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Craig Morgan (center left) with some members of his care team: (left to right) Chelsea Apland, a Friendship Ark Homes coordinator; Gina Smith, RN; Carrie Adams, BSN, RN, clinical supervisor for cardiac rehab, and Andy Nichols, a Friendship Ark Homes supervisor.

Something was clearly wrong with Craig Morgan. Those closest to him could sense it. He wasn’t himself. He seemed tired and confused.

Craig, unfortunately, couldn’t really explain what he was going through. A resident of Friendship Ark Homes (FAH) in Ames, Craig is an adult with intellectual disabilities. While his communication skills are limited, he’s an endearing guy, agreeable almost to a fault. His response to any question is often, “Yeah,” accompanied by a big smile.

His well-being depends on those who know him best being able to read his moods and actions, and, by doing so, help others provide Craig what he needs.

“Craig is eager to please. He’ll always say ‘yes’ and can feign understanding whether he has it or not,” says Andy Nichols, a supervisor at FAH who has known Craig for years. “That’s a big part of working with Craig in the community – helping him understand and helping others understand him.” This was vitally important when Craig was brought to McFarland Clinic and then to Mary Greeley in early August.

“His spirits were fine,” says Nichols. “He was a little more confused than normal and over the weekend had become very weak and tired. We thought he might have pneumonia.”

From McFarland, Craig was sent to Mary Greeley’s emergency department for immediate tests. It wasn’t pneumonia. Craig had experienced a heart attack.

Diagnosis and Big Decisions

Craig was admitted to Mary Greeley’s intensive cardiac care unit (ICCU). The next day, he underwent an angiogram performed at Mary Greeley’s cardiac catheterization lab by Iowa Heart
cardiologist Dr. Ravinder Kumar.

Kumar discovered that all three of Craig’s major heart vessels were seriously blocked. He had suffered what’s called a NSTEMI (Non-ST elevation myocardial infarction). It is sometimes called a silent heart attack. Conversely, a STEMI (ST-elevation myocardial infarction) is an immediate emergency type of heart attack.

Heart bypass surgery was considered the best option, but Craig’s family and FAH caregivers felt that he wouldn’t be able to understand the recovery and rehabilitation requirements of such invasive surgery. Doing the surgery was as potentially dangerous for Craig as putting him through it.

A decision was made to monitor Craig’s condition, to treat it medically and not surgically. That decision was promptly reconsidered after Kumar visited Craig the next day in the ICCU.

“He was miserable,” says Kumar. “Just sitting up on the side of the bed would make him exhausted. There’s no way we wanted him going home feeling like this.”

Kumar spoke to a colleague, and Craig was transferred to Des Moines for a high-risk stenting procedure to open his blocked arteries, with the help of an Impella heart pump during the procedure. (Mary Greeley’s cardiac cath lab can perform stent procedures but does not have the Impella device.)

Rehab Challenge

Carrie Adams, BSN, RN, clinical supervisor of Mary Greeley’s cardiac rehabilitation center, was surprised when she ran into her old high school friend Andy Nichols in the halls of the hospital that day in August.

“One of my guys had a heart attack,” