DiversityNursing Blog

By JAN HOFFMAN

How well can computers interact with humans? Certainly computers play a mean game of chess, which requires strategy and logic, and “Jeopardy!,” in which they must process language to understand the clues read by Alex Trebek (and buzz in with the correct question).

But in recent years, scientists have striven for an even more complex goal: programming computers to read human facial expressions.

The practical applications could be profound. Computers could supplement or even replace lie detectors. They could be installed at border crossings and airport security checks. They could serve as diagnostic aids for doctors.

Researchers at the University of California, San Diego, have written software that not only detected whether a person’s face revealed genuine or faked pain, but did so far more accurately than human observers.

While other scientists have already refined a computer’s ability to identify nuances of smiles and grimaces, this may be the first time a computer has triumphed over humans at reading their own species.

“A particular success like this has been elusive,” said Matthew A. Turk, a professor of computer science at the University of California, Santa Barbara. “It’s one of several recent examples of how the field is now producing useful technologies rather than research that only stays in the lab. We’re affecting the real world.”

People generally excel at using nonverbal cues, including facial expressions, to deceive others (hence the poker face). They are good at mimicking pain, instinctively knowing how to contort their features to convey physical discomfort.

And other people, studies show, typically do poorly at detecting those deceptions.

In a new study, in Current Biology, by researchers at San Diego, the University of Toronto and the State University of New York at Buffalo, humans and a computer were shown videos of people in real pain or pretending. The computer differentiated suffering from faking with greater accuracy by tracking subtle muscle movement patterns in the subjects’ faces.

“We have a fair amount of evidence to show that humans are paying attention to the wrong cues,” said Marian S. Bartlett, a research professor at the Institute for Neural Computation at San Diego and the lead author of the study.

For the study, researchers used a standard protocol to produce pain, with individuals plunging an arm in ice water for a minute (the pain is immediate and genuine but neither harmful nor protracted). Researchers also asked the subjects to dip an arm in warm water for a moment and to fake an expression of pain.

Observers watched one-minute silent videos of those faces, trying to identify who was in pain and who was pretending. Only about half the answers were correct, a rate comparable to guessing.

Then researchers provided an hour of training to a new group of observers. They were shown videos, asked to guess who was really in pain, and told immediately whom they had identified correctly. Then the observers were shown more videos and again asked to judge. But the training made little difference: The rate of accuracy scarcely improved, to 55 percent.

Then a computer took on the challenge. Using a program that the San Diego researchers have named CERT, for computer expression recognition toolbox, it measured the presence, absence and frequency of 20 facial muscle movements in each of the 1,800 frames of one-minute videos. The computer assessed the same 50 videos that had been shown to the original, untrained human observers.

The computer learned to identify cues that were so small and swift that they eluded the human eye. Although the same muscles were often engaged by fakers and those in real pain, the computer could detect speed, smoothness and duration of the muscle contractions that pointed toward or away from deception. When the person was experiencing real pain, for instance, the length of time the mouth was open varied; when the person faked pain, the time the mouth opened was regular and consistent. Other combinations of muscle movements were the furrowing between eyebrows, the tightening of the orbital muscles around the eyes, and the deepening of the furrows on either side of the nose.

The computer’s accuracy: about 85 percent.

Jeffrey Cohn, a University of Pittsburgh professor of psychology who also conducts research on computers and facial expressions, said the CERT study addressed “an important problem, medically and socially,” referring to the difficulty of assessing patients who claim to be in pain. But he noted that the study’s observers were university students, not pain specialists.

Dr. Bartlett said she didn’t mean to imply that doctors or nurses do not perceive pain accurately. But “we shouldn’t assume human perception is better than it is,” she said. “There are signals in nonverbal behavior that our perceptual system may not detect or we don’t attend to them.”

Dr. Turk said that among the study’s limitations were that all the faces had the same frontal view and lighting. “No one is wearing sunglasses or hasn’t shaved for five days,” he said.

Dr. Bartlett and Dr. Cohn are working on applying facial expression technology to health care. Dr. Bartlett is working with a San Diego hospital to refine a program that will detect pain intensity in children.

“Kids don’t realize they can ask for pain medication, and the younger ones can’t communicate,” she said. A child could sit in front of a computer camera, she said, referring to a current project, and “the computer could sample the child’s facial expression and get estimates of pain. The prognosis is better for the patient if the pain is managed well and early.”

Dr. Cohn noted that his colleagues have been working with the University of Pittsburgh Medical Center’s psychiatry department, focusing on severe depression. One project is for a computer to identify changing patterns in vocal sounds and facial expressionsthroughout a patient’s therapy as an objective aid to the therapist.

“We have found that depression in the facial muscles serves the function of keeping others away, of signaling, ‘Leave me alone,’ ” Dr. Cohn said. The tight-lipped smiles of the severely depressed, he said, were tinged with contempt or disgust, keeping others at bay.

“As they become less depressed, their faces show more sadness,” he said. Those expressions reveal that the patient is implicitly asking for solace and help, he added. That is one way the computer can signal to the therapist that the patient is getting better.

Source: Nytimes.com

DURHAM, N.C. — Before scrubbing in on a recent Tuesday morning, Dr. Selene Parekh, an orthopedic surgeon here at Duke Medical Center, slipped on a pair of sleek, black glasses — Google Glass, the wearable computer with a built-in camera and monitor.

He gave the Internet-connected glasses a voice command to start recording and turned to the middle-aged motorcycle crash victim on the operating table. He chiseled through bone, repaired a broken metatarsal and drilled a metal plate into the patient’s foot.

Dr. Parekh has been using Glass since last year, when Google began selling test versions of its device to thousands of handpicked “explorers” for $1,500. He now uses it to record and archive all of his surgeries at Duke, and soon he will use it to stream live feeds of his operations to hospitals in India as a way to train and educate orthopedic surgeons there.

“In India, foot and ankle surgery is about 40 years behind where we are in the U.S.,” he said. “So to be able to use Glass to broadcast this and have orthopedic surgeons around the world watch and learn from expert surgeons in the U.S. would be tremendous.”

At Duke and other hospitals, a growing number of surgeons are using Google Glass to stream their operations online, float medical images in their field of view, and hold video consultations with colleagues as they operate.

Software developers, too, have created programs that transform the Glass projector into a medical dashboard that displays patient vital signs, urgent lab results and surgical checklists.

“I’m sure we’re going to use this in medicine,” said Dr. Oliver J. Muensterer, a pediatric surgeon who recently published the first peer-reviewed study on the use of Glass in clinical medicine. “Not the current version, but a version in the future that is specially made for health care with all the privacy, hardware and software issues worked out.”

For his study, published in The International Journal of Surgery, Dr. Muensterer wore the device daily for four weeks at Maria Fareri Children’s Hospital at Westchester Medical Center in New York. He found that filming rapidly drains the battery and that the camera — which is mounted straight ahead — does not point directly at what he is looking at when he is hunched over a patient with his eyes tilted downward.

He also had to keep the device disconnected from the Internet most of the time to prevent patient data and images from being automatically uploaded to the cloud. “Once it’s on the cloud, you don’t know who has access to it,” Dr. Muensterer said.

Google has yet to announce a release date for Glass, and the company declined to comment on how many of its testers were doctors or affiliated with hospitals. But “demand is high,” said Nate Gross, a co-founder of Rock Health, a medical technology incubator. “I probably get asked every few days by another doctor who wants to somehow incorporate Glass into their practice.”

And already, outside hospitals, privacy concerns have led some bars and restaurants to ban the devices. Legislators have proposed restrictions on the use of Google Glass while driving, citing concerns about distraction. Doctors, too, are raising similar concerns.

The Glass projector is slightly above the user’s right eye, allowing doctors to see medical information without turning away from patients. But the display can also be used to see email and surf the web, potentially allowing doctors to take multitasking to dangerous new levels, said Dr. Peter J. Papadakos at the University of Rochester Medical Center, who has published articles on electronic distractions in medicine.

“Being able to see your laparoscopic images when you’re operating face to face instead of looking across the room at a projection screen is just mind-bogglingly fantastic,” he said. “But the downside is you don’t want that same surgeon interacting with social media while he’s operating.”

Indeed, similar technology has not always had the smoothest results. Studies have found, for example, that navigational displays can help surgeons find tumors, but they can also induce a form of tunnel vision, or perceptual blindness, that makes them more likely to miss unrelated lesions or problems in surrounding tissue. And in aviation, pilots who wear head-mounted displays that show crucial flight information can lose sight of what is happening outside their windshields, said Dr. Caroline G. L. Cao, who studies image-guided surgery at Wright State University.

“Pilots can get so focused on aligning the icons that help them land the plane,” she said, “that they miss another plane that is crossing the runway.”

One doctor who does not allow the device in his practice, Dr. Matthew S. Katz, the medical director of radiation oncology at Lowell General Hospital in Massachusetts, said that security and distractions were primary concerns. A doctor wearing Glass could accidentally stream confidential medical information online, he said, and patients might not feel comfortable with their doctors wearing cameras on their faces.

Until Glass has been better studied in health care and equipped with safeguards, Dr. Katz said, doctors should be forced to check their wearable computers at the clinic door.

“From an ethical standpoint, the bar is higher for use in a medical setting,” said Dr. Katz, who is also an outside adviser for the Mayo Clinic Center for Social Media. “As a doctor, I have to make sure that what I’m doing is safe and secure for my patients — ‘First, do no harm.’ Until I am, I don’t want it in my practice.”

Bakul Patel, the senior policy adviser at the Food and Drug Administration’s Center for Devices, said the agency would regulate only those Glass software programs that function as medical devices, the same approach it takes on health applications on hand-held devices.

“The glasses have been on our radar and we’re excited about it,” Mr. Patel said.

Hospitals that are experimenting with Glass say they are doing so very carefully — obtaining patient consent before procedures, using encrypted networks, and complying with the federal regulation that protects patient privacy, known as Hipaa.

Medical software developers say they, too, have security and privacy in mind. Pristine, a company based in Austin, Tex., createdan app that lets emergency room nurses and doctors beam in specialists for consultations. The company plans to sell a customized version of Glass directly to hospitals. It erases Google’s software and configures the glasses with its own Hipaa-compliant programs.

Another company, Augmedix, which has done pilot tests of Glass at medical centers in the San Francisco area, said patients were informed that their doctors would be wearing the device. In a study of 200 cases, only two or three patients asked that their doctors remove it, said Ian K. Shakil, a co-founder of Augmedix.

Some hospitals see Glass as a relatively low-cost and versatile innovation, much like smartphones and tablets, which more than half of all health care providers use to get access to patient data and other medical information.

But hand-held devices are not very useful in the sterile world of surgery. Because Glass is voice-activated and hands-free, it may be particularly well suited for the surgical suite, where camera-guided instruments, robotics and 3D navigation systems have been commonplace for years.

Dr. Pierre Theodore, a cardiothoracic surgeon at the University of California, San Francisco, calls wearable computers “a game changer.”

“In surgery, Google Glass is incredibly illuminating,” said Dr. Theodore, who uses Glass to float X-rays and CT scans in his field of view at the operating table. “It helps you pinpoint what you’re looking for, so you don’t have to shift your attention away from the operation to look at a monitor somewhere else.”

At Indiana University Health, Dr. Paul P. Szotek, a Level 1 trauma surgeon, is developing an app for Glass for use by paramedics.

The app streams a live feed from the glasses to the closest emergency rooms, so that doctors can see accident victims at the scene and give paramedics potentially lifesaving instructions — like when to go directly to a Level 1 trauma center.

“Last year, I lost a lady on the table from a spleen injury that was absolutely survivable because she was taken to a local hospital and then the delay was over two hours to get her to me,” Dr. Szotek said. “With this wearable technology, we’ll be able to assess patients on the scene and decrease the mortality associated with trauma significantly.”

Dr. Szotek met with Google in March to discuss his software, called 1st Sight. He and other Glass-wearing surgeons recently founded a group — the International Society for Wearable Technology in Healthcare — that is holding its first meeting in Indianapolis in July.

At Duke, Dr. Parekh performs back-to-back surgeries on most days, wearing the Glass headset as he moves from one patient to the next.

About six years ago, he founded a charity with the goal of advancing foot and ankle surgery in India. He travels there every year with a team of expert surgeons to hold clinics and training sessions for local orthopedic surgeons.

