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Missouri Foundation for Health Grant Helps with Hospital Readmissions

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House calls have returned for some Texas County Memorial Hospital patients thanks to an $110,567 grant from the Missouri Foundation for Health (MFH).

The MFH grant specifically targets chronically ill patients that have been inpatients at TCMH. Certain patients will qualify for a home visit from the TCMH healthcare provider following the patient’s discharge from the hospital with the hope of keeping the patient from being readmitted to the hospital within a short amount after discharge.

The grant funds will be divvyed out over the next three years to pay the wages and travel expenses of a TCMH healthcare provider, to purchase a portable ultrasound unit and a defibrillator, to provide additional critical care education and to pay for patient care supplies needed for patients in their home.

“Missouri Foundation for Health has a special projects funding opportunity available for grants like this one,” Jay Gentry, TCMH Healthcare Foundation director, said. Gentry pursued the grant on behalf of TCMH.

Based in St. Louis, MFH is an independent philanthropic foundation dedicated to improving the health of the uninsured and underserved in the region. TCMH has received grants for other project in the past.

“The goal of the project is to make 150 home visits per year, and decrease the number of readmissions of chronically ill hospital inpatients,” Gentry said.

The focus of the grant is on chronically ill Medicare patients with cardiopulmonary issues, but other classifications of patients are identified at TCMH and cared for in the home, too.

Statistics show that half of all Americans have a chronic illness, and 25 percent of persons with a chronic illness have more than one chronic condition. Chronic conditions include heart disease, diabetes, asthma, obesity and high blood pressure.

For many years, TCMH has been collecting data on hospital patients and hospital readmissions, and the information is reported to the Center for Medicare Services (CMS). Annual Medicare reimbursement levels at hospitals are based on a number of different criteria specified by CMS, including readmissions of hospital patients.

“Many of the inpatients at TCMH have multiple chronic conditions, so the potential readmission rate is high,” Gentry said.

Statistics show that chronically ill hospital inpatients have the most likelihood of readmission to the hospital within the first three days after discharge from the hospital.

“Following up with the patient in his or her home after they are discharged from the hospital is one way to slow or cut readmissions,” Gentry explained.

Candidates for the house calls are identified during their inpatient stay at TCMH.

Mary Barnes, a registered nurse overseeing case management at TCMH, and Angie Gimpel, social worker at TCMH, follow each patient’s hospital stay. They use a scoring tool that helps them determine if a particular patient is a candidate for follow up care in the home.

The scoring method takes into account the chronic conditions a patient has, how long the patient has been hospitalized, whether the patient in an inpatient or observation patient, and the number of emergency room visits by the patient in the last six months.

Patients that score 90 to 95 percent with the scoring tool are targeted for home visits. Barnes or Gimpel will connect with the patient asking him or her if a home visit would be okay after they are discharged from the hospital. When a patient approves the home visit, Chip Lange, physician assistant at TCMH, is contacted about making the home visit following discharge.

Lange tries to connect with his home visit patient prior to their discharge from the hospital.

“I try to give the patient a face to put with the name before I make the home visit,” Lange said. “Plus, if I see them before they go home, I have the opportunity to assess how they look and sound before they leave the hospital which gives me a baseline for their health when I see them in their home.”

Lange has already started seeing patients in their homes, a process he describes as going “very well”.

A typical home visit takes place 24 to 72 hours after the patient is discharged from the hospital. Lange noted that the most critical time for a patient’s readmission to the hospital is within the first three days of discharge.

Lange does a physical assessment of the patient, provides medication information and instructions, follows up with discharge information and assesses the patient’s home to determine if other resources such as a walker or home health are needed to improve the patient’s health and safety at home.

“A much more complete picture of the patient is available when you visit their home,” Lange said, adding that the patients he has visited at home like having Lange “on their turf”.

“There’s a lot less pressure for the patient because they aren’t worried about getting to the appointment on time, finding a ride to the appointment or the other stresses of leaving the home for an office visit,” Lange explained.

Lange noted that in addition to the comfort the patients find from the home visit, he’s able to spend whatever time is needed with the patient getting a clear look at the patient’s medications and the administration of the medication.

“The home visit is much more slow-paced, and we usually have pretty good discussion about the patient’s health,” Lange said.

The grant allows TCMH to make home visits to chronically ill inpatients following their discharge throughout the TCMH service area. The grant targeted Medicare patients at TCMH, but any patient that meets the criteria is eligible.

Jean Freeman-Crawford, program officer for the Missouri Foundation for Health, presented a ceremonial check to Texas County Memorial Hospital for the house call grant for chronically ill patients.  Shown with the check are (left to right) Chip Lange, physician assistant at TCMH; Wes Murray, TCMH CEO; Freeman-Crawford, and Jay Gentry, TCMH Healthcare Foundation director.

Jean Freeman-Crawford, program officer for the Missouri Foundation for Health, presented a ceremonial check to Texas County Memorial Hospital for the house call grant for chronically ill patients. Shown with the check are (left to right) Chip Lange, physician assistant at TCMH; Wes Murray, TCMH CEO; Freeman-Crawford, and Jay Gentry, TCMH Healthcare Foundation director.


Health Tips for Women over Age 50

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tracey arwoodBy Tracey Arwood, CNM

1. Continued pap smears at least every three years to screen for cervical cancer until age 65.

2. Colon cancer screening with a conoloscopy or sigmoidoscopy starting at age 50.

3. Yearly blood pressure screen with annual physical exam

4. Cholesterol/lipid screen every five years starting at age 45. This is a fasting blood test.

5. Annual mammograms to screen for breast cancer starting at age 40 until age 75.

6. Osteoporosis screen with a bone mineral density test every 2 years starting at age 65 or sooner based on risk factors.

7. Screening for Type 2 Diabetes based on risk and elevated blood pressure.

Other screenings based on risk may include screening for sexually transmitted infections, depression, genetic testing for breast cancer genes, thyroid disorder, hepatitis B and C, and HIV.

All adults should receive a yearly flu vaccine, a tetanus booster every 10 years, a shingles vaccine at age 60 or older and a pneumonia vaccine at age 65 or older.

For optimal health, I recommend: a yearly medical exam, daily moderate physical activity for at least 30 minutes per day. Eat at least five cups of fruits and vegetables of various colors per day, limiting fried and sugary foods, preparing most meals from scratch at home and switching to whole grain whenever possible. If you are overweight, losing just 10 percent of your body weight can significantly decrease your risk of heart attack. A daily walk outside for at least 15 minutes a day can decrease symptoms of depression, provide stress relief, and provide exercise to prevent chronic health problems. Stopping or decreasing smoking can decrease your risk of many cancers, heart disease, stroke, breathing problems, and chronic pain. Women should limit alcohol intake to no more than one glass per day. A daily supplement of calcium and vitamin D will help prevent osteoporosis in postmenopausal women.

For additional information contact Tracey Arwood, CNM at the TCMH Medical Complex in Houston at (417) 967-5639.


Preventative Screenings and Exams are the Key to Good Health

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The rise of preventative medicine has shown that a patient’s quality of life can be enhanced with regular healthcare screenings and exams. Preventative medicine can also save money for insurance companies such as Medicare.

Medicare was established in 1965 as an acute care insurance policy to cover illness and injury. Medicare did not pay anything to help keep Medicare recipients well when it was established, but the program has evolved with healthcare to include coverage for a preventative healthcare program for every Medicare enrollee.

Jeffery Kerr, DO, a nationally recognized geriatrician and the medical director of the emergency department at Texas County Memorial Hospital, sees a majority of Medicare-covered patients in the hospital and in his nursing home practice. He is a believer in the benefits of utilizing the preventative coverage provided by Medicare.

“Preventative medical services are the most underutilized part of the Medicare program,” Kerr said. “But preventative screenings and exams are the key component to the Medicare program and helping beneficiaries maintain their health and quality of life.”

For new Medicare enrollees, a first-time physical exam called the “Welcome to Medicare Physical” starts each Medicare recipient on the path of preventative healthcare. Eighty percent of the cost of this exam is covered during the first 12 months that a person is enrolled in Medicare Part B.

During the “Welcome to Medicare” exam, the healthcare provider will record medical history, check blood pressure, vision, weight and height. The healthcare provider will make sure the patient is up-to-date with preventive screenings and services, such as cancer screenings and shots. Depending on a person’s general health and medical history, further tests may be ordered if necessary. For example, a person at risk for an abdominal aortic aneurysm may get a referral for a one-time screening ultrasound at their “Welcome to Medicare” physical exam.

A screening lipid panel to evaluate cholesterol and triglycerides is covered each year for Medicare recipients. Good cholesterol levels decrease risk of heart attack and stroke.

“Our genetics play a big role in our cholesterol and triglycerides,” Kerr explained. “You can be thin and in shape and still have elevated cholesterol levels.”

Elevated levels of cholesterol and triglycerides in the arterial walls create sticky areas for blood to attach and create clots. These clots can proceed to clog arteries—usually in the brain, heart and legs.

Screening colonoscopies are covered every 10 years by Medicare. Colonoscopies can find polyps and tumors. Because some colon cancers originate in polyps, the polyps founds during screening colonoscopies can be removed during the screening exam.

Lipid panels and colonoscopies are two part of preventative healthcare covered by Medicare for men and women. There are also preventative screenings recommended and covered specifically for men and for women.

Men and women may also receive a bone mass measurement, medically referred to as a Dexascan, covered by Medicare. The criteria for Dexascan vary for men and women. Because women are more likely to experience bone loss or osteoporosis, a healthcare provider may order a Dexascan every two years as part of a preventative medicine program.

“Osteoporosis can creep up on a person, and many times is not recognized until that person fractures a hip or has a vertebrae crumble,” Kerr said.

Kerr noted that bone health can be improved with some medications or treatment plans prepared by a healthcare provider.

Specifically for men are the annual prostate screening antigen (PSA) with a digital rectal exam (DRE) and a testosterone level evaluation.

“Prostate cancer can be slow growing without symptoms,” Kerr explained.

Often, the first sign of prostate cancer is bone pain. At that point, the cancer has spread to the bone and is incurable.

“A PSA is a simple blood test, and the DRE is performed at the same time to evaluate the size of your prostate,” Kerr said.

A testosterone level test is also a blood test; checking for the level of androgen in blood. According to Kerr, a normal testosterone level can increase the quality of life for men of all ages.

Women enrolled in Medicare can receive screening mammograms, gynecologic exams and hormone therapy in the preventative portion of Medicare coverage.

“Screening mammograms have proven that breast cancer does not have to be deadly,” Kerr explained. “The benefits far outweigh the risks.”

Mammograms are covered every year in the Medicare program. A screening mammogram can find nodules that cannot be felt by a patient.

The annual female gynecologic exam includes a test to find abnormal cells in the cervix that are or may become cancerous, commonly known as a pap smear. This test can also determine the level of hormones circulating in a woman’s body. A rectal exam may also be included annually to evaluate the stool for occult blood, which can be a warning sign for cancer.

“A woman’s healthcare provider can determine the frequency of gynecological exams based on the needs of the woman and her health history,” Kerr said.

Hormone therapy may also be a part of a female Medicare recipient’s preventative health plan as evaluated and prescribed by a healthcare provider. Low estrogen levels can cause fatigue, vaginal dryness, urinary problems and decreased sex drive.

Kerr stressed the importance of each Medicare enrollee having a relationship with a primary care doctor. “If you don’t have a regular healthcare provider or have not seen your doctor about a preventative program, I encourage you to do so,” Kerr said.

As a long-time physician at TCMH, Kerr has worked closely with the hospital’s physicians and mid-level providers.

“TCMH has healthcare providers that can work with anyone who needs to set up a preventative care program,” Kerr said, noting that all of the preventative screening tools are available at TCMH, too.

“Many older adults do not like to travel far from home to get the healthcare they need, so we are very fortunate to have the staff and services available in Texas County to help our elderly stay healthy when they get started on a preventative healthcare plan,” Kerr said.


Increased Inpatient and Outpatient Volumes at Hospitals = Positive August Bottom Line

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Increased inpatient and outpatient volumes at Texas County Memorial Hospital combined to give the hospital its second positive bottom line for the year, board members heard at their monthly meeting on Tuesday.

The TCMH August financial report showed a positive bottom line of $232,039.15, dropping the year to date deficit to $643,612.21.

In the financial report, Linda Pamperien, chief financial officer at TCMH, explained that inpatient revenues were down $21,459.00 from budgeted expectations and outpatient volumes were up $332,656.00 from budgeted expectations.

“Every outpatient department but two had increased numbers for the month of August,” Pamperien said, adding, “We also had 20 swing bed admissions in August compared to our usual nine to 12 swing bed admissions.”

Pamperien noted that TCMH is still down 168 inpatient admissions compared to 2013.

“We have had an amazing turn around on outpatient revenue in the last two months,” Pamperien said.

Wes Murray, chief executive officer at TCMH, expressed hope that the uptick in volume was the “new norm”.

“We have made staffing changes, cut expenses, and changed our services to save money for over a year now,” Murray said. “This is where the bar needs to be right now.”

Murray told board members that he was going to continue to challenge the department managers to add to their monthly department numbers.

“We continue to face serious financial challenges without state Medicaid expansion,” Murray said, explaining that merit raises for hospital employees have been put on hold for a second year.

According to Murray, hospital volumes are down across the nation, but TCMH has made efforts to grow volumes. In the past year, hospital departments have spent time educating area healthcare providers about the ancillary services offered in each department. Efforts have been made to encourage area residents to support their local hospital and healthcare providers by using local healthcare services.

“We all have to work together on many different levels to try to help ourselves in these tough times,” Murray said, adding. “All of our departments can be busier.”

Murray and Pamperien also attributed the change in numbers to the addition of new healthcare providers.

Pamperien provided surgery case numbers showing 66 cases in May; 55 cases in June; 124 cases in July and 105 cases in August.

“We are back up to where we were a year ago in the number of cases we are doing in our surgery department,” Murray said, adding, “And the bottom line is indicative of us getting that department back where it was.”

Murray explained that with the addition of general surgeons Linda Milholen, MD and Leroy Wombold, DO and obstetrician and gynecologist, Christopher Baldwin, MD, there was “room for growth” with the surgical case numbers.

“More services are being offered in surgery than ever before,” Dr. Jonathan Beers, vice chief of staff, agreed. “There are things that we used to send to Springfield that we can now keep here.”

Murray noted that members of the medical staff have expressed their pleasure and support of Milholen and Baldwin.

“Our surgery department depends on strong referrals from the primary care physicians,” Murray said.

Amanda Turpin, quality management director at TCMH, reported that as a member of the Hospital Engagement Network (HEN), TCMH received funds from the Center for Medicare Services (CMS) that allowed her to attend the National Association for Healthcare Quality conference this month.

Funding was also provided for Turpin to attend additional classes at the conference that will allow her to take the exam to become a Certified Professional on Healthcare Quality.

Turpin and two additional hospital departments provide monthly data to HEN. TCMH has been reporting to HEN for two years, and the data is compiled and shared at national, regional and state levels.

In addition to the educational funding, TCMH received a $3,000.00 stipend from CMS to help offset the cost of man hours for the data collection and reporting by three departments.

“Our participation in the Hospital Engagement Network is voluntary but highly encouraged by CMS,” Turpin said. “It’s nice to receive a little something for the effort that we put into collecting and compiling data for the network.”

Murray reported that the hospital’s emergency department has seen a rise in the number of transfers by ambulance to the department and a higher acuity level among patients in the department.

“As we thought might happen when we doubled the size of the ER, we need to change the strategy of handling patients in our department,” Murray said.

The new strategy includes using mid-level providers in the ER during peak times. The mid-level provider—a physician assistant or nurse practitioner—will provide care for the primary care cases that end up in the emergency department but could be seen in an office-based clinic setting.

“We hope that utilizing a mid-level provider in the ER will help us establish those patients with a primary care provider in one of our clinics,” Murray said.

Murray explained that TCMH still has low emergency room waiting times compared to national averages, but when acuity levels rise in the patients in the ER, wait times increase.

“The peak times in the ER are becoming more consistent, and we want the service we provide in the ER to go as smooth as possible,” Murray said.

Chip Lange, physician assistant at the TCMH Medical Complex, is already helping out during peak times in the TCMH emergency department. Ray Bruno, a family nurse practitioner, and Jeff Blue, physician assistant, are also expected to begin to provide additional coverage in the emergency department very soon.

Two new hospital department directors stopped in at the monthly meeting—Angela Raymond and Connie Brooks. Raymond, a registered nurse with family ties in Licking, has taken the helm in the TCMH obstetrics department. Brooks, a long time TCMH nurse from Mountain View, is heading up the education department at the hospital.

Present at the meeting were Murray; Pamperien; Beers; Turpin; Joleen Senter Durham, director of public relations; Dr. John Duff; Ellen Willis; Jenna Saraga, and board members Omanez Fockler; Janet Wiseman; Mark Hampton; Dr. Jim Perry, OD, and Russell Gaither.

The next meeting of the TCMH board of trustees is Tues., Oct. 28th at 12 p.m. in the hospital board room.


New PA Gets Exactly What She Wanted at Licking Clinic

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Whitney Young, PA

Whitney Young, PA

For Whitney Young, the perfect ending comes with a new beginning.

As the latest addition to the TCMH Family Clinic in Licking, Young can tick off all plusses to her new position—in the area, close to home, smaller town, rural health clinic, tied to a larger healthcare facility. Check, check and check!

“This is exactly what I was looking for,” Young said with an enthusiastic smile.

Young attended college and graduate school to become a physician assistant, a task that took seven years. She is pleased to have found a job that met all of her criteria, which included a requirement to practice for the first two years in an underserved area.

“I am a National Health Service Corps scholar,” Young said, explaining that the National Health Service Corps (NHSC) requires its scholars to practice in an underserved in exchange for covering loans associated with medical training programs.

Young knew that she wanted to work in a rural setting, preferably close to her hometown of Rolla. When she began looking for a position that met the NHSC requirements in the South Central Ozarks, there were none to be had.

Young contacted TCMH in early 2014, and at the time there were no positions available.

“I decided I would just find a position in the Midwest that met the NHSC requirements, and after I did my required amount of time, I would leave and return home,” Young explained.

As Young began looking outside of the South Central Missouri area, Kimberly Olving, the first physician assistant to work at the TCMH Family Clinic in Licking gave notice that she would be leaving in late July to follow her husband to a new job.

“I knew this was the position I wanted,” Young said about her interview.

Not only did the TCMH Family Clinic position fulfill Young’s NHSC requirements, it was connected to a hospital, too.

“I wanted to work for an organization that had additional resources available for me to use,” Young explained.

To top off the perfect ending to her job search, Young was able to spend her final weeks of physician assistant training working in the TCMH Family Clinic with Olving and Joshua Wolfe, MD.

Olving departed in late July, and Young took and passed her board examination in August and began immediately seeing patients at the clinic.

Patients at the clinic might not guess that Young is a new graduate of physician assistant school. She projects an ease with her patients and their medical conditions. It’s easy for Young to find common ground since she also enjoys hunting, fishing, camping and four-wheeler riding, just like many of her patients.

Young didn’t “grow up” planning to go into healthcare, but she was familiar with the field because she had family members with jobs in healthcare.

Young spent some time shadowing family medicine physicians, a surgeon and a physician assistant, and she knew that she wanted to do something in healthcare other than nursing.

“It was in college that I decided I wanted to pursue the physician assistant career path,” Young said. She attended Westminster College in Fulton where she majored in biology.

Young was able to participate in the cadaver program at Westminster, and she believed that a career as a physician assistant would give her the opportunity to do “hands on” patient care using a “team approach”.

“I liked the way that physician assistants’ worked with a collaborating physician for patient care,” Young said. She also thought that the career path would give her some flexibility in finding a job with hands-on patient care but without hospital inpatients and hospital call requirements.

After graduating from college Young worked as a patient care assistant in the psychiatric unit at Phelps County Regional Medical Center in Rolla. While there, she gained additional experience in healthcare.

Young chose to attend Wichita State University in Wichita, KS for physician assistant training. While in school, she did clinical rotations at rural clinics and hospitals in Kansas, at an Indian Health Service hospital, and internationally in the country of Bolivia.

Because Young planned to return to rural Missouri, she followed a “family medicine” track, training to provide care for patients from birth to end of life.

As a mid-level provider, Young hopes to be able to provide education to her patients when they come to see her.

“I want to have a personal relationship with my patients,” Young said, explaining that she wants to see patients when they are sick, but she also wants to help her patients through preventative medicine and catching healthcare issues early.

“I want to keep my patients healthy, if possible,” Young said.

Young believed that a rural health clinic like the TCMH Family Clinic would provide her with a diverse patient population, and in her first week she saw patients ranging from a two-week old infant to a 91-year old patient.

In addition to preventative medicine, Young has special interest in women’s healthcare and pediatrics. She is also able to provide care for some patients with chronic conditions, too. Young sees patients of all ages—from birth to end of life.

During her eight-week preceptorship at the TCMH Family Clinic, Young was able to meet many of the established patients at the clinic as well as learning the electronic medical records system and other operations of the clinic.

“Kim and Dr. Wolfe were great teachers,” Young said. With a well-established patient base at the Licking clinic, Young was able to “hit the ground running” seeing a diverse group of patients from her first day of work.

“It’s a perfect practice for me,” Young said.

Young is currently commuting daily from her parent’s home in Rolla to Licking, but she hopes to find something closer to Licking in the future.

When she’s not working, Young has plenty of cousins that are close in age and other family members in the area that she spends time with. She enjoys the usual Ozark outdoor activities as well as following college sports and St. Louis Cardinals baseball. She also plays golf and on a church softball league.

Young is accepting new patients at the TCMH Family Clinic in Licking. She sees patients Monday through Friday, and the clinic accepts most forms of private insurance including Medicare and Medicaid. For additional information or to make an appointment, contact the clinic at (573) 673-3011.


King Named Employee of the Month

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Texas County Memorial Hospital has named Lance King of Houston the August employee of the month.

King is a physical therapy assistant in the TCMH physical therapy department. He has worked at TCMH since May 2011. King was nominated for the award by Ellen Willis, physical therapy department director.

“Lance is a great asset to the PT department,” Willis said. “He approaches all of his work with a positive attitude.”

King is known for willingness to help out in the physical therapy department and in other hospital departments when extra assistance is needed.

“Lance always helps out without any expectation of reward or recognition,” Willis said, calling him an “ideal employee”.

As employee of the month, King received a certificate honoring his achievement; a pin; $100 cash; a special parking place in the TCMH lot; one day of paid vacation; a membership in the TCMH Fitness Center; a $50 gift card, and gift certificates to Paws N Claws, D&L Florist, Janstiques and Blissful Nirvana Massage. A reception will be held at the hospital in honor of King.

King is eligible for the 2014 TCMH employee of the year award.

Lance King (right), Texas County Memorial Hospital August employee of the month, with his supervisor, Ellen Willis.

Lance King (right), Texas County Memorial Hospital August employee of the month, with his supervisor, Ellen Willis.


Licking Clinic Approved Site for Vaccines for Children

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The Texas County Memorial Hospital Family Clinic in Licking has been approved as a “Vaccines for Children” site by the Missouri Department of Health and Senior Services.

The Vaccines for Children program is funded by the Centers for Disease Control and Prevention and provides free vaccines to children who qualify.

The Vaccines for Children program is designed to help protect all children against vaccine-preventable diseases. Unfortunately, many children are not vaccinated because their parents either do not have health insurance or their health insurance does not cover vaccines.

Children are eligible to receive free vaccines before their 19th birthday who meet one of the following criteria:
• are Medicaid-eligible;
• do not have health insurance;
• are an American Indian or Native Alaskan; or
• are underinsured.

Underinsured children must receive their vaccine at a Rural Health Clinic like the TCMH Family Clinic or at a Federally Qualified Health Center. Underinsured is when a child has health insurance but the plan doesn’t provide vaccine coverage; doesn’t cover certain vaccines or covers vaccines but with a fixed dollar limit. Underinsured does not include those with unmet deductible or who are unable to pay the deductible.

The TCMH Family Clinic in Licking joins the TCMH Medical Complex in Houston, Cabool Medical Clinic and TCMH Mountain Grove Medical Complex in participating in the Vaccines for Children program.

All vaccines are free through the Vaccines for Children program, but parents may be charged a small fee from the clinic to cover the office visit and cost of administering the vaccine.

Dr. Joshua Wolfe, a board certified family medicine physician, and Whitney Young, physician assistant, see patients at the TCMH Family Clinic Monday through Friday. For additional information or to make an appointment for a vaccination, contact the clinic at (573) 674-3011.


TCMH Tops in Nation for Efficiency of Patient Care

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Texas County Memorial Hospital is in the top five percent of hospitals in the nation for providing efficient care for Medicare patients, hospital board members heard at their monthly meeting on Tuesday.

Amanda Turpin, quality management director at TCMH, presented new data to hospital board members regarding a “value-based purchasing score” from the Center for Medicare Services (CMS) that means TCMH will collect an additional 1.16 percent of payment for Medicare patients in fiscal year 2015.

“We have not received a value-based purchasing score until this year,” Turpin said, explaining that TCMH has not had enough surgical patients since value-based purchasing went into place for the hospital to receive a score.

Since 2012 CMS has looked at hospital data related to patient experience, patient outcomes and clinical process of care, but TCMH has not had enough patients in the various areas for the hospital to be given a value-based purchasing score.

In 2013 CMS began looking at “efficiency”, or the cost of care associated to Medicare inpatients at TCMH. The score TCMH received for efficiency was enough to qualify the hospital for a value-based purchasing score.

“Our average spending per Medicare patient at TCMH was $16,227. The state average was $18,783, and the national average was $19,253,” Turpin said.

Turpin explained that CMS awarded points for either improvement over past scores, or achievement compared to other hospitals. CMS awarded to TCMH 9 out of a possible 10 achievement points available for efficiency. CMS also awarded achievement points to TCMH in 7 out of 8 areas for patient experience. CMS awarded to TCMH 8 and 5 points out of a possible 10 points for mortality and safety of patients.

“All of these numbers were combined to give us a value-based purchasing score of 69, which is well above the state and national average,” Turpin said.

For fiscal year 2015, the average value based purchasing score for the state of Missouri is 44 and the average value based purchasing score across the nation is 41.

“In a time when healthcare dollars are so important, our patients can know that they are getting the most care for the dollars they spend,” Turpin said.

With the value-based purchasing program, Medicare has taken 1.5 percent of reimbursement from hospitals across the nation. The 1.5 percent cut to all hospitals is then redistributed to hospitals based on their value-based purchasing score.

Some hospitals lose the 1.5 percent in reimbursement for the year. Some hospitals get a portion of the funds back. TCMH will receive the 1.5 percent and an additional 1.16 percent for fiscal year 2015 for all Medicare patients.

“Every hospital has a goal of breaking even, but this value based purchasing score will actually reward us for the care that we have provided our patients,” Turpin said.

The actual dollar amount the additional 1.16 percent in reimbursement will likely equal approximately $60,000 in the upcoming year depending upon the number and acuity of Medicare inpatients at TCMH.

“This is great news,” Wes Murray, chief executive officer at TCMH, said.

Dr. John Duff, senior vice president at CoxHealth in Springfield called the scored “tremendous”, explaining that CoxHealth works diligently on their own value-based purchasing score.

“Achieving that score is not easy to do,” Duff said. “You are gaining back dollars from other hospitals.”

Murray noted that the hospitals that are losing Medicare funds in the next year will “want it back”, creating additional work for TCMH in the upcoming year.

“In the past we have not been rewarded for managing our patients and expenses well,” Murray said, “So this score is a great reward for the things that we have done well for many years.”

Turpin noted that the Customer Quality Team at TCMH continues to work on ways to improve patient experience within all areas of the hospital from medical staff interactions with patients to overall inpatient stays to ancillary services provided to patients.

“Most of our hospital inpatients receive a survey after their stay, and we need patients to complete those surveys and return them,” Turpin said.

About 30 percent of patients at TCMH return their inpatient stay survey, which is on par with the national average for inpatient surveys returned to hospitals.

In other news, the hospital board unanimously passed a resolution to put a compliance policy in place to meet United States Department of Agriculture and Rural Development loan guidelines. The resolution is the final piece that TCMH board members and the Texas County Commissioners must approve to close the $19.1 million low-interest loan TCMH received from USDA and Rural Development to expand the hospital in 2013.

The compliance policy allows TCMH to be audited annually to ensure that the hospital is using the federal funds for tax exempt purposes only.

“This resolution is simply putting a policy in place to do what we said we would do when we took out the loan in the first place,” Murray said.

In the July financial report, Linda Pamperien, chief financial officer at TCMH, reported that TCMH received $516,585 in Medicaid cost report settlement for 2006 through 2009. Although the funds do not get added to the current fiscal year’s bottom line, the funds can go into the hospital’s funded depreciation account.

“We are still owed over $1.2 million for Medicaid cost reports from 2010 through 2013,” Pamperien noted.

Pamperien reported that new physicians providing surgical care at the hospital—Dr. Christopher Baldwin, Dr. Linda Milholen and Dr. Leroy Wombold—sent outpatient volumes up at the hospital for the month of July.

Inpatient volumes were low at the hospital during July. TCMH ended the month with a loss of $134,840.36 and a year to date loss of $875,651.36.

Pamperien explained that the monthly losses were partially due to increased depreciation expense related to the construction completed in 2013 and the new equipment and fixtures purchased for the new construction..

“We have incurred $1.1 million in depreciation expense in the first seven months of the year,” Pamperien told board members.

Murray explained to board members that TCMH could not “go down this road forever”.

“It’s a big number, and we do need to make that number back so we can reinvest in our facility and in healthcare in our county,” Murray said, describing the losses as “unsustainable over several years”.

Pamperien reported that cash flow is still positive and hospital reserves are strong.

Pamperien also explained that bad debt or uncompensated care at the hospital continues to rise. In July, $566,269.80 was written off as bad debt. Some of those funds will be collected down the road through a collection agency, but the majority is “lost”.

“In July 59 percent of our bad debt came from patients that came in through the emergency department,” Pamperien said, equating that percentage to $332,000 of care given to uninsured patients.
Pamperien reminded board members that TCMH cannot turn away anyone regardless of his or her ability to pay for care.

“This is where expansion of the Medicaid program in the state of Missouri would greatly benefit TCMH,” Murray said.

Murray explained that 82 percent of people that would qualify for expanded Medicaid coverage in the state are employed, working full-time or part-time jobs.

“Many of those people that come to the ER to seek care cannot afford to pay for their care and wait until they have acute healthcare issues before they seek treatment,” Murray said. “There are a percentage of patients that came through the ER in July and that we will continue to see that would receive healthcare coverage through Medicaid if the program were expanded.”

Omanez Fockler, chairperson of the TCMH board of trustees, commended TCMH for educating staff and members of the public regarding Medicaid expansion needs in the state.

“These are the nuts and bolts of the issue that the community wants to know,” Fockler said.

Present at the meeting were Murray; Pamperien; Duff; Fockler; Dr. Schaun Flaim, chief of staff; Doretta Todd-Willis, chief nursing officer, Joleen Senter Durham, public relations director; and board members Janet
Wiseman, Dr. Jim Perry,OD and Mark Hampton.

Board member, Russell Gaither, was not present at the meeting.

The next meeting of TCMH board of trustees is Tue., Sept. 28 at 12 p.m. in the hospital board room.


First Certified Nurse Midwife Joins Staff at TCMH

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Tracey Arwood is first certified nurse midwife ever employed by Texas County Memorial Hospital.

Tracey Arwood, CNM

Tracey Arwood, CNM

At TCMH Arwood has found what she calls “the perfect relationship”—the opportunity for women to receive their healthcare from a certified nurse midwife, an obstetrician/gynecologist or a family medicine physician.

“There are three different options for women’s health and obstetrical care,” Arwood said. “That’s very uncommon for a rural area, and I’m happy to be a part of it.”

Arwood is familiar with rural America. She grew up in Wichita, KS, and after graduating high school, she moved with her family to Missouri.

Arwood has always leaned toward healthcare and providing education to the patients she served. She pursued a bachelor’s degree in health science at Truman State University in Kirksville, MO. Her degree had a community health concentration, and she also minored in psychology and women and gender studies.

While in Kirksville, Arwood found two things that would become a key part of her future. She met Chris—who would later become her husband, and she took a test at the university career center that pointed her toward the field of midwifery.

“I wanted to do something that was more individualized and personal than the traditional community health worker role,” Arwood said, adding that in her time in community health in Kirksville, she came into contact with midwives that worked in the area.

“It’s a special opportunity to be present with a patient and their family at the beginning of life,” Arwood said, explaining that she felt a calling to be the healthcare provider present when new lives entered the world.

The Arwood’s moved to St. Louis where Tracey completed a fast-track nursing program through Barnes-Jewish College of Nursing. After getting her bachelor’s degree in nursing, Arwood began pursuing a master’s degree in nursing through Frontier Nursing University in Hyden, KY. Arwood trained in the Community Nurse-Midwifery Education Program at Frontier.

“I was always interested in the field of women’s health,” Arwood said, adding, “Women’s health is an area of need because many healthcare providers do not choose to specialize in women’s health.”

Arwood believes that when women’s reproductive health is overlooked in the healthcare field, it becomes hard for women to access quality reproductive healthcare and information.

Frontier Nursing University, a school located in rural Kentucky, was founded in 1939 by Mary Breckenridge. Breckenridge was concerned with improving the health of children in rural Kentucky, but she quickly realized that improving a child’s health actually began with the mother of the child, before the birth of the child.

While completing her education, Arwood grew her women’s health and obstetrics experience through positions she held in various hospitals in St. Louis and Kansas City. Arwood worked in the mother-baby, behavioral health and women’s care units. She also worked independently as a doula, helping women prepare for and carry out plans for birth as well as providing postpartum and breastfeeding support.

Arwood was a National Health Service Scholar while in school, so after completing her midwifery training, she had to find an underserved area that met certain criteria for her employment. She and her family moved to Garden City, KS where Arwood went to work as a certified nurse midwife for the United Methodist Mexican American Ministries, a healthcare outreach program to the residents of Southwest Kansas.

Arwood collaborated with a family medicine and obstetrics trained physician, and she cared for patients in four clinics in four different rural communities.

“I very quickly began to do deliveries,” Arwood said, explaining that she delivered her patients at three hospitals in Southwest Kansas–Garden City, Dodge and Liberal.

Arwood cared for a lot of immigrant patients and had a very busy practice.

“I saw everyone,” Arwood said. “Many of my patients were uninsured, and I was the only healthcare provider that would see them.”

A combination of administrative issues at the clinic where she worked and the failing health of a parent caused the Arwoods to begin look back toward Missouri for a new home and a place for Tracey to practice.

Arwood also describes her new position at TCMH as “perfect”. They are close to her parents in Marshfield and Chris Arwood’s family in Clinton, MO.

“There was definitely a need for an additional obstetrical provider, and everyone at TCMH was very nice and excited to have me,” Arwood said about her interview at TCMH.

The Arwood’s liked the “small town feel” of Houston and Mountain Grove. Tracey was also not intimidated about providing obstetrical care to patients through the two clinics–Houston and Mountain Grove—25 miles apart.

“Everything about this position is an improvement over my previous job,” Arwood said. “At TCMH there seems to be good communication between everyone, and there’s a positive feeling of collaboration in providing care for the patients.”

In order to bring Arwood to TCMH the hospital medical staff had to amend their by-laws to allow a mid-level provider to practice in the obstetrics department. TCMH also recruited Dr. Christopher Baldwin, a board certified obstetrician and gynecologist, to collaborate with Arwood.

“It was an easy process coming here,” Arwood said, adding that she “likes the vision” of TCMH chief executive officer, Wes Murray. “He believes in promoting the hospital and its services and understands how important healthcare services are in rural America.”

Arwood is also pleased with the opportunity to collaborate with Baldwin.

“Dr. Baldwin has a great deal of experience,” Arwood said, adding, “He’s friendly, and he stays very calm about patient care.”

Arwood is passionate about women’s healthcare, and she relishes her role as mid-level provider that allows her to spend more time with her patients. She believes that the field of midwifery is growing as more women seek a midwife to oversee the birth of their child.

“Midwives are key globally in saving the lives of moms and babies,” Arwood explained. “In the US certified nurse midwives have low Cesarean section rates and better breast feeding rates.”

Arwood noted that in her practice she likes to spend time with her patients explaining healthcare choices and discussing the risks and benefits with those patients.

“My approach to care is to collaborate with patients and their family members,” Arwood said. “Each woman receives individualized care.”

Arwood believes that focusing on the woman and her pregnancy experience creates a better experience overall.

“I consider the woman’s overall health, how she’s taking care of herself and any social issues,” Arwood explained, adding, “The better the pregnancy experience, the better the bond between the mother and the baby.”

Arwood noted that many studies are finding links between chronic issues in children and the lifestyle habits of the mother when she was pregnant with the child.

“Women are more likely to make positive changes to their lifestyle and health habits during pregnancy than at any other time in their lives,” Arwood said. “I want to be the healthcare advocate and educator that my patients can connect with and trust to help influence those positive changes during pregnancy.”

Arwood will provide care for low-risk obstetrics patients, and she plans to take call and provide one-on-one support during labor for her patients whenever possible. Arwood is trained and experienced in assisting with breastfeeding initiation, newborn care and any complications that may arise postpartum.

Arwood can provide care for infants in the hospital, and after birth, babies will be referred to Dr. William Wright, a family medicine physician in the TCMH Medical Complex in Houston.

Arwood also provides complete women’s healthcare from 13 years of age through menopause. She provides birth control counseling and care, infertility treatment and low-risk obstetrics care. She will see her patients in Houston at the TCMH Medical Complex on Monday and Wednesday and patients at the TCMH Mountain Grove Clinic on Tuesday and Thursday. She plans to attend to her own patient deliveries as much as possible.

The Arwood’s have two children—Jaeda, age 3, and Corbin, age 5. They enjoy spending time in the outdoors together.

“I grew up doing outdoor stuff, and we enjoy camping, hiking and biking as a family,” Arwood said, explaining that they spent a lot of time with extended family, too.

Arwood also enjoys reading and watching movies.

“We are really excited there’s a drive-in here,” Arwood said. “And we’ll spend a lot of time at the library, too.”

Arwood is accepting new patients in Houston at (417) 967-5639 and in Mountain Grove at (417) 926-1770.


Dr. Linda Milholen Takes the Helm at TCMH Surgery Department

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Linda Milholen, MD grew up in rural America—35 miles west of Hot Springs, AR, to be precise.

Milholen knows what it’s like when there is only one doctor in town. As a teenager, Milholen babysat for the county doctor when he and wife went out for their weekly bowling outing.

“It was not uncommon for the doctor to come home to five or six people waiting to be seen in cars in the driveway,” Milholen explained. “I would triage the patients in advance before the doctor got home.”

Although Milholen didn’t set out from high school to become a doctor, those teenage years spent working for the county doctor and a post-high school job spent working with oral surgeons prepared her for a future that would take her down the path of hospitals, operating rooms and anesthesia.

Linda G. Milholen, MD

Linda G. Milholen, MD

Milholen’s husband, Bruce, has been a key figure in her life. They met when she was 3 and he 6. They married three weeks after Linda Milholen graduated from high school.

Both Milholens attended Georgia Institute of Technolgy in Atlanta. Bruce Milholen pursued a degree in engineering, and Linda Milholen studied applied mathematics.

“I wasn’t really sure what I wanted to do when I started college,” Milholen said, explaining that applied mathematics was the ‘general degree’ for undeclared students at Georgia Tech.

The Milholens both held full-time jobs while attending college, and due to her previous healthcare experience, Linda Milholen got a job as a tech in a local operating room.

“Within nine months I was scrubbing in on open heart surgeries,” Milholen said. She continued her studies in math at Georgia Tech, taking as many science electives as possible with plans of attending medical school after graduation.

Milholen continued to work in the OR through four years of medical school at Emory University in Atlanta. While in medical school she knew she wanted to practice medicine as a surgeon.

After medical school Milholen’s internship year was spent at Charity Hospital in New Orleans, LA, and she completed her general surgery residency at the University of Louisville in Kentucky.

While doing an endoscopy residency rotation at a small hospital outside of Louisville, Milholen learned that the hospital—Fort Logan Hospital in Stanford, KY—was seeking a full-time general surgeon. Milholen took the position. During that time, she also worked on active staff at Garrard County Memorial Hospital in Lancaster, KY and Casey County Hospital in Liberty, KY.

Milholen recalled a time that one hospital had a patient that had been trampled by a horse and another hospital several miles away needed her assistance with a patient requiring a Caesarean section.

“I saw the patient that had been trampled and ordered tests; while waiting for the tests to come back, I traveled to the other hospital to do the C-section,” Milholen said, adding “Everyone had a great outcome.”

Milholen didn’t mind splitting her time between communities.

“It wasn’t difficult to drive from one to the other to take care of patients,” Milholen said.

Milholen cared for patients in multiple hospitals for 22 years until financial pressures forced one hospital to close. Milholen learned of a job opening at Citizen’s Memorial Hospital in Bolivar, and she and Bruce relocated to Southern Missouri.

Milholen practiced in Bolivar for several years until her partner retired. Not wanting to practice on her own in Bolivar, Milholen took a position with St. Francis Hospital in Mountain View in 2009, where she worked until July of this year.

Milholen learned that Texas County Memorial Hospital was looking for a general surgeon in the spring of this year, and she inquired about the position.

“This is a good, solid community hospital,” Milholen said about TCMH.

TCMH extended a contract to Milholen, and she began full-time employment at the hospital on July 28.

“Wes shares my vision for providing healthcare services in rural America,” Milholen said about TCMH chief executive officer, Wes Murray. “We are here to provide a service that people need.”

Milholen explained that many patients cannot afford to or may not have a way to travel to Springfield or Rolla for surgical services.

“Even people that can travel to larger hospitals for surgery are better served by having their surgery locally,” Milholen said. “They can be taken care of by people that know them, and they are close to home.”

Milholen noted that in her years in healthcare, the hospital is “a vital part of the community”, especially in small communities.

“A hospital is a good employer in a community, and it’s a vital component to attract industry to a community,” Milholen said, describing TCMH as “a fine little hospital”.

As a general surgeon at TCMH, Milholen will do laparoscopic and open surgery and upper and lower endoscopy. Milholen has special interest in breast surgery, and she does ultrasound guided breast biopsy and breast conserving surgery. She removes skin lesions and does skin grafts.

Milholen’s clinic office is located inside TCMH in a newly remodeled area, the Outpatient Surgery Clinic. The outpatient clinic is outfitted with a procedure room for small surgical procedures, and the new clinic location gives Milholen easy access to the hospital’s surgery department and hospital inpatients.

The Milholens are relocating to Houston with their two cats, Gabby and Sprinkles.

Bruce Milholen is a self-employed electrical engineer, and he works regularly at Truman Medical Center, too.

When Linda Milholen isn’t working, she enjoys reading and needlework. She practices tai chi and is interested in finding a local tai chi group.

Milholen recently began serving as the priest at Church of the Transfiguration in Mountain Grove, her home parish since moving to the area in 2009.

Milholen grew up as Methodist, but as a teenager, she had a very positive experience at an Episcopal funeral service. Milholen joined an Episcopal church after completing her residency. She was ordained as a deacon in the Episcopal Church in 1996.

“I had no intention of becoming a priest,” Milholen said, but when retiring Father Brad Ellsworth, the priest at Church of the Transfiguration, approached her about the position, Milholen thought carefully about it, and ultimately went to a school for ministry in Topeka, KS.

Milholen was ordained as a priest in the Episcopal Church in April, and she has taken the unpaid position at the parish in Mountain Grove.

“I have strong lay leadership to help me; they know that I cannot always be available because I also need to work at the hospital,” Milholen said, explaining that the lay leaders can lead sermons and visit the sick in her absence.

Milholen describes her role and the role of others in the church as “very much the model of the early church”.

“I love these people,” Milholen said of the congregation, which “felt like home” from the first time she stepped through the church door.

Much like the congregation that she is committed to, Milholen feels a strong connection to the patients in rural Missouri.

“I grew up in a farming community,” Milholen said. “These are people I understand.”

Milholen is accepting new patients at the TCMH Outpatient Surgery Clinic at (417) 967-1252.


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