AUGUST 2013 COVERING THE I-4 CORRIDOR. Halifax Health Brooks Rehabilitation Center for Inpatient Rehabilitation

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1 AUGUST 2013 COVERING THE I-4 CORRIDOR Halifax Health Brooks Rehabilitation Center for Inpatient Rehabilitation

2 Our Team-Approach Just Got Better Ilan Aharoni, MD Irteza B. Inayat, MD Two New Providers, A Broader Range of Care A leader in comprehensive digestive care, Central Florida Hepatology & Gastroenterology is proud to welcome two new physicians to our team. Ilan Aharoni, MD and Irteza B. Inayat, MD are board certified in gastroenterology and internal medicine, and fellowship trained in gastroenterology. Both physicians can diagnose and treat a wide range of digestive diseases, and specialize in the treatment of chronic liver disease, advanced colorectal neoplasm using EMR technique and RadioFrequency Ablation of Barrett s Esophagus. This addition will expand our GI diagnostic capabilities and broaden our team approach to handling the growing number of gastroenterology cases in Central Florida. Featuring Direct Access allows eligible patients to schedule their routine colonoscopy without a pre-office visit. Comprehensive Care for Digestive and Liver Disorders Most Major Health Insurance Accepted Now Welcoming New Patients FHMG North Orange Avenue, Suite 200, Orlando, Florida toll free office

3 contents AUGUST 2013 COVERING THE I-4 CORRIDOR 4 COVER STORY Photo: PROVIDED BY HALIFAX HEALTH ON THE COVER: Patient and physical therapist work on Easy Stand to improve balance and regain muscle strength. It takes persistence and patience to bring a new medical facility to reality. After three years of work and a strong desire to fill a huge need for neurological and orthopaedic rehabilitation patients in Volusia and Flagler counties, Halifax Health and Brooks Rehabilitation have joined forces to create a state-of-the-art inpatient rehabilitation center to serve a wide variety of patients on more than an outpatient basis. Halifax Health, Volusia and Flagler s only designated Comprehensive Stroke Center, will open the doors to the Center for Inpatient Rehabilitation in September An open house for the new, 40-bed facility is scheduled for August 28. The Center for Inpatient Rehabilitation will begin to accept new patients for rehabilitation on September Florida Hospital Peninsula Rehabilitation Unveils $3 Million Renovation at Community Open House 23 REVOLUTIONIZING RECTAL CANCER SURGERY 28 CURRENT TOPICS DEPARTMENTS 2 FROM THE PUBLISHER 10 Behavioral Health 11 PULMONARY & SLEEP DISORDERS 14 MARKETING YOUR PRACTice 16 ORTHOPAEDIC UPDATE 18 CANCER 20 Medical Malpractice Expert Advice 26 DIGESTIVE AND LIVER UPDATE Photo: PROVIDED BY HALIFAX HEALTH FLORIDA MD - AUGUST

4 FROM FROM THE THE PUBLISHER PUBLISHER Iam I pleased to bring you another issue of Florida MD. As physicians, you know that providing Iam pleased to bring you another issue of Florida MD Magazine. It s hard to imagine anyone who is not familiar with the March of Dimes and the work they do to a disability diagnosis can be difficult for a parent to hear; and these parents will rely on your guidance to identify the best plan for their child s development. I am pleased to remind Florida physicians of the support, education and therapy services offered at UCP of Central Florida, a not-forprofit charter school and therapy clinic helping children ages birth to 21 achieve their optimal potential always reinventing themselves to create new programs and services. Coming up next month is the annual March for Babies. It s a wonderful team-building opportunity for according to their abilities. UCP offers options for families such as integrated onsite therapy during the - school day and/or outpatient therapy and rehabilitative services. Please join me in supporting this truly tions on how you and your family can join the march or how to form a team for your wonderful organization and the good work they do. whole practice. I hope to see some of you there. Best regards, Coming Next Month: The cover story focuses Warm regards, on the Poinciana Medical Center which opened last month. Editorial focuses on Pediatrics and Donald B. Rauhofer advances in NICUs as well as Autism. Publisher Donald B. Rauhofer Publisher/Seminar Coordinator UCP s education and therapy programs Join UCP s more than education a million and therapy people programs walking in are March geared of toward Dimes, children March with for all Babies kinds and of disabilities When and delays including cerebral palsy, raising spina money bifida, to Down s help give syndrome, every baby autism, a healthy speech start! and language Invite your delays, family developmental and friends delays and Saturday, rehabilitative April 24th needs stemming from injury. UCP s education and therapy teams collaborate closely with physicians and other professionals 7am Registration to provide 8am each Walkchild with a to join you in March for Babies, or even form a Family Team. You can also join with comprehensive interdisciplinary approach where families are an essential part of the team. your practice and become a team captain. Together you ll raise more money and share In addition to the educational programs (available for infants through high school), UCP s Where Physical Therapy focuses on preserving, a meaningful developing and experience. restoring physical function. Speech Therapy develops verbal and non-verbal Lake communication Lily Park, Maitland skills, as well remediation of oral-motor and feeding challenges. Occupational Therapy programs aim to improve fine motor, self-help, sensory motor and Steps visual for perceptual New Users: skills. All three disciplines Some utilize keys diverse to success: approaches, Ask your techniques, friends, devices, For physical more agents information and modalities on March to help 1. each Go child to marchforbabies.org reach their individual goals. family and colleagues to support you by for Babies please call: Phone: (407) Services Click JOIN are provided A TEAMat UCP s six campuses as part of their in-house educational program, as well as on-site outpatient therapy, Fax: (407) summer Search enrichment for your team and name services in at the some local community facilities. Many education programs are free of charge for eligible children. reason why people do not donate is that Therapy services most common funding sources are Medicaid, commercial insurances and private Central pay. Florida You can Division positively impact the search box. no one asked them to give (don t be shy)! 65,000 Central Florida youth who have a least one disability by referring them to the Experts 341 for children N. Maitland with Avenue, Special Needs. Suite 115 Learn 4. Click on your team name ing them is an easy way to ask. more at Maitland, FL You re done! Your personal page has been created for you and you are ready to begin password for future reference. fundraising! ADVERTISE ADVERTISE IN IN FLORIDA FLORIDA MD MD For more information on advertising For more information on advertising in in Florida MD, call Publisher Donald the Florida MD Central Florida Edition, Rauhofer at call Publisher Don Rauhofer at (407) , (407) , fax (407) or fax (407) or press releases and all other Send press releases and all other related information to: related information to: Florida MD Magazine P.O. Box Oviedo, FL PREMIUM REPRINTS Reprints of cover articles or feature Reprints of cover articles or feature stories in Florida MD are ideal for stories in Florida MD are ideal for promoting your company, practice, promoting your company, practice, services and medical products. Increase services and medical products. Increase your brand exposure with your brand exposure with high quality, high quality, 4-color reprints to use as 4-color reprints to use as brochure brochure inserts, promotional flyers, direct mail pieces, and trade show pieces, and trade show handouts. handouts. Call Florida MD for printing Call Florida MD for printing estimates. estimates. Publisher: Donald Rauhofer Photographer: Associate Publisher: Donald Joanne Rauhofer Magley / FloridaMD Contributing Photographer: Writers: Tim Kelly Cherie / Tim Faircloth, Kelly Portraits, Harinath Sheela, Donald Rauhofer MD, Daniel / Florida T. Layish MD MD, Magazine Arnold B. Etame, Contributing MD, PhD, Writers: Nikhil Joanne Rao, MD, Magley, David Sam Gaughan, MD, Pratt César RPh, Mitchell Santiago, Levin, MD, James MD, Jennifer D. Huysman, Psy.D, Thompson, Steve Vincenzo Chavoustie, Giuliano, Jennifer MD, Thompson, David S. Corey Klein, Gehrold MD, Stephen P. Toth, CLU, Jennifer Designer: Roberts Ana Espinosa Florida Florida MD MD Magazine is published is published by Sea Notes by Sea Media,LLC, Notes Medical P.O. Box Seminars, , Oviedo, PA, P.O. FL Box , Call Oviedo, (407) FL for Call more (407) information for Advertising more information. rates upon Advertising request. rates Postmaster: upon request. Please Postmaster: send notices Please on Form send notices 3579 to on P.O. Form Box , to P.O. Oviedo, Box , FL Oviedo, FL Although every precaution is taken to ensure accuracy of published materials, Although every Florida precaution MD cannot is taken be held to ensure responsible accuracy for opinions of published expressed materials, Florida facts MD expressed Magazine by cannot its authors. be held Copyright responsible 2012, for Sea Notes Media. opinions All expressed rights reserved. or facts Reproduction expressed by in its whole authors. Copyright in part without 2010, written Sea Notes permission Medical Seminars. is prohibited. All rights Annual reserved. subscription Reproduction rate $45. in whole or in part without written permission is prohibited. 2 FLORIDA MD MAGAZINE - MARCH 2010 FLORIDA MD - AUGUST 2013

5 THE ONLY NCI COMPREHENSIVE CANCER CENTER BASED IN FLORIDA MOFFITT CANCER CENTER OFFERS A LEVEL OF CARE THAT STANDS ABOVE THE REST. FOR OUR DOCTORS AND SCIENTISTS, THIS MEANS MORE RESEARCH, MORE CLINICAL TRIALS AND MORE PEOPLE TREATED THAN ANY OTHER HOSPITAL IN THE STATE. FOR YOUR PATIENTS, THIS MEANS THE BEST CHANCE FOR BEATING CANCER. REQUEST AN APPOINTMENT AT MOFFITT.ORG/REFER MOFFITT CANCER CENTER MAGNOLIA DRIVE, TAMPA, FL MOFFITT CANCER CENTER AT INTERNATIONAL PLAZA 4101 JIM WALTER BOULEVARD, TAMPA, FL H. LEE MOFFITT CANCER CENTER & RESEARCH INSTITUTE AN NCI COMPREHENSIVE CANCER CENTER TAMPA, FL MOFFITT CLOSER TO OUR PATIENTS. CLOSER TO A CURE. FLORIDA MD - AUGUST

6 COVER STORY Halifax Health Brooks Rehabilitation Center for Inpatient Rehabilitation Partnership takes Daytona Beach s Rehabilitation Medicine to the Next Level By Cherie Faircloth It takes persistence, patience and evidence-based proof to bring a new medical facility to reality. After three years of work and a strong desire to fill a huge need for neurological and orthopaedic rehabilitation patients in Volusia and Flagler counties, Halifax Health and Brooks Rehabilitation have joined forces to create a state-of-the-art inpatient rehabilitation center to serve a wide variety of patients on more than an outpatient basis. Halifax Health, Volusia and Flagler s only designated Comprehensive Stroke Program, will open the doors to the Center for Inpatient Rehabilitation in September An open house for the new, 40-bed facility is scheduled for August 28. The Center for Inpatient Rehabilitation will begin to accept new patients for rehabilitation on September 1. Halifax Health s physical and neurorehabilitation outpatient center has long enjoyed a reputation for providing the best multidisciplinary rehabilitation medicine in Volusia and Flagler counties. Many patients suffering from orthopaedic and neurological conditions such as stroke, traumatic brain and spinal cord injuries, post-polio and multiple sclerosis, eventually moved their care to Halifax Health, known for its state-of-the-art approach to rehabilitation medicine. According to Lydia Hendrix, recently appointed director for the new Halifax Health Brooks Rehabilitation partnership, there have been many success stories of patients who returned to full, daily life activities due to the dedication of the Halifax Health team a group of rehab specialists who have served Volusia and Flagler with outpatient rehab for more than 14 years. With a projected increase in population growth of greater than 10 percent by 2016 in Volusia and Flagler counties, and 35 to 40 percent of that estimated to be senior citizens, there was strong evidence to support the need for the Center for Inpatient Rehabilitation in the region. Halifax Health filed with the Agency for Health Care Administration (AHCA) Certificate of Need Office for the 40-bed inpatient rehab facility and was initially denied a request. After three years of appealing to the State of Florida, approval was granted to move forward with the project in Left to right: Jorge Lopez-Perez, MD, Medical Director, Dr. Carolyn Geis, Director, Lydia Hendrix, RN, BSN, MS, CRRN. Photo: PROVIDED BY HALIFAX HEALTH 4 FLORIDA MD - AUGUST 2013

7 COVER STORY Photo: PROVIDED BY HALIFAX HEALTH Patient and therapist work on RT 300 cycle mapping points of muscle fatigue for measurement and documentation. Brooks Rehabilitation of Jacksonville, provider for inpatient rehabilitation for Halifax Health, was chosen as the exclusive partner for Halifax Health s endeavor. Brooks Rehabilitation has been a leading provider of rehabilitation services to Northeast and Central Florida for more than 35 years and is the highest accredited rehab provider in Florida and among the highest in the United States. As effective as the outpatient rehab services were at Halifax Health historically, the expertise and knowledge base at Halifax Health now has a nationally renowned partner. In the past, the level of rehab treatment and skill required to rehabilitate a stroke victim or someone with a traumatic brain injury had to be referred out of the area, most often to Brooks Rehabilitation Center. But the long distance drive for families who needed to remain close to loved ones during the critical recovery process was less than ideal. The most frustrating thing for Halifax Health was to refer the most serious rehabilitation patients to inpatient programs far away from home and family. There has been a close working relationship with Brooks Rehabilitation in Jacksonville for inpatient services for many years. The great reputation Brooks Rehabilitation has is a wonderful match for the level of care provided and the mission at Halifax Health. Brooks provides an extension of Halifax Health s work with patients in need of rehabilitation, but in a sustained inpatient setting. Halifax Health was referring longterm rehab patients to Brooks 90 miles away and sometimes to the Shepherd Center in Atlanta, which is 400 miles away. It s not acceptable to send patients so far away from family and friends when that type of support is so crucial to a patient s full rehabilitation recovery. It was a loop that had to be closed in order to give patients the best possible outcomes, Hendrix says. Halifax Health announced in May 2011 it would proceed with the inpatient rehabilitation unit with Brooks Rehabilitation as a partner. Both shared the costs of building the planned $12.8 million facility which is nearing completion in the Fountain Tower at Halifax Health. Now in the final construction phase, the unit will have 20 beds per floor, serving neuro patients on the eighth level and ortho patients on the ninth level. The rehab design team has reconfigured each level for the ease and functionality of providing a full spectrum of physical and neurorehabilitation services, use of stateof-the-art rehabilitation equipment as well as common areas for congregate activities, dining and socializing. Some of the most advanced rehab equipment includes the RT300 electrical stimulation cycle from Restorative Therapy. The RT300 is a cycle that uses functional electrical stimulation (FES) to stimulate up to 10 muscle groups in either the arms or legs for neuromuscular reeducation. It is for patients who may have multiple sclerosis or have had a stroke, spinal cord injury or traumatic brain injury. RT300 works on making the movement patterns stronger in the arms, legs and/or trunk. The bike can cycle for the person or assist the person to perform the movements. It recognizes when the person fatigues and can adjust the amount of stimulation needed. It saves the data so the therapist is able to use it for documentation purposes. The new center will also feature a Bioness H200 Wireless Hand Rehabilitation System. This lightweight device also incorporates the use of FES. It is an orthosis with built in electrodes which the therapist fits to the patient and then programs to stimulate the hand musculature to achieve grasp, pinches and release. The center will feature a modern, vibrant and active theme, a true rehab-centric location where staff will teach functional improvement and compensatory skills to patients and families every day in patient rooms, hallways and dedicated gym space on both floors. Most impressive will be the two activities of daily living (ADL) suites that will house patients and their caregivers who are ready to move into the independent living phase of their recovery. The ADL suite is just like an efficiency apartment with a kitchenette, standard bathroom fixtures and traditional living room seating. FLORIDA MD - AUGUST

8 COVER STORY Photo: PROVIDED BY HALIFAX HEALTH Patient in Easy Stand working on his visual perceptual accuracy and muscle coordination. Typically, a patient has sustained a servere neurological or musculoskeletal event, including surgery or other procedures before they are admitted to inpatient rehabilitation. The average length of stay in an inpatient rehabilitation setting is usually 15.5 days but that average varies widely depending on the diagnosis and injury. Average stays can range from 10 days for a joint replacement and up to 25 days for a spinal cord injury. Neuro patients include anyone who has experienced a spinal cord, traumatic brain or other neurological injury. Stroke makes up about 23 percent of neuro rehab admissions, according to national averages. Orthopaedic rehabilitation cases such as amputees, hip fractures or trauma comprise approximately 12 percent of admissions. In addition to Volusia s growing senior population, who makes up a high percentage of those needing both neuro and ortho rehab care, the need for rehab services is amplified by the numerous sporting and tourism attractions such as Bike Week, Biketoberfest and NASCAR events. Dr. Carolyn Geis, Medical Director of the Center for Inpatient Rehabilitation, points out that the Daytona area presents a variety of rehab challenges. Motorcycle accidents and sporting injuries are quite common here. We serve people from all over the country with trauma injuries. Many are thousands of miles from home. After we were able to stabilize their condition at Halifax Health, the rehab process was often delayed until the patients were able to travel home. This delay in intiating rehab was not optimal. With the expertise that Brooks Rehabilitation brings to Halifax Health, we will be able to provide the best intensive inpatient rehabilitation for all types of injuries without delay or interruption. Dr. Geis continued, Our goal for every patient is to return them to the highest quality of daily life that they are capable of achieving. Halifax Health has always provided the best possible postacute care options to patients on an outpatient basis. The inpatient rehabilitation component is crucial for the absolute best patient outcome. Together, Halifax Health with intensive stroke care concentration and Brooks Rehabilitation have combined their expertise to develop a rehabilitation-centric destination program for acute inpatient rehab patients that will differentiate us from other facilities in Central Florida, says Hendrix, who notes, The inpatient rehabilitation programs and rehabilitation equipment will closely duplicate what is available at Brooks Rehabilitation s Jacksonville facility. Hendrix says Brooks is one of the busiest rehab providers in the country with a stellar reputation for the best patient outcomes. The volume of treatment provided to hundreds of patients each year while still yielding excellent outcomes for patients is a testament to the level of care that led to the decision for Halifax Health to select Brooks as a partner for the new inpatient facility, Hendrix explains. Inpatient rehabilitation patients must pass strict requirements to be admitted to the new facility. Nationally, 10 percent of trauma patients will still require post-acute care following hospitalization. If admitted to Halifax Health Brooks Rehabilitation Center for Inpatient Rehabilitation, patients will receive post-acute care 6 FLORIDA MD - AUGUST 2013

9 COVER STORY that meets the needs of those who still require a hospital level of care plus an extensive range of rehabilitation services. A patient must meet the criteria established by the Centers for Medicare/ Medicaid Services (CMS) and must present with one of 13 diagnoses to qualify, including stroke, spinal cord, neuromuscular disorders such as multiple sclerosis, severe forms of arthritis and joint replacements. Preadmission screening 48 hours prior to admission is routine with a post-admission physician evaluation required within 24 hours. An individualized overall plan of care is required to be in place by day four, weekly team conferences are held for every patient and face-to-face physician visits are mandatory a minimum of three days each week. Patients must also be able to tolerate the intensity of the three hours of therapy required each day. Inpatient rehabilitation is evaluated by time sensitive assessments and documentation requirements that must meet CMS regulations. This level of coordination with measures in place will serve to assure not only quality care but the best possible outcomes for patients. Inpatient rehabilitation at Halifax Health will help to provide a strategic advantage for future payment reform that focuses on coordination of care across the healthcare continuum. This is a high level of care, not something that you would find in a nursing home or other general rehab setting. More than 50 percent of patient treatment is performed by rehabilitation professionals other than nursing staff, with it conducted away from the bedside. It is a rigorous program that will eventually lead to a patient and caregiver moving into our ADL suite, preparing for a return home, Hendrix explains. All inpatient rehabilitation will be overseen by physiatrists, or, more commonly known as rehabilitation medical doctors. The new department will be headed up by Dr. Geis, who came to Halifax Health in Currently the medical director for rehabilitation medicine at Halifax Health, she will assume the additional title and responsibilities as medical director of Halifax Health Brooks Rehabilitation Center for Inpatient Rehabilitation. Dr. Jorge Lopez-Perez, also a Rehabilitation Medicine Specialist will join Dr. Geis in providing medical rehabilitation care to patients admitted to the Center for Inpatient Rehabilitation. Geis initiated the development of the outpatient neurorehabilitation program 14 years ago with the goal of simply providing excellent patient care. Expanding these services to include the inpatient rehab component is the natural progression of providing truly comprehensive care for patients who have sustained catastrophic injuries. Geis believes her job is to make sure clinical services are delivered safely and effectively. My role is to guide the team through the rehabilitation process and to ensure that all services integrate smoothly in order to allow patients to achieve their highest level of independence. Medical safety and quality outcomes are my overarching goals. In order to assure these are met, our team of physicians, nurses, specialists in physical, occupational and speech therapy, psychologists, dieticians, and case managers will meet weekly to address each individual patient s progress and set patient goals for the following week. This is a fully integrated team approach which has proven to produce the results for patients that we require. It also ensures every patient will participate in their own care in order to build on gains leading to the best quality of life we can achieve, Geis explains. Therapist electronically documenting clinical progress record of patient using walker. Photo: PROVIDED BY HALIFAX HEALTH FLORIDA MD - AUGUST

10 COVER STORY SERVICES OFFERED Photo: PROVIDED BY HALIFAX HEALTH RT 300 cycle interactive display gauging workout regimen. Utilizing the comprehensive outpatient program which already exists at Halifax will provide necessary follow-up for all patients. Geis looks forward to a seamless experience from hospitalization to inpatient intensive rehab to outpatient follow-up. In the future, Halifax Health and Brooks Rehabilitation will continue the interest that Brooks Rehabilitation has in research. A state-of-the-art research facility will be added to the Halifax Health location. But for now, Volusia and Flagler counties can count on an inpatient rehabilitation center which ensures patient and caregivers stay together through the lengthy and emotionally demanding rehabilitation process. This union created a synergy when they chose to combine two regional leaders clinical and management strengths in order to offer excellent and comprehensive inpatient rehabilitation care. CONTACT INFO: HALIFAX HEALTH 303 Clyde Morris Blvd. Daytona Beach, Florida halifaxhealth.org Intensive inpatient, Interdisciplinary care including: Physical Medicine and Rehabilitation physician oversight Rehabilitation Nursing 24/7 Physical Therapy Occupational Therapy Speech Therapy Recreational Therapy Cognitive Therapy Case Management Rehabilitation of: Stroke Brain Injury Spinal Cord Injury Orthopaedics Hip Fracture Amputee Neurological Disorders (Multiple Sclerosis, Parkinsons, Motor Neuron Diseases, Muscular Dystrophy) Technologies: Biofeedback Environmental Control Lab Wheelchair Clinic VitalStim for dyspagia Gait and Balance re-training 8 FLORIDA MD - AUGUST 2013

11 Looking for Solutions to Help Empower Your Staff to Keep Patients Safe? Continuous and Contact-Free Monitoring of Heart Rate, Respiratory Rate and Motion to Potentially Allow the Clinical Team: Pressure Ulcers Alarm Rate designed to prevent 1! Bedside Unit Contact-free Sensor Central Display 1 Mobile Alerts on a Medical-Surgical Hospital Unit To learn more about the EarlySense System, please contact EarlySense at or MKUS-508, Rev. 1 FLORIDA MD - AUGUST