In January, at a conference in Jaipur, Dr. Parekh performed surgery and used Glass to stream the procedure on his personal website. That day, the site drew in so many visitors from India and elsewhere that it crashed.

“I’ve been even more excited about Google Glass since then,” he said.

Source: nytimes.com

By Kirsten Chua

Everybody knows that the nursing profession has two different sides—it is both science and art. That said, nursing as a science is more apparent.

For example, if you are a nurse, you must know the patient-based nursing care plan (NCP). You must also know the disease mechanisms of all diseases, medications, and management from all sides. Nurses also need to be up to date on new policies, practices, and procedures. Moreover, they need to know how to manipulate new diagnostic equipment and machines.

The science of nursing is easily noticeable and it is very critical for each one to know.

What Is the Art?

Meanwhile, the art of nursing is more than a great deal of science. It is more than just knowing; it is doing. It bridges information from nurses to patients in a skillful way. It is the application of all the science known to nursing to give the utmost care the patient needs.

During your first year in the nursing profession, you are in the heat of the moment. You now belong to that bunch of young professionals who are enthusiastic and motivated in practicing their craft. Maybe many could attest that when you first become a nurse you see the art more than the science of it.

But it is sad to note that as time passes by the semblance of the nursing being an art bleeds out. At the drop of a hat, you get suffocated from the career you once loved.

The Human Touch

In the past 7 years that I have been a clinical instructor, I have seen so many changes in the healthcare arena and how nursing should be. But one thing remains: human nature.

Our patients’ needs have remained constant and relentless. As Maslow’s hierarchy of needs suggests, these include food, sense of belonging, warmth, compassion, self-actualization. These basic needs have been addressed in the same way since the dawn of science. However, the ways to meet them may have changed from time to time.

The art of nursing may have been in each person even before entering the profession. That innate capacity to respond to the needs of individual is already the art of nursing. In nursing school, this vivacity is awakened through constant interaction with the patients in various settings.

Nurses are called to perform relational work. Therefore, the motivation to keep that art in us should be continuously burning. We have the power to heal the sick. An effective nurse is one who gives nursing care independently and collaboratively with other healthcare teams.

The art of nursing comes in as a nurse independently does his or her job. The options s/he considers in taking a certain action and ultimately the action s/he does to respond to patient needs are the art of nursing.

It is in the nurses’ hands to promote positive changes in patients. Everyday we are faced with patients who are in different conditions. In this case, individualized nursing care is noteworthy. Knowledge is not enough. Compassionate care is paramount.

Where Is the Art?

In my experience, I have witnessed things in which nursing as an art is not manifested. I squirmed while hearing a nurse teaching pre-operative patients without compassion. Instead of comfort, fear is built within the patients.  I have observed nurses, who are not well informed about a disease process, explain things to patients without using therapeutic communication. I have noted procedures done outside the context of the protocols and sterile technique.

Sadly, many of these incidents are from those who have been in the profession for so long. Science is applied, but where is the art in this perspective?

Clearly, nurses must be equipped with the science of nursing. But until the art of nursing is recognized as a necessary principle for patient care, nurses will likely to continue to demonstrate behaviors that make them good technicians. However, they will not necessarily be good nurses.

As a field grounded in compassion and direct patient care, the art of the nursing profession is more important than the science. And this is where the so-called calling comes into play. 

Source: nursetogether.com

By Joan Banovic

Judge's notes: This team made a change for the greater good. The initiative benefits not just the hospital but their community and beyond. They used a scientific, research-based approach and gained support from multidiscipline teams, management and administration.

It started with a single question: "Why can't I recycle this?" In the main operating room, we perform approximately 1,500 cases per month, all requiring sterile instrumentation, sterile water, sterile saline, packaged sterile supplies and implants. All of our supplies are packaged in disposable recyclable material. Operating rooms across the country contribute the largest amount of municipal trash in a hospital, secondary only to food services. If we were able to recycle half of what we used, we could make a major impact not only to our landfills and community, but potentially our small part of the world.

Jennifer Pallotta, BSN, RN, CNOR, inpatient operating room, masterminded the project. She empowered all who chose to become involved. Together, Jennifer and I spearheaded this massive undertaking. We gathered nurses, technicians, anesthesiologists and the Environmental Services Department staff to help assist with our endeavor. Together, we would all make a difference.

