research team.

Kapil G. Kapoor, MD  is a Board certified ophthalmologist specializing in vitreoretinal surgery.   wagnerretina.com

Hospice House & Support Care of Williamsburg

James E. Lesnick, MD, Neurosurgery; Past Senior Vice President of Riverside Medical Group and Riverside Business & Venture Development (retired) 

 

In 1982, professional hospice services didn’t exist in Hampton Roads. That year, Hospice Support Care of Williamsburg began to change the lives of terminal patients and their families, ultimately building a unique residential program and ushering a new type of care into the region.  

As a neurosurgeon, Dr. James Lesnick saw firsthand how hospice eased the burden on his patients and their loved ones. Now retired from practice and his prominent leadership and business roles at Riverside, Dr. Lesnick has been a member of Hospice’s Board of Directors for six years and will serve as President for the next two. 

“This program has always been about a community rallying together to take care of its own families,” he says. “We are blessed to have it, so it’s an honor to be part of it and help continue its history.” 

Hospice House & Support Care of Williamsburg, or HHSCW, is a nonprofit social model hospice, picking up where medical hospice leaves off to cover service gaps. The overarching goal is to keep people out of hospitals during their final days, and to let family caregivers simply be loved ones again.   

“With expert help, a wife can just be a wife in those last precious days – not the person struggling to provide care,” he says. “A husband can be a husband, a child can be a child, and so forth. That is immensely important and comforting.”

The four-bedroom Hospice House in James City County, which opened in 2002, provides 24-hour care in a homelike setting. Surrounded by gardens and woods, it features a kitchen, family room, sunroom and fireplace. 

HHSCW also offers in-home respite care, loaned medical equipment, bereavement support groups, and online and print resources on the dying process and responsibilities such as planning for funerals and tending to legal and financial matters. Programs are free to residents of Williamsburg, James City County and upper York County, with occasional reach outside those areas if possible.  

More than 700 people a year participate in HHSCW’s educational and support groups, which include general grief management sessions and targeted options such as surviving suicide loss; coping with the death of a child, grandchild, sibling, spouse or parent; and navigating cancer care. HHSCW also organizes memorial ceremonies and hosts a walking club and social group.

HHSCW is constantly forming new community partnerships. One more recent program, “Final Gifts Vigil”, aims to ensure that no person ever dies alone at Sentara Williamsburg Regional Medical Center. Instead, trained volunteers sit with dying patients who don’t have loved ones nearby, a model that HHSCW would like to expand to other hospitals. 

“One of the worst things for nurses is knowing someone has passed when they’re not in the room,” Dr. Lesnick notes. “This is a great relief for them, and it’s simply the right thing to do.”

Dr. Lesnick is a longtime leader and innovator in the local medical community. After moving to Williamsburg in 1986, he opened a neurosurgery practice there in 1991 and helped bring the Chesapeake Regional, Riverside and University of Virginia Radiosurgery Center to Newport News. He led Riverside Medical Group for eight years and spent another three at the helm of Riverside Business & Venture Development, presiding over periods of rapid growth. He retired this past January.    

Financial donations and volunteer efforts are crucial to HHSCW; each year, more than 300 volunteers provide about 15,000 hours of time. As a Board member, Dr. Lesnick has served as Secretary-Treasurer and Chair of the Finance Committee and is looking forward to his term as President.  

“Families don’t have to feel alone and overwhelmed in these difficult days,” he says. “We have so many resources here, and we want to reach as many people as possible.”

To learn more, visit williamsburghospice.org, call (757) 253-1220 or send email to info@williamsburghospice.org.

Britney Emons, PA-C, MPA

Congratulations, it is an Honor to Feature Britney Emons, PA-C, MPA Physician Assistant, NowCare-Suffolk, Bayview Physicians Group

 

As a little girl, Britney Emons fell in love with toy stethoscopes and white doctors’ coats, as well as the idea of helping people feel better. 

Emons always wanted to be a physician – until the day she realized that what she really wanted was to be a Physician Assistant. 

She was a patient that day, as well as a recent college graduate feeling a bit daunted at the thought of four years of medical school. Her primary care provider didn’t have a needed appointment slot, so she went to the practice PA instead. 

“It turned into me interviewing her about the job,” Emons remembers. “I went home thinking, ‘That’s it.’ She later let me shadow her for a day, and I saw the time she had to connect with her patients. It changed my life. It’s the best decision I’ve ever made.” 

As a PA at a bustling Urgent Care center, Emons handles a wide variety of cases, from suturing lacerations and draining abscesses to treating acute exacerbations of chronic obstructive pulmonary disease and asthma. She works in close partnership with the center’s physicians. 

“I love that we see a little bit of everything, which keeps me really well rounded. The days go by very quickly. It’s never boring, especially during cold and flu season,” she says.

Patient education is one of Emon’s biggest priorities. She regularly reminds herself that medicine is confusing and intimidating to many people, so she uses simple language, diagrams and handouts to help empower them. Many returning patients request to see her.  

“If they understand what’s happening with their bodies and why they need to take a certain medication, they will take more responsibility for their own health,” she notes. “They’ll take better care of themselves.”  

Born in Virginia Beach, Emons grew up in Chesapeake and graduated from East Carolina University with a degree in Health Education and Promotion. As she studied for medical school entrance exams and looked over the curriculum, however, she began to worry that becoming a doctor wouldn’t fit well with her desire to start a family. 

Emons worked as a Medical Assistant in Cardiology for two years before that appointment with her PA convinced her to enroll at Eastern Virginia Medical School for a Masters of Physician Assistant degree. By the time she started the 27-month program, she had given birth to her oldest daughter, now 9. 

“She was only 6 months old, which definitely wasn’t easy,” Emons relates. “My husband and I moved in with my parents so they could help. To complete all my studying, I was at school from 7 a.m. to 11 p.m. I was able to graduate with honors and develop a lot of confidence in my preparation. It was well worth the temporary sacrifice.”

After earning Board certification in 2012, Emons worked in Obstetrics and Gynecology for three years before concerns about irregular hours prompted her move into Urgent Care. Today, she works 12-hour shifts several days a week, devoting those to her patients and spending days off with her children. 

Speaking of kids, Emons is now a mom of four girls, including twins born just this past January; she and her husband Jonathan, who works at Norfolk Naval Shipyard, also have two female guinea pigs. “He’s surrounded,” she laughs. In her rare spare time, Emons enjoys going to the beach, pool and gym. 

Emons only sees the Physician Assistant role growing with an aging population and continuing physician shortages. “PAs can be trained more quickly and have the flexibility to move between specialties,” she says. “We can do almost everything a doctor can do, usually without being as rushed. I love my job.”  

We are grateful for local Nurse Practitioners and Physician Assistants who serve our health care community! 

Please let us know if there is an NP or PA you would like to see honored in a future edition. holly@hrphysician.com

Medicine Then & Now

The Lifesaving Evolution of Cardiology
Dramatic developments have given cardiologists more treatment options than ever before

By Kasey Fuqua

 

Of all the fields of medicine, perhaps none has changed as drastically as cardiology over the last 40 years. New medicines, devices and procedures have given patients numerous, successful treatment options and helped extend life, sometimes by decades, for millions of Americans.

Deepak Talreja, MD

“Cardiology is one of the disciplines where the growth has been stratospheric,” says Dr. Deepak Talreja, cardiologist with Bayview Physicians and president of Cardiovascular Associates. “I think there is no field in which technology has changed as quickly as cardiology.”

Heart Attacks
Technology and engineering have had one of the largest impacts on the treatment of heart attacks. As recently as the 1970s, heart attack care consisted of a wait-and-see approach.

John Parker, MD

“For people with heart attacks, there wasn’t much you could do,” says Dr. John Parker, cardiologist at Sentara. “I don’t know how many nights I just spent the whole night in the ICU managing someone’s blood pressure and trying to keep them alive. It was a very humbling experience. We were grateful when people did well.”

In 1978, heart attack care began to change when Dr. Peter Rentrop used the first catheterization procedures to open occluded arteries. He also began the use of streptokinase to bust up clots.

Though these procedures were used to treat heart attacks, they were not performed in emergency situations but were carefully scheduled. Physicians used large French catheters and balloons, but no stents yet existed to keep arteries open. Procedures could take hours, as doctors inflated the balloon again and again to open the artery.

These procedures also had little equipment, Dr. Parker says. Low resolution video screens with video tape were the only way to visualize inside the heart vessels. Doses of radiation were also very high.

Thanks to improved patient outcomes, interventional cardiology began to develop quickly. In Virginia Beach, Dr. John Griffin was involved in clinical trials that proved urgent balloon angioplasty led to better outcomes than streptokinase. Smaller catheters were developed. Digital imaging made seeing inside the blood vessels easier than ever. New drug-eluting stents, instead of just holding the artery open, released medicines to help prevent scarring and stenosis of the blood vessel.

Ronald McKechnie, MD

“Now if someone has a heart attack, I am notified by paramedics who are at their house with an EKG,” says Dr. Ronald McKechnie, a Bayview cardiologist at Chesapeake Regional Medical Center. “This allows us to rapidly mobilize our team and perform a cardiac catheterization, where we can actually open up the occluded artery with a stent within 90 total minutes of that notification. Patients are sometimes even healthy enough to go home the next day.”

Heart Disease Prevention
The speed and quality of heart attack care, combined with improved medications, is a key factor in preventing a secondary heart event. But cardiologists are now increasingly turning their attention to preventing primary heart events.

“Once you start having heart attacks, things start going downhill,” says Dr. Joseph Adinaro, cardiologist at Riverside Health System. “If we push that back by 10 years, we’ve made good improvement in quality of life. That’s the exciting stuff for me.” 

Joseph Adinaro, MD

Dr. Adinaro says the effectiveness of statin medications is a key factor in the decrease of coronary artery disease deaths over the last 20 years. While these medicines used to only be available to people who had experienced a heart attack, they are now available to the millions of Americans with strong risk factors for heart disease.

“We realized that almost everyone benefits from cholesterol medicines,” says Dr. Adinaro. “If you give someone a cholesterol medication, it will reduce the risk of stroke or heart attack by 30 percent or so over the next 10 years, even if their cholesterol is normal.”

Dr. Adinaro says the new focus is finding the patients, such as people with diabetes or peripheral vascular disease, who have a high enough risk to benefit from the medicines in their lifetime. Dr. Adinaro believes genetics may play a role in this search.

“We are hopeful that we can identify these patients that have a higher risk and treat them early,” says Dr. Adinaro. “I’m hoping that down the line we have some really useful genetic tests that will improve our ability to care for patients, but we’re still not there yet.”

While genetics isn’t playing a large role in treatment yet, personalized medicines are now available in cardiology. Immunotherapy for high cholesterol is an option for the small portion of patients who cannot tolerate or who don’t respond appropriately to statins.  

Injectable PCSK9 inhibitors use the patient’s own antibodies to deactivate proprotein convertase subtilisin kexin 9 in the liver and reduce LDL cholesterol by about 60 percent. Though these medicines are promising, costs are currently too prohibitive to allow them to be first line therapy. 

“It’s the newer realm of medical treatment to use the immune system itself to clear cholesterol,” says Dr. Talreja. “But because they are personalized antibodies, they are more expensive to create and we’re trying to drive costs down.”

Structural Heart Conditions
Though genetics and personalized medicine are exciting advances, both Dr. Talreja and Dr. McKechnie agree that the single largest advance made in cardiology in the last 5 years has been the transcatheter aortic valve replacement (TAVR). This device has changed how structural heart defects are treated — and who qualifies for treatment.

“For 40 years, the only real treatment for aortic valve defects was an open-heart surgery where we replace the valve,” says Dr. Talreja. “There are obvious risks of performing the procedure in higher-risk patients. Understandably, as patients get older, surgeons are reluctant to do it because the surgery has considerable risk for those patients.”

As a minimally invasive procedure, TAVR opened up treatment options for older or higher-risk patients. The new heart valve is inserted through a catheter into the old valve. Once in place, the valve expands and takes over the heart valve’s work immediately.

The procedure has shown great success in improving heart valve function while reducing risks of surgery for patients. Even patients in their 90s have undergone the procedure in Hampton Roads, further increasing their longevity and quality of life.

Currently, the TAVR procedure is approved only for intermediate and high-risk patients. However, clinical trials are currently underway to see if the device is also appropriate and safe enough for younger, low-risk patients.

Abnormal Heart Rhythms
Other devices are also expanding treatment for abnormal heart rhythms. Forty years ago, the only treatments for heart rhythm problems were beta blockers and other medicines. But the creation of pacemakers and implantable defibrillators in the 1980s were a life-changing improvement for people with arrhythmias.

Lee Kanter, MD

“The first implantable defibrillators were so big, the battery packs had to be in the abdomen in order for them to have enough charge to shock the heart and save someone’s life,” says Dr. Lee Kanter, cardiologist with Tidewater Physicians Multispecialty Group. “At the time, the charge was delivered by patches around the heart.”

Over time, technology has allowed the changes from patches to leads and to no leads at all. Smaller devices can be implanted inside the chest. Changes to the electrical waveform meant devices needed less energy for an effective charge.

Evolut TM PRO Valve
Photo courtesy of Medtronic ©2019

One of the biggest changes is that defibrillators no longer need testing. In the past, to test the efficacy of the defibrillator, patients were put in life-threatening rhythms and then shocked with their new, implanted device. 

“It was very stressful for everyone in the room, the physician and patient and patient’s family,” says Dr. Kanter “Thankfully, the success of the implant has gone way up, while the risk has come down.”

Congestive Heart Failure 
The success of all these new treatments are leading to longer lifespans, which in turn may be contributing to an increased number of people with congestive heart failure (CHF). Fortunately, from medicines to devices, the quality and length of life for patients with heart failure has improved dramatically.

CardioMEMS™ PA sensor CardioMEMS is a trademark of Abbott or its related companies. Reproduced with permission of Abbott, © 2019. All rights reserved.

A key aspect of CHF treatment today is telemonitoring, which may involve a scale and blood pressure cuff connected to the Internet or a new device called CardioMEMS™. These devices wirelessly send information to the physician’s office for more accurate monitoring of fluid levels, blood pressure, and more. 

“CardioMEMS is a device implanted in a 30-minute procedure,” says Dr. Talreja. “It’s the size of a grain of rice and sits in one of the great arteries of the body.”

The device doesn’t contain a battery, but charges via induction when patients lie on a specialized pillow. The patients only need to lie on the pillow for seconds for the device to charge, take a measurement of the pressure inside the blood vessel and relay that information to the physician’s office. If a patient’s measures are out of parameters, nurses can call to ask about diet and prescribe him or her a dose of medicine to reduce fluids.

“With this device, we can dramatically reduce the number of admissions and improve survival and quality of life,” says Dr. Talreja. “The device is an incredible cost savings for patients, health insurance, and hospital systems.” 

LINQ in hand. Photo courtesy of Medtronic ©2019

In addition to better monitoring, patients also have better choices in medications for heart failure. Sacubitril/valsartan dilates blood vessels and keeps them open, reducing blood pressure and relieving many symptoms of congestive heart failure. Patients on this new medication have a lower risk of mortality and hospitalization, as well as lower rates of shortness of breath and swelling. Its success has helped it quickly replace older medicines like enalapril.

In 2001, patients were given access to a new, FDA-approved treatment option: a biventricular pacemaker. Dr. Kanter was one of the physicians who participated in the MIRACLE study that led to the use of this device.

“The study was remarkably beneficial,” says Dr. Kanter. “It was really life changing for very sick people who we didn’t have much to offer.”

The three-lead pacemaker stimulates the heart, providing improved pumping ability. Patients showed improved quality of life, reduction in the size of the heart, and improved exercise tolerance.

The biventricular pacemaker, also called cardiac resynchronization therapy, has also evolved. Dr. Kanter says that while the first pacemaker took four hours to place, new tools allow placement within just an hour and a half. 

In addition to pacemakers and heart transplant, patients also have a third surgical treatment option: the left ventricular assist device (LVAD). This device is implanted in the left side of the heart and attached to an external battery pack on a harness. It takes over much of the work of the heart, improving quality of life.

“Some people get that device when waiting for a heart transplant, but over the past ten years, many people can get it for continuation of life if they don’t have a transplant option,” says Dr. McKechnie.

Thanks to devices like the LVAD, in just 40 years cardiology has evolved from medications and blood pressure management to a field full of successful treatment options. As technology continues to evolve, patients will have more options than ever for a long, quality life.

Medical Update Spring 2019

Support for Seniors at Home
How PACE programs are helping families care for loved ones

 

As the population continues to age and millions more Americans suffer from dementia each year, the health care system is feeling the strain of caring for older adults. One solution is a 40-year-old federally- and state-regulated program called Program of All-Inclusive Care for the Elderly (PACE).

“Assuming they aren’t going to cure dementia anytime soon, something has got to give,” says Dr. Kate Robichaud, a family medicine physician and Medical Director of the Sentara PACE program. “If we could expand PACE or the concepts of PACE out to the larger community, that would be a good step toward solving this problem.”

What is PACE?
PACE provides comprehensive support to help seniors stay in their homes instead of moving into nursing facilities. These programs serve as both health care provider and payor for the participants enrolled and offer numerous services through their adult day care centers, which are staffed by PACE physicians, social workers, therapists, nurses and more.

“It’s the entire system coordinated in one place,” Dr. Robichaud says. “It allows us to really wrap our care around a person, while acknowledging and respecting his or her age and disabilities.”

PACE programs provide transportation to and from day centers, where participants can receive medical services that may include:

• Dental care

• Nutritional counseling

• Durable medical equipment 

• Exercise programs

• Hearing services

• Lab tests, X-rays, and other tests

• Pharmacy services

• Physical, occupational, and speech therapy

• Primary care office visits

• Psychiatric care and counseling

• Social work services

• Vision care

Additionally, participants are given a meal and snacks and are able to socialize and engage in recreational activities. If a participant needs specialty care, PACE staff can arrange and provide transportation to those appointments.

“The primary goal is to provide the services for families to keep their loved ones at home,” says Dr. Robichaud. “But it’s not just about keeping them at home; it’s about balancing the quality of the life for the family and the participant themselves.”

Hampton Roads is home to two PACE programs. The Sentara PACE program, run by the Sentara Life Care Corporation, has day centers in Norfolk and Portsmouth. InnovAge, a nationwide PACE provider, has a center in Newport News. Combined, these two programs serve almost the entirety of Hampton Roads.

Eligibility for PACE Programs
Qualifications for the PACE program are set by the Centers for Medicare & Medicaid Services. Participants must be:

• Aged 55 or older

• Able to live safely in the community

• Living in a service area currently served by a PACE program

• Qualified for nursing facility level of care as certified by Virginia’s Department of Medical Assistance Services (DMAS)

Kate Robichaud, MD

Dr. Robichaud says over half of the participants in Sentara PACE have dementia. The program also serves patients with a mental illness such as schizophrenia, or an intellectual disability such as Down syndrome.

The Benefits of PACE Programs
The coordinated, comprehensive care that PACE programs provide allow more seniors to stay at home, while decreasing fall rates and improving vaccination rates. 

The programs also represent a cost-savings for both families and the healthcare system. Nationwide, InnovAge’s PACE participants have an average of less than one emergency room visit per year, and a hospital readmission rate of just 16 percent. By staying at home, these patients also spend less on care than they would in nursing facilities.

For primary care physicians in the community, PACE also provides an opportunity to ensure some of the most complex patients receive the right care for them. PACE provides far more coordination than a primary care physician can offer alone.

“Having been a primary care physician in the community for 15 years, I remember having patients that I just felt weren’t getting the services they needed, because logistically it was too overwhelming for them to coordinate,” Dr. Robichaud says. “These patients need a whole lot more than just my medicine and oversight; they need socialization and dignity in taking care of their day-to-day needs. It’s a relief to families and the community that PACE can provide that.”

The Future of PACE Programs
Though PACE programs have existed for 40 years, rollout of these programs has, until recently, been slow. While programs exist in 31 states, they only care for about 45,000 seniors.

In an effort to fuel program expansion, Congress recently updated some PACE regulations. For instance, nurse practitioners now can serve as primary care providers, and PACE participants have the option to see a community physician as their PCP.

“We are governed by CMS, DMAS, and local community boards that oversee day centers,” says Dr. Robichaud. “There are a lot of regulations we have to adhere to, so improving flexibility is going to be key to expansion.”

Population density also presents limitations. While rural communities may be home to seniors who qualify, arranging transportation to a day center can be too difficult. However, PACE programs are even seeing expansion in these sparse areas. Recently, Sentara PACE began serving residents in Surry, Franklin and Isle of Wight County. 

InnovAge, meanwhile, has grown nationally. Since 2017, the company has expanded into Virginia and now operates four PACE centers in the state; it also offers programs in four other states. As the nation’s largest PACE provider, InnovAge understands how to develop programs within regulation requirements, which can be one of the most challenging aspects of opening a new center.

PACE is just one piece of the larger senior care puzzle, but with proper nationwide expansion, it could help provide the relief that participants, families and the healthcare system need.

Offset Taxes with Retirement Account Contributions

Consider using tax-advantaged accounts to help lower your tax bill.

 

Even in the wake of complex tax provisions, a key to lowering your tax bill is really quite simple: report lower taxable income. Since few of us actually want to earn less, the next option is to deposit as much income as you can into tax-advantaged accounts. If you haven’t contributed the maximum amount to a qualified retirement plan at work, now is the time to update your contribution amounts for 2019.

• For reference, contributions for 401(k) and other retirement plans for the 2018 tax year were $18,500 a year (or $24,500 for those age 50 or older).

• Consider making additional salary deferrals if you are eligible to participate in an employer supplemental employee retirement plan (SERP). This will enable you to further maximize contributions to reduce your taxable income now and defer more compensation into later years when your tax rate may be lower.

• Also consider saving on a pre-tax basis for healthcare. You can accumulate funds on a tax-deferred basis to pay for healthcare expenses through either a Health Savings Account (HSA) or flexible savings account (FSA). Your workplace may offer one, both or neither of these options, so check with your employer.

• If you work for yourself, consider contributing to a solo 401(k) retirement plan, SEP IRA or SIMPLE plan.

• Once you maximize employer retirement plans, consider contributing to an IRA if you meet the income limits. Traditional IRA contributions are tax deductible if your modified adjusted gross income is under $73,000 for individuals or $121,000 for joint filers. 

• You have until April 15 to establish a new IRA and make contributions for the prior year. 

The Raymond James financial advisors at Towne Investment Group and Towne Wealth Management can talk with you about retirement account contribution strategies.  Please contact Arch Brown at 757-962-4981 or any of the other financial advisors with any of your questions.

Arch M. Brown, Jr. is a financial advisor with Raymond James Financial Services, Inc. and a Managing Partner at Towne Wealth Management.

Raymond James financial advisors do not render advice on tax or legal matters. You should discuss any tax or legal matters with the appropriate professional.  Securities are offered through Raymond James Financial Services Inc., member FINRA/SIPC, and are: NOT insured by FDIC or any governmental agency, NOT guaranteed by TowneBank, NOT deposits of TowneBank, and are subject to risk and may lose value. Towne Investment Group, Towne Wealth Management and  TowneBank are not registered broker/dealers and are independent of Raymond James Financial Services, Inc. Investment advisory services are offered through Raymond James Financial Services Advisors, Inc. Main Office: 5806 Harbour View Boulevard, Suite 202, Suffolk, VA 23435. (757)-638-6850.  www.towneinvestmentgroup.com

Rheumatoid Arthritis and Heart Disease

By Kristi V. Mizelle, MD, MPH, FACR

 

For many patients with moderate to severe rheumatoid arthritis (RA), treatment advances in recent years have significantly improved disease outcomes and quality of life. However, RA is not limited to joints but is a systemic inflammatory process that also can increase the risk of heart disease in RA patients. Therefore, a focus on whole-body health, in addition to pharmacological interventions to manage and control RA, is crucial.  

Often for RA patients, this debilitating disease brings with it many life-altering aspects, from medication management to multiple appointments, flare-ups and joint deterioration. If one adds the often monumental shift in routines and overall health management, the fight to control this disease can seem insurmountable. Fortunately, advancements in medication are helping to alleviate some of these challenges, but the multifaceted approach needed to manage this often complex condition and its comorbidities can be challenging to communicate to patients.

As with many conditions, the treatment and ongoing management of RA are intimately connected to whole-body health. Outside of the characteristic symmetrical joint swelling, pain and prolonged morning stiffness, other more severe systemic manifestations, such as pleurisy, pericarditis, vasculitis, and uveitis, among others, are much less well known. A particularly concerning and often silent RA comorbidity is heart disease, particularly coronary artery disease. 

RA treatment efforts often focus – and rightfully so – on management and disease control to achieve remission, but consideration of the disease’s long-term effects must also be taken into account. Counseling and interventions on diet, exercise, smoking, and diabetes have a significant impact on the management of risk factors for heart disease and cannot be stressed enough for RA patients. Fortunately, in the primary care setting, these conversations are happening daily. 

To take it a step further, early identification of patients at an increased risk for RA, before primary or systemic manifestations occur, can make a tremendous impact on the treatment and management of RA. 

There is no perfect answer or protocol to detect RA early. At this time, symptoms, family history, laboratory studies like elevated c-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and autoantibodies like rheumatoid factor and anti-cyclic citrullinated peptide, routine joint exams, and imaging studies like x-rays, MRIs, and ultrasound are the best diagnostic tools available. However, suspected diagnosis and referral to a rheumatologist as soon as possible can make all the difference in controlling RA to avoid the irreversible damage that this disease is capable of inflicting.

As it relates to heart disease, RA should be considered just as significant a risk factor for coronary artery disease as diabetes. Much of the focus and energy devoted to managing risk factors for diabetic patients can inform the treatment methods for RA patients, who, like those with diabetes, are as vulnerable to coronary artery disease if not well managed. 

Controlling for these factors will require a significant emphasis on the importance of whole-body health and the complex interplay of risk factors. Collaboration between an RA patient’s rheumatologist, primary care provider and cardiologist can help RA patients control their disease and achieve remission while mitigating heart disease risk for better outcomes.

Kristi V. Mizelle, MD, MPH, FACR is a Board-certified Rheumatologist in Newport News. To learn more about Dr. Mizelle and her practice, visit MyTPMG.com 

Why Spinal Fusion may be the Best Treatment Option for Your Patients

By Jeffrey R. Carlson, MD

 

Patients come to me for treatment guidance for their back, neck and limb pain, pinched nerves and spinal stenosis. Most have searched Google for their symptoms and available treatment options.  They also may seek a second opinion from me as a fellowship-trained spine surgeon. After explaining multiple options for the treatment of their symptoms, including medications, physical therapy and injections, we then discuss the possibility of surgery. The question I’m asked most frequently is, “What type of surgery do I need?” For spinal disorders there are generally two types of surgery: decompression or fusion. These two can also be combined into a decompression + fusion surgery.  

Understandably, patients are concerned that a spinal fusion will cause them to lose flexibility. They also don’t like the idea of screws and rods being left in their bodies, even though this internal bracing greatly increases the likelihood of a successful fusion. Patients with spinal bones that move too much (instability) need a fusion, as the reason a disc wears out or herniates is often related to the abnormal movement of the spinal bones. When this occurs, the patient will need a decompression to take the pressure off the nerve AND a fusion to stabilize the bones, providing a long-term solution for the disc.

Recently, the Spine Patient Outcomes Research Trial (SPORT) published their findings on surgery in patients with spondylolisthesis (bones sliding abnormally and compressing the nerves). They followed patients from 13 medical centers for eight years after their surgery. Patients having surgical decompression were compared to those who had decompression + fusion and to patients who were randomized with no surgical treatment. Over the course of the eight-year study, patients with decompression + fusion had significantly greater improvements than those who didn’t have a fusion or didn’t have surgery. During the study, a large portion of the non-surgical group of patients opted out of the non-surgical treatment and pursued a surgical option. The study recommendation highlighted that patients with instability of the spine will have a more successful treatment with spine surgery that includes a fusion.

While some patients’ diagnoses will only require removal of the pressure on a particular nerve, there are patients with instability of the bones in the neck or lower back who will have a better outcome with a fusion. Our practice has developed technologically-advanced hardware (screws, rods and plates) which provides internal bracing to the spinal bones, allowing patients to be more active during their recovery period while affording fusion rates of almost 100%. Fusions without hardware (often done in the past) required patients to spend more time in an external brace and resulted in a fusion rate closer to 60%. Just like patients with metal in their hips and knees from a hip or knee replacement, the hardware placed in the spine has a particular purpose for improving patients’ long-term function and satisfaction with their surgery.

Jeffrey R. Carlson, MD is the President and Managing Partner of Orthopaedic & Spine Center in Newport News, VA. He holds a fellowship in Orthopaedic Trauma surgery and a combined Neurosurgery-Orthopaedic fellowship in complex spine surgery from Brigham and Women’s Hospital in Boston.  osc-ortho.com

Overlooked Causes of Chronic Ankle Pain

By Alexander Lambert II, MD

 

Ongoing pain in the ankle joint is a common complaint in orthopaedics practices, and properly diagnosing the root cause can be challenging. One frequently overlooked factor is an ankle sprain, whether fairly recent or dating back a decade or longer. 

By definition, a sprain involves some degree of tearing in a ligament, ranging from just a few fibers to the entire band of connective tissue. The vast majority are fairly minor and heal properly with rest, ice and possibly a temporary brace. 

However, a good number of these injuries are undertreated. People may not realize the extent of the damage or seek any treatment; many also return to regular activity too quickly. Physicians also tend to miss high ankle sprains involving the ligament between the tibia and fibula. 

Even if a tear in an affected ligament fully heals, it can do so in a stretched position that causes long-term laxity in the ankle. In those cases, tendons surrounding the joint often are forced to act as secondary stabilizers. 

Over time, that chronic strain can lead to persistent tendinitis, which many physicians correctly diagnose and treat without realizing it is actually a secondary condition, with a damaged ligament the primary issue. Therefore, the tendinitis temporarily resolves with rest and anti-inflammatories but recurs once the patient returns to exercise. 

In cases of chronic ankle pain, patients often have no problems with daily activities but begin to notice symptoms after starting a new or more strenuous workout routine, particularly one with cutting moves, jumping, climbing or running on uneven surfaces. In fact, I have encountered patients who don’t even remember the initial ankle sprain because it occurred years ago. 

Unfortunately, MRI is not a good test for determining ankle instability. Images can reveal tendinitis, but miss evidence of sprains occurring more than six months prior to the study. A ligament may appear intact and normal but actually have healed elongated. 

If tendinitis proves persistent and X-rays rule out causes such as osteochondral defects or stress fractures, a physician must carefully check for subtle laxity in the ankle. That requires stressing ankle ligaments in different positions when the patient is fully relaxed and hasn’t tensed in anticipation of a maneuver. This can require two or three repeat assessments. 

If a sprain injury is the cause of chronic pain, treatment options include activity modification, ankle bracing for certain activities, and physical therapy to return balance and strength to the joint. A smaller group of patients benefit from surgery to reconstruct the impacted ligament. 

Of course, ensuring that a sprain heals correctly in the first place is the best solution. With a more significant injury, patients may need anywhere from six weeks to three months of recovery time. That patience may potentially prevent years of ankle problems in the future.

Alexander Lambert II, MD is an orthopaedic sports medicine specialist for Hampton Roads Orthopaedics Spine & Sports Medicine, based in the Williamsburg office. He also is a team physician for the College of William & Mary. hrosm.com