12 Behavioral Health Patient Retention, It s All About You! By James COVER D. STORY Huysman, PsyD, LCSW Did you know that approximately 70% of patients leave their health care providers because of a perceived attitude of indifference? That s a startling statistic and it speaks volumes about how we re doing as keepers of the public trust. Patient retention is all about the relationship between the patient and your office. People choose to be around people they like and feel safe with. That s equally true when they select a health care professional. A changing patient population is a fact of life in health care; patients move away or pass away. But often it actually boils down to simply feeling ignored, rushed through the office visit, long waits, not having questions answered, or not having telephone calls returned. Our patients have the right to expect these several fundamental values: Stay on schedule as much as possible. Their time is important and that is the first way they gage our respect for them and their time. To be treated with respect. Medical care is personal and so must be the care we deliver. Making eye contact with a patient can make all the difference in their perception of you. Being heard and understood is an essential value for all the seniors we serve. Listen carefully and respond to all their questions and concerns, no matter how small or how many times asked. Include their caregivers whenever possible. Did you realize that each point above begins with our own concept of self-care? We cannot take anyone to any place we have not taken ourselves. Conducting feedback and patient satisfaction surveys whenever possible shows that we are listening and growing in the process. Getting this feedback with humility and being open to change is vital. The medical world is now referring to clinics as medical homes. Surely we have all heard the adage home is where the heart is? Hence, a medical home needs to be a healthy, happy and safe place to reside. It all stands to reason that the health and wellness of all homes begins with everyone taking responsibility for their own health and wellness. Hence, a healthy staff is a staff that allows patients to feel safe and secure. Understandably, we have our own fears, stress and anxiety because of events in our personal lives. However, projecting them onto our patients and co-workers is entirely another issue and should be addressed forthwith. Without self-care and strong, healthy boundaries, our patients might be finding a new health care provider as the ACA rolls out. Setting a friendly, caring tone throughout your office is an important factor in patient retention. There is no better referral than word of mouth. I know so many of you have heard me say Take Your Oxygen First. With all humility, as co-author of a book by that name, it should be the mantra of all medical professionals. It may sound odd, but us caring for our own mind, bodies and spirits is the beginning of any retention strategy in the months to come. Self-care is where the health and healing of a home starts. When we tend not to take care of ourselves; get mad at ourselves, and our co workers and patients we are not being a steward of any patient retention strategy. We stop feeling safe to ourselves and to the people around us. When we do not take care of ourselves, we tend not to take responsibility for our actions and it affects everything and everyone in the environment. I m sure we can all identify the effects toxic drippers have on us in the workplace and elsewhere. We need to be examples of the health and wellness we strive to foster and promote. We really can t change someone else s behavior; we can only change ourselves. However, in business we need to be able to tell other people when they are acting in ways that are not acceptable to us or our organization. We need to start learning how to be emotionally honest with ourselves, how to start owning and examining our own feelings, and how to communicate in a direct and honest manner. Every good business takes an inventory. Perhaps the best place to begin our overall patient retention strategy then is by taking our own. Understand that understanding ourselves is the key to patient retention. To become what I call the corrective emotional experience for our patients and their families is the secret sauce for clinic success and effective patient retention. Dr. James Huysman, PsyD, LCSW aka Dr. Jamie is a fierce advocate of patient-centered healthcare and a work force in touch with its own wellness. He is a popular conference speaker and media guest on the topics of caregiver burnout, compassion fatigue and addictions and healthcare reform. Dr. Jamie blogs for Psychology Today and sat on the NASW committee to establish national protocols for certification and standardization of caregiving practices. He writes for Florida MD and Today s Caregiver magazines. He co-founded the Leeza Gibbons Memory Foundation and created the signature programming for its psychosocial drop-in model, Leeza s Place, opening 8 national locations, each with a different funding partner, in a four year period. He co-wrote the acclaimed caregiving book, Take Your Oxygen First: Protecting Your Health and Happiness While Caring for a Loved One with Memory Loss, with Gibbons and Dr. Rosemary Laird. He also contributed to the Healing Project s offerings, Voices of Caregiving and Voices of Alcoholism. He currently works as Vice President of Provider Relations and Government Affairs for WellMed Medical Management in Florida, a UnitedHealthcare company. 10 FLORIDA MD - AUGUST 2013

13 Shift Work Sleep Disorder By Daniel T. Layish, MD PULMONARY AND SLEEP DISORDERS Optimal sleep and wakefulness requires proper alignment between an individual s intrinsic circadian rhythm and their desired sleep wake schedule. The word circadian comes from the Latin circa meaning about and dian meaning day. Our intrinsic circadian rhythm is controlled by an internal clock in the hypothalamus (suprachiasmatic nucleus). The hypothalamus receives signals from the retina that entrain the circadian rhythm to the light dark cycle. The circadian rhythm affects the timing of sleep. There is also a homeostatic sleep drive, which controls sleep intensity, and it is determined by how long an individual has been awake. Shift work sleep disorder is a recurrent or persistent mismatch between a person s habitual sleep wake schedule and their endogenous circadian rhythm. Shift work sleep disorder can be associated with insomnia or excessive sleepiness (or both). The conventional time cues (zeitgeber = time giver in German) of sunlight and social activities are frequently out of phase with the altered sleep schedule in an individual with shift work sleep disorder. Many shift workers revert back to their traditional daytime schedule during non-work days. By definition, the course of shift work sleep disorder parallels the period of the shift work and remits with termination of shift work. An individual with shift work sleep disorder may use a large portion of their free time for recovery of sleep, which may have negative social consequences such as marital discord SLEEP FACTORS and impaired social relationships. Shift work sleep disorder tends to be more common after age 50. Between 5 and 8% of the population is exposed to night work on a regular or periodic basis. Shift work sleep disorder is usually a clinical diagnosis. A formal sleep study (polysomnogram) may be helpful to exclude other etiologies of a patient s symptoms. The sleep study should ideally be performed during the regular hours of sleep of the individual having the study. To diagnose shift work sleep disorder one must exclude any other medical or psychiatric conditions which could account for the symptoms. In addition, the symptoms should not meet criteria for any other sleep disorder which can produce insomnia or excessive daytime sleepiness (such as Jet-lag syndrome). Women appear to be slightly more prone to developing shift work sleep disorder. Interestingly, women tend to quit their shift work less often than men. The occurrence of shift work sleep disorder may vary depending upon the speed and direction of shift rotation. It may also vary depending upon a patient s diurnal preference. It appears to be less common in individuals who identify themselves as night owls. Individuals with shift work sleep disorder have been found to have higher rates of peptic ulcer disease as well as more sleepiness related motor vehicle accidents. Other consequences of this disorder include absenteeism from work, higher rates of depression and missed family and social activities as well as chronic fatigue and poor work performance. There have also been studies which link shift work sleep disorder to glucose intolerance as well as higher risk for alcohol and substance use. Sleep diaries can be CIRCADIAN FACTORS SHIFT WORK COPING ABILITY ENVIRONMENTAL FACTORS helpful in assessing patients with shift work sleep disorder. Actigraphy can be useful as an adjunct to history, physical exam and sleep diary. Actigraphy recording should consist of at least three consecutive 24-hour periods. Circadian rhythm markers (such as core body temperature monitoring or timing of melatonin secretion) are more difficult and typically are not used in routine clinical settings. Treatment for shift work sleep disorder can include exposure to bright light in the work place as well as administration of wake promoting agents during evening work hours. Other treatments include scheduled napping as well as hypnotic agents to improve daytime sleep. Maintaining a regular sleep wake schedule during both work and non-work days is also recommended (as well as minimizing light or noise in the bedroom and allowing sufficient time in bed for sleep during the daytime). Other recommendations include limiting light exposure by using dark sunglasses during the morning trip home from work. The timing of light FLORIDA MD - AUGUST

14 PULMONARY AND SLEEP DISORDERS 12 FLORIDA MD - AUGUST 2013

15 PULMONARY AND SLEEP DISORDERS therapy is critical. The American Academy of Sleep Medicine recommends light exposure before the core temperature is reached in an individual with a morning/evening/night schedule (versus administrating light therapy after core temperature in an individual with a night/evening/morning schedule). Studies have utilized various light intensities from 2350 to 12,000 lux. Some but not all studies of bright light therapy have also restricted daytime light exposure. Different schedules of light exposure have also been used. Melatonin has both sleep promoting (hypnotic) and phase shifting properties. Melatonin (when given to night workers before their daytime sleep) may enhance daytime sleep and appears to have no effect on subsequent nighttime alertness. In a study published by Czeisler in The New England Journal of Medicine in 2005, modafinil resulted in decreased accidents/near accidents during the commute home (versus placebo). Treatments for shift work sleep disorder can include modafinil (Provigil) as well as armodafinil (Nuvigil). These medications are non-amphetamine stimulants believed to act on the hypothalamus, although their exact mechanism of action is unknown. Shifts can be permanent, fixed or rotating. Shift can rotate forward (clockwise) (from morning to evening to nighttime) or backward (from night to afternoon to early morning shift). Rotating shifts seem to cause more sleep difficulties than permanent shifts and counter clockwise rotation affects sleep wake activities more than clockwise rotation. The speed of rotation and the length of the shift may also impact an individual s symptoms. It appears that workers on permanent night shifts sleep one to four hours less than day workers and individuals on rotating shifts sleep about two hours less than day workers. There are several factors involved in this. Shift workers must try to sleep at a time when their circadian/wakefulness drive is exerting pressure on them to remain awake. The desire to spend time with family or take care of household or social obligations is also a factor. Environmental factors such as noise and light may also be obstacles to sleep quality for shift workers. Table 1: Factors influencing the effect of shift work on sleep and wakefulness Type of shifts (permanent, rotating). Duration of shifts. Speed of rotation (slow or fast). Direction of rotation (clockwise or counter clockwise). Social and family disruption. Exposure to natural or artificial light. Existing health problems. Age (over 50 is more adversely affected than younger individuals) Gender (female shift workers seem to have more difficulty coping with shift work than men). In general, the circadian clock adjusts better to clockwise rotation because it is naturally easier to delay sleep to a later hour. Typically, longer shifts (such as hours) cause more sleepiness than eight hour shifts. Women doing shift work tend to get less sleep than men when they are not working because of their persistent family and social obligations. Overall, night and rotating shift workers comprise approximately 6% of all workers. About 1% of the working population in the United States is believed to suffer from shift work disorder. Increased awareness of this disorder should allow more individuals to receive proper diagnosis and therapy. Daniel Layish, MD, graduated magna cum laude from Boston University Medical School in He then completed an Internal Medicine Residency at Barnes Hospital (Washington University) in St.Louis, Missouri and a Pulmonary/Critical Care/Sleep Medicine Fellowship at Duke University in Durham, North Carolina. Since 1997, he has been a member of the Central Florida Pulmonary Group in Orlando. He currently serves as Medical Director of the Intensive Care Unit, Respiratory Therapy and Pulmonary Rehab at Winter Park Memorial Hospital. Dr. Layish may be contacted at or by visiting ENDO-SURGICAL CENTER OF FLORIDA Recognized by American Society for Gastrointestinal Endoscopy (ASGE) One of 450 endoscopy units to be granted this recognition since 2009 To be recognized by ASGE, a peer-reviewed application process must prove: their roles policies specific to ongoing assessment of performance relative to key quality indicators infrastructure and personnel dedicated to infection control and prevention The Place Doctors Choose for Themselves. 100 N. Dean Rd., Suite 102, Orlando, FL Call for more information or to schedule a colonoscopy or endoscopy. FLORIDA MD - AUGUST

16 Marketing Your Practice Boosting Your Facebook Engagement By Jennifer Thompson, President of Insight Marketing Group When it comes to social media, the name of the game is engagement. After all, what good are all of those fans and followers if they don t care about or pay attention to what you re doing? Just last month, my team and I guided one of our orthopaedic clients into the top ten national medium-sized companies competing to win the Social Madness Competition presented by The Business Journals. After winning the Orlando round, presented locally by The Orlando Business Journal, it was on to the nationals to compete against 44 other similarly sized companies. So what did we do to make it into the top ten and how did it benefit the practice? Below are some of the strategies we employed to become the little orthopedic practice that could. Identify Your Facebook Target Demographic When your office utilizes social media, whom exactly are you trying to reach? If you just say, Patients, you haven t looked into your page insights deep enough. By clicking on the People tab you ll get a top-level overview of who your followers are gender, age and even location. This information is key when crafting your messaging, as you wouldn t have the same message for an 18 year-old-male that you would for a 64-year-old female. For this client, we target year old females using key imagery and posts that appeal to the mom demographic. Find Your Most Successful Post Types Facebook is great for communicating with patients in part because it s so versatile. You can post a myriad of topics and ideas that appeal to your specific fanbase and Facebook will keep track of how successful each post is for you. For free. Photos, status updates, links, videos post some of each to find out which ones resonate with your fans. We ve found that photos generally work best from an engagement standpoint both in terms of clicks and interactions ( likes, comments and shares ). After photos, our most successful results have come with status updates, followed by links and then videos TH ANNUAL Orthopaedic Update for Allied Healthcare Professions Conference Presented by Foundation Saturday, August 10, 2013 Check-in Begins at 7am at the Rosen Centre Hotel Online Registration Now Open Join fellow Orthopaedic HealthCare Professionals for a day complete with: Be sure and check out our NEW and IMPROVED website at Insightful lectures from specialists around the country Certified continuing education credits (pending Category I CME s) Lunch provided at one of the area s most pristine resorts Register at OrlandoOrthoFoundation.org If you have any questions, please contact Bob Hammons at or him at 6 Convenient Offices to Serve You: Downtown Orlando Winter Park Sand Lake Lake Mary Oviedo Lake Nona 14 FLORIDA MD - AUGUST 2013

17 Create Interesting Content That Fits Your Successful Post Types Sounds easy, right? For the most part it is (though it gets a little more difficult when competing against the top companies in the country for months on end, but I digress). If photos work well, be sure to plan ahead and have some fun, creative ones scheduled for the month. Remember, Facebook and Marketing Your Practice Be sure to determine your Facebook page s demographics before attempting to craft your messaging. social media as a whole is supposed to be personal, so not everything has to just be an office photo with a doctor. Those are great and they shouldn t be ignored; however, don t feel like you can t put up a crazy themed photo or a popular meme, too. When updating your status, let people know what s going on in your office. Having a staff appreciation day? Show your fans your office has some personality. Happy it s Friday? Tell the world. Odds are, they are, too. We ve also found that our followers really enjoy posts that relate to charitable giving and those that ask them questions while presenting facts. For example, come up with a statistic that relates to your practice and have your followers fill in the blank. Or, ask them to answer a true or false question about something you treat in your office. It may sound silly, but simple exercises like this will get people engaged, and it will get them to share the content with their friends and family (i.e. potential new patients). The End Result Ultimately, engagement should be your goal with social media, not click through rates to your website. Social media is your way to become more than just a medical practice to your patients. It s your way to become a part of their lives outside of the office. As an added benefit, when done correctly, you ll see benefits within your A snapshot of the Facebook reach and engagement levels for one of our clients. practice walls as well. For example, just within the contest period alone, we had several patients tell us they scheduled an appointment with the practice because they found them on Facebook or saw a post their friend Liked. We were also able to schedule at least one surgery, thanks to someone finding the practice on, you guessed it, Facebook. Thanks to an increase of more than 800 page likes, we were also able to exponentially grow the practice s organic reach to thousands of potential patients in just a few short months without spending a dollar. It s all about engagement. Marketing Your Medical Practice: A Quick Reference Guide Are you ready to finally start marketing your practice? Visit to get your copy of Marketing Your Medical Practice: A Quick Reference Guide by Jennifer Thompson and Corey Gehrold. Encapsulating their real world medical marketing knowledge and expertise, this easy-to-read ebook gives you all the tips and tricks you ll need to start marketing your practice today in a fast, fun and friendly format just like the articles in this series. To learn more, visit Looking for more information? Contact Jennifer Thompson today for a free consultation and marketing overview at or her at Jennifer Thompson is president of Insight Marketing Group, a full-service healthcare marketing group focused on digital and social media administration, referral and partnership development, creative services and graphic design, online reputation management/development and promotional products. She is co-author of Marketing Your Medical Practice: A Quick Reference Guide and an avid Twitter user, regularly posting medical practice marketing tips, articles and more at You can learn more about her and her company at FLORIDA MD - AUGUST

18 ORTHOPAEDIC UPDATE ifuse Implant System Revolutionizing Sacroiliac Joint Fusion Surgery By Corey Gehrold The ifuse Implant System is a new, minimally invasive approach for sacroiliac (SI) joint fusion surgery to treat conditions including sacroiliac joint disruptions and degenerative sacroiliitis. The procedure utilizes a smaller incision and a guide pin to provide stability to the SI joint, which results in less pain and a quicker recovery time for patients. Why Would a Patient Need SI Joint Fusion Surgery? A patient would be recommended for SI surgery when they exhibit symptoms of chronic sacroiliac inflammation and degeneration, and when conservative methods of treatment such as medication, therapy and injections have failed, says G. Grady McBride, M.D., a board certified orthopaedic surgeon specializing in cervical and lumbar spinal surgery at Orlando Orthopaedic Center. SI joint dysfunction, when the sacral bone joins the pelvis bone, may lead to pain in the lower back or upper buttock area. The pain is fairly common and frequency does increase with age. SI joint dysfunction is quite common in patients who have undergone lumbar fusions. In fact, some studies have indicated up to 50 percent of patients having lumbar fusions or lumbosacral fusions develop degeneration in the adjacent sacroiliac joints. With the ifuse system there are no conflicts with lumbar fusion devices, meaning if a patient previously had spinal surgery, they may still be a candidate for the new procedure. New Vs. Old Methods of SI Joint Fusion Surgery The traditional SI joint fusion surgery involved open surgery that could last up to several hours, required a large incision and a prolonged hospital stay and recovery. The surgeon would remove cartilage tissue from the joint and use bone grafts from another part of the body to help fuse the SI joint. But with the ifuse Implant System, patients no longer have to endure much of the discomfort and inconvenience experienced with the traditional procedure. The ifuse Implant System requires a very small incision and uses a special guide pin to place rigid titanium implants specifically made to stabilize and fuse the heavily loaded SI joint. These small implants are designed to stabilize the SI joint and allow healing through minimization of micromotion. The advantages to the patients are that, as a minimally invasive procedure, the recovery is quite rapid and you re out of the hospital the next day with minimal down time, says Dr. McBride. Patients can be up walking the evening of surgery with a walker and they will only need to limit weight-bearing for approximately three weeks. The Surgery Process The road to an ifuse Implant System starts at the initial exam. If a patient is experiencing lower back symptoms predominately below the L5 vertebra and the physician is able to determine pain originates in the SI joint, the doctor will request X-rays or a CT scan to look for signs of degeneration of the joint. A common test to determine whether a patient may be a candidate for SI surgery is to do a selective injection of Lidocaine or an anesthetic agent in the sacroiliac joint, says Dr. McBride. If the G. Grady McBride, MD, Orlando Orthopaedic Center Spine Specialist. sacroiliac pain is completely relieved for several hours then that would indicate the source of the pain and suggest they may benefit from the ifuse Implant System. Once all conservative measures have failed and if the patient chooses to undergo the ifuse surgery, the patient will be contacted by the physician s office and a surgery will be scheduled. On the day of surgery, the patient will be admitted and administered a general anesthetic. They will then be placed lying face down on the surgical table while the surgeon uses the specially designed ifuse system to guide the instruments that prepare the bone and insert the implants. The entire procedure is performed through a small incision (approximately 2-3cm long), along the side of the buttock. During the procedure, X-ray guidance provides the surgeon with live imaging to facilitate proper placement of the implants. Typically three implants are placed, depending on the patient s size. Surgery is usually completed in less than 40 minutes and the patient is returned to their room and instructed to start limited weight-bearing activities shortly after surgery. Patients will return to their physician s office between one and two weeks following surgery for a follow-up appointment to assess the incision and for follow-up X-rays. Based upon the physician s recommendation, patients will also have to come back to the office 12 weeks post-surgery for more X-rays and to determine whether they may resume full weight-bearing activities. ifuse Implant System Results Overall this system has had a very high success rate with very few failures, says Dr. McBride. Healing is usually complete by the six to eight week timeframe, but I usually will limit my patients from doing anything strenuous for a three to four month period. Hopefully by that time the patient has made a full recovery and their sacroiliac pain has resolved. Check out to learn more about the ifuse Implant System and how it can help your patients. 16 FLORIDA MD - AUGUST 2013