Our first step was educating ourselves in the art of recycling. We did it at home; how difficult could it be? We spoke with our managers and gained support and buy-in, for without them this huge practice change would have never been achievable. We joined our hospital-based "Green Team" and educated ourselves on what would be required. We then began to educate the staff, slowly introducing the concept of recycling product from the operating room. Surgery and anesthesia chairmen were informed of our initiative via emails and introductions at committee meetings. It was imperative that we had the surgery and anesthesia staff as involved as the perioperative personnel. An area of concern would be the Environmental Services Department, for without them our study could be in jeopardy. We were amazed at the enthusiasm that they displayed when we began our educational process with them. We informed them that without their support, our study would surely fail. It was a priority for Jennifer and me to ensure that they were comfortable with the process, and truly understood what a driving force their support would be. By empowering the Environmental Service Department, we gained allies that would last much longer than our study.

We initiated a pilot program. Phase I we monitored and measured five operating rooms: ENT/gynecological, laparoscopic, orthopedic, robotic and neurosurgical procedures. We would do this for a period of one month, three times a week. We would base our results on the amount of trash (weight) that we produced, separating only red bag waste from regular trash.

Coincidentally, the end of Phase I coincided with our institution's signing a Memorandum of Understanding with the Environmental Protection Agency. Not only did we have buy-in and support from our managers, but we also received support from our president and chief executive officer, as well as our executive vice president and chief nursing and patient care officer.
Once the one-month period was complete and we had our baseline statistics, the real fun began. We would need to educate staff on recycling of operating room supplies: What could be recycled as opposed to what could not be. What material was acceptable, and what we needed to watch out for. We began an educational program that consisted of in-services, posters, banners and giveaways. Jennifer and I made ourselves available at all times for questions and answers for whoever had concerns.

Phase II of our project began with the same five operating rooms, but the difference is that a recycling trash receptacle was now added. We learned from Phase I of our study that the majority of supplies placed into the red hazardous waste bag did not need to be there. A serendipitous moment came when we were able to remove the red bag receptacle from the operating rooms, and only have it available upon need. We were able to reduce our red bag waste by 50% percent; not only eliminating the financial cost of the bags, but also dramatically decreasing the cost of disposal.

During Phase II of our study we continued positive reinforcement, taking pictures of staff recycling to encourage the team. The staff members enjoyed seeing their photos displayed on the bulletin boards - all caught in the act of recycling. The staff began to take pride and ownership in the project, and began to realize that they were making a difference in something that they had full control over. Acts of positive peer pressure began to emerge. Recycling even caught on with our surgeons being more vigilant on where they disposed of their gowns and gloves; not wanting to contaminate the recyclable items.

The end of Phase II was celebrated amongst the staff. We held a party during our monthly staff in-service decorating the room, serving coffee and breakfast to the staff. We celebrated the fact that we as a team were able to increase our recycling by 34%, hence decreasing 34% of municipal waste that is dumped into our landfills. We cut our hazardous red bag waste by 50%, eliminating the cost of supplies of red bags as well as disposal fees. Our celebration ended with each registered nurse entering the operating suite with a 64-gallon blue recycling bin for each of the 22 operating rooms in the main operating arena. 

This greening initiative was very exciting. The recycling bug caught on. In an age where hospitals need to remain conscious of the earth and be aware of the potential hazards that we can add to the environment, the act of giving back and being green is something that we all can do. By recycling in the operating room, we showed the rest of the medical center that it was certainly possible for them to participate and play a part in this new culture.

This was truly the start of a new era all arising from one simple question, "Why can't I recycle this?"

What is your place of employment doing about recycling? 

Source: nursing.advanceweb.com

By Michael O'Connor

Wet snowflakes fell on that day after Christmas 1973 as she glanced out the window.

Nancy Whittaker just wanted to return a few presents with her boyfriend, but her parents worried about her making the 40-mile trip from Beatrice to Lincoln. Maybe it was best if they made the drive another day, after the weather improved.

Source: Omaha.com

By Heather Stringer

When Carrie Bilicki, RN, MSN, ACNS-BC, OCN, met a 60-year-old patient who had been diagnosed with aggressive endometrial cancer, she began to have a persistent — albeit unconventional — idea. 

Bilicki, a cancer nurse navigator in Wisconsin at the time, recently had attended a lecture about a progressive treatment for this type of cancer that involved using a chemotherapy drug traditionally prescribed for ovarian cancer. The patient’s cancer had spread to nearby organs, and she had a poor prognosis. Bilicki convinced the physicians to try the alternative medication. Unfortunately, the patient faced another serious hurdle: The insurance company would not cover the cost of the medication because it was not the standard treatment. At that point, the woman seemed to face the unenviable choice between cancer treatment and financial ruin.

Although patients and providers would like to hope this type of extreme dilemma is the exception, the case may be representative of the near future for two reasons. First, as a 60-year-old, the woman was a baby boomer, and researchers predict the incidence of cancer will increase dramatically as this large segment of the population ages. According to a study published in the Journal of Clinical Oncology in 2009, the U.S. can expect a 67% increase in cancer incidence among older adults between 2010 and 2030. 

Second, statistics suggest cancer treatment is becoming increasingly unaffordable, even for those with insurance who struggle to afford steep copayments. For example, The US Oncology Network — a national group of about 1,000 oncology physicians who treat more than 750,000 cancer patients per year — reported about half of the patients covered by a Medicare Part D plan have required copay assistance for oral chemotherapy for the past several years.

“My message to my peers is to know the financial resources available because there are hundreds of them,” Bilicki, who now is a clinical nurse specialist in breast services at Froedtert Center for Diagnostic Imaging in Milwaukee, Wis., said. “There are foundations, specialty organizations and websites that tell us where to get help. If a patient does not have an advocate to link them to that resource, they will never know it is available.” 

What's new?

For many patients, the desire to find a way to afford medication is driven not only by the fact that they have cancer, but also because the treatment options available today have increased the odds of survival. 

“By far one of the biggest advancements is more personalized medicine that targets cancer cells rather than traditional chemotherapy that did not differentiate between good and bad cells,” Kim George, RN, MSN, ACNS-BC, OCN, a cancer program consultant from Wichita Falls, Texas, said. “For example, now we can test biopsy tissue for specific tumor antigens and biomarkers and then prescribe treatments that target those antigens.” 

The advancements in cancer treatment also are reflected in improved survival rates. According to the Surveillance Epidemiology and End Results Cancer Statistics Review 1975-2009, for example, the 5-year survival rate for breast cancer among women in the U.S. between 1975 and 1977 was 75%. Between 2002 and 2008 that number jumped to 90%. During the same time periods, the 5-year survival rate for both men and women with colon cancer has increased from 50% to 65%. 

“Another major advancement has been the increase in availability of oral chemotherapy and biotherapy,” George said. “It has shifted the care setting. Years ago, the majority of cancer patients received IV infusions, and now more patients can take their medication orally at home. It is wonderful for convenience, and it is also less painful.” 

However, George said, reimbursement is not always a given with oral chemotherapy. “A lot of oncology medications are given off-label, which means that the FDA has not approved a drug for a specific diagnosis, so it may not be covered by some insurance policies,” she said. 

Point the way

The art of navigating the path to financial assistance for cancer medication is not simple, and organizations such as The US Oncology Network, based in The Woodlands, Texas, have hired professionals to help patients connect with funding resources and launched the OncologyRx Care Advantage pharmacy in 2006. Nurses in the network can refer patients to Care Advantage staff who help them apply for financial assistance. 

“The types of drugs used to treat cancer today are definitely more expensive than when I started working in oncology almost 30 years ago,” said Lori Lindsey, RN, MSN, NP, OCN, a clinical services program manager with The US Oncology Network. “Multidrug regimens, including oral targeted therapies, can sometimes cost $30,000 for a round of treatment, although the use of these drugs has markedly improved outcomes and increased survival for some diseases.” 

For patients who are uninsured, the best option is to apply directly to the drug manufacturer for patient assistance, said Meg Asher, a patient access coordinator/patient advocate lead at the Care Advantage pharmacy. “When we learn that a patient is without insurance, we notify the doctor’s office and send a manufacturer’s application to them for the patient’s use,” Asher said. “Under these circumstances, we will not be the dispensing pharmacy; the manufacturer has their own specified pharmacy that will service the patient.”

Even those who are insured under Medicare Part D often require assistance because the copayments can be thousands of dollars, Asher said. For these patients, the Care Advantage advocate team helps patients connect with various foundations that provide copay assistance in the form of grants. Some of the foundations assist patients who suffer from a specific disease, while others help those who are taking a specific drug for a disease. 

While some facilities have staff trained to help patients find financial assistance, this is not always the case. For these patients, one resource is the Patient Advocate Foundation, a nonprofit organization with case managers who help patients with life-threatening illnesses to maintain financial stability. 

“When I was a hospital nurse, I honestly didn’t know about a lot of the resources available to help patients after they left my care,” Pat Jolley, RN, the clinical director of research and reporting at PAF, said. “Many people have never had to ask for financial help in the past, and they are unaware that there are options. If they are newly diagnosed, we try to educate them about the likely expenses down the road to help identify potential problems. In my experience, when patients contact us saying they cannot afford one thing, it is usually just the tip of the iceberg.” 

For example, PAF assisted a 62-year-old woman with breast cancer who was insured, but she was having difficulty scheduling her needed mastectomy because of outstanding medical bills. She was living on Social Security disability payments, and her insurance did not cover surgeries, scans or tests. The woman received a bill for $50,000 that included the cost of previous care and several office visits. By negotiating with the hospital and the providers, the PAF case manager was able to reduce the bill to a total of $950 and also facilitate the scheduling of her mastectomy. 

Suffering in silence

For Bilicki, one of her personal goals is to encourage patients to consider the financial aspect of their cancer care before they decide to pursue a particular form of treatment. 
“Nobody wants to talk about their financial state, and I think far too often patients suffer in silence rather than saying that they are having trouble with copayments, so what I do is proactively tell them about some of the resources,” Bilicki said. “Just because they have insurance does not mean they will have resources to afford the costs, so I empower all patients right off the bat to proactively seek out assistance if they need it.”

After patients have been diagnosed with cancer, Bilicki encourages them to learn about the resources at the American Cancer Society, which has patient navigators trained to help people connect with financial resources. She also tells them about a group called Patient Resource LLC, which has a website and a patient magazine that includes national, state and local resources available for financial assistance. 
In the case of the woman with endometrial cancer who could not afford a medication that was not covered by her insurance, Bilicki helped her apply for the drug manufacturer’s patient assistance program. Based on her income and medical necessity, she qualified for full assistance. She was on the medication for 15 months, and, despite her initial grim prognosis, the cancer has been in remission for the past five years. 

“I can always remember the tears and fear in their eyes when I first meet patients, and each time it feels like I’ve won the lottery when I help them secure the treatment they need, and they start smiling again,” Bilicki said. “Part of my big mission for my colleagues is to advocate for these patients so they do not miss out on options that can change their lives.” 

A little help can mean a lot

Point the way for patients who need assistance financing cancer treatments, by seeking resources such as the following:

• PatientAdvocate.org — Provides sources for copay assistance and answers questions about disability and insurance processes
• PatientResource.com — Features information on different types of cancer, newsletters and financial and advocacy resources
• CureToday.com — Provides an extensive list of national resources for advocacy, financial and pharmaceutical assistance
• RxOutreach.org — A nonprofit organization that helps low-income families who cannot afford the medication they need 
• CDFund.org — Chronic Disease Fund — A nonprofit organization that helps patients obtain lifesaving medications
For a list of drug assistance programs from pharmaceutical companies, visit Cancersupportivecare.com/drug_assistance.html.

Source: Nurse.com

by David Tennebaum

The single-use timer that will wholesale for about a dollar is designed to make a nurse’s life easier.In medicine, time isn't just money: it can mean the difference between life and death. Clot-busters must be given in the first hour of arrival in a hectic emergency room. Intravenous medications can spoil, and catheters that overstay their welcome invite infection.

By Susan Chapman and Bethany J. Phoenix

Because the Affordable Care Act requires that individual and small-group plans include coverage for mental health care that is comparable to that for general medical care, many analysts expect the demand for mental health services to dramatically increase over the next few years. In California, finding enough mental health providers to meet the demand will be a challenge, as the federal Health Resources and Services Administration has identified 128 Mental Health Professional Shortage Areas in our state.

After documenting vacancy rates for mental health professionals in county-operated mental health programs and state hospitals, the California Mental Health Planning Council suggested that one way to address this shortage is to increase the recruitment and preparation of psychiatric/mental health nurse practitioners (PMHNPs) as primary mental health providers. Given the direction of health care service delivery in the US, perhaps the most important advantage PMHNPs offer is that they are educated in an integrative practice model that stresses connections between physical and mental health and emphasizes health promotion. This is especially critical in public mental health settings, where many patients struggle to get to any health care appointment, much less multiple appointments with multiple providers.

Using PMHNPs to address shortages and increase access to care in public mental health settings, however, faces a number of challenges. To help understand and address these challenges, we are collaborating with the California Institute for Mental Health (CiMH) to conduct a Robert Wood Johnson Foundation-funded study that will include case studies in five California counties with a history of using PMHNPs. The aim is to document best practices, identify unnecessary restrictions on NP practice and formulate strategies to remove these restrictions. By the conclusion of the study in 2015, we hope to have evidence-based information for key stakeholders – from public mental health care systems to state policymakers – about how PMHNPs can help increase access to mental health services in the state.

One thing the study will allow us to do is examine in more detail presumed barriers that have emerged both anecdotally and from prior research. To begin with, just as with primary care, there is a need to rapidly fill the pipeline by incentivizing existing and future students to work in public mental health. That’s why beginning in 2009, California’s Mental Health Services Act began funding educational stipends to PMHNP students at three schools of nursing, including UC San Francisco. The stipend requires that students “pay back” their stipend by working in a public mental health setting for the equivalent of a year of service for each year of stipend funding.

That’s a fine start, but many of our colleagues across the state are concerned that scope-of-practice laws and the lack of good practice models for PMHNPs in California appear to undermine the effort to prime the pipeline.

For example, UCSF School of Nursing faculty member Aaron Miller was educated in Oregon and says that the biggest difference between the two states is that, “In Oregon, NPs can practice without a collaborative agreement with a physician…and the scope-of-practice law in Oregon contains an explicit description of the NP’s scope of practice: assessment, diagnosis, creation of plan and treatment.” By contrast, he says, in California NPs must always have a collaborative agreement in place with a supervising physician, and in every setting they have to devise agreed-upon standardized procedures that define what the NP can do – essentially, the scope of practice. Moreover, at present, practice models in the state do not facilitate optimal billing for PMHNP services.

Ebony Anderson, one of our former stipend students, says these limitations have dampened her willingness to strike out into independent practice as a psychiatric mental health nurse practitioner.

Thus, even as many in the state recognize that NPs can provide high-quality care and organizations are starting to utilize NPs’ full scope of practice, a number of factors may be erecting unnecessary obstacles to meeting the mental health needs of many Californians – especially in areas already short on qualified providers. These factors include reimbursement challenges, the effort involved in defining acceptable scope for each setting and finding physicians willing to provide NPs with the mandated level of supervision – and bill for services under their provider numbers, if appropriate.

Our charge, among other things, is to examine how and to what degree these factors affect the state’s ability to meet expected growth in demand for mental health services. Such research is the lifeblood of policy change. Our hope is that the results of our work will enable the state to fully leverage an educational system that is training PMHNPs to deliver outstanding care but, at least at the moment, sending them into a health care system that is not yet taking full advantage of their strengths.

Susan Chapman and Bethany J. Phoenix are leading a study to examine the structural, practice and policy opportunities and barriers that affect psychiatric/mental health nurse practitioners’ ability to most effectively use their skills and expertise in public mental health settings. Chapman directs the Health Policy Nursing specialty in the Department of Social and Behavioral Sciences at UC San Francisco School of Nursing. Phoenix is vice chair of the School’sDepartment of Community Health Systems and coordinates the School’s Psychiatric/Mental Health Nursing specialty. The study is supported by the Robert Wood Johnson Foundation’s Future of Nursing National Research Agenda, which is coordinated by the Interdisciplinary Nursing Quality Research Initiative, a national program of the Robert Wood Johnson Foundation.

Source: Science of Caring