19 I would recommend Peninsula to anyone. The level of care is second to none. Lonnie B. Former Rehabilitation Patient Experience a Strong Rebound When it comes to recovering from stroke, spinal cord injury, hip fracture or major multiple trauma, trust the greater Daytona area s inpatient rehabilitation facility accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). Peninsula Rehabilitation is here to be your partner on your patients road to recovery. Our patients can expect: To receive intensive therapy for up to 3 hours daily with a multidisciplinary team of therapists To find comfort in 24/7 nursing support, with cardiopulmonary and telemetry services To be seen daily by a physician To return to a better quality of life, faster than similar patients at comparable facilities Ranked in top 5% nationally - patient experience scores Hospital Consumer Assessment of Healthcare Provider Systems (HCAHPS) 2012 Governor s Sterling Award for Excellence State of Florida Area s only stroke-care accredited facility CARF International To schedule a tour of the newly renovated Peninsula Rehabilitation or to get an evaluation for referral, call (386) FLORIDA MD - AUGUST FHMMC

20 CANCER Stereotactic Radiosurgery for Brain Metastases By Arnold B. Etame, MD, PhD and Nikhil Rao, MD Cancer metastasis remains a leading cause of death in the United States. Brain metastases, in particular, represent one of the most feared complications of disseminated cancer, resulting in a very grave prognosis. Systemic chemotherapy has a very limited role in the direct management of brain metastases largely due to delivery constraints across the blood-brain barrier. Patients with uncontrolled brain metastases could have a survival of less than 3 months. Whole brain radiotherapy (WBRT) has been delivered over the past thirty years with evidence of successful palliation of Multiple beams deliver pin-point radiation to two tumors in the brain. symptoms but concern about the potential for long term neurologic sequelae from treatment. While radiotherapy still remains the main management modality for patients with brain metastases at present, there has been much interest in exploring alternate treatment strategies, such as optimizing patient selection for the integration of surgery and advanced stereotactic radiation modalities. In select cases, surgery followed by radiotherapy is desired. When indicated, surgery is often reserved and effective for large symptomatic lesions, ideally solitary. Post surgical radiotherapy options include WBRT or fractionated stereotactic radiotherapy to the surgical resection bed (FSRT), either of which is favorable to local disease control. In patients with small asymptomatic lesions (<3cm), stereotactic radiosurgery (SRS) is ideal in lieu of surgery. SRS refers to the delivery of a high dose of radiotherapy to a very precise targeted volume. When given as a single fraction, it could represent a dose approximately 10 times greater than the typical radiation dose. Unlike WBRT, SRS is very focally applied. SRS has the advantage of targeting lesions in areas that are not easily surgically accessible, as well as for patients who might not be optimal surgical candidates given their debilitated status. SRS thus provides a relatively lower morbidity alternative compared to conventional surgery. At the Moffitt Cancer Center and Research Institute, we have made tremendous advances in the treatment of brain metastases with a paradigm shift towards SRS as a primary treatment modality for most of our brain metastases. As a consequence, we have realized several long-term survivors within our radiosurgery cohort. Being a comprehensive cancer center Arnold B. Etame, MD, PhD with nationally renowned breast, thoracic and melanoma oncology programs, we encounter a substantial volume of patients with brain metastases. The radiosurgery program comprises an interdisciplinary team of radiation oncologists, neurosurgeons, and radiation physicists. Patients are evaluated simultaneously by a neurosurgeon and a radiation oncologist to determine Nikhil Rao, MD radiosurgery eligibility. We employ a frameless system which has the added benefit of enhanced patient comfort compared to frame-based systems. Our experience with this approach mirrors those of other institutions whereby we have found excellent local control of metastatic lesions, even for tumors that were usually radio-resistant to conventional radiation. Interdisciplinary collaboration is essential to the effectiveness of this treatment approach. Once patients are deemed to be ideal SRS candidates, a planning high-resolution MRI of the brain is obtained. The very high-resolution scan enables detection of metastases that are in the millimeter range. In addition, for frameless SRS applications, Different colors represent the doses of radiation delivered to each tumor, note how quickly the dose decreases from the high to low dose region. 18 FLORIDA MD - AUGUST 2013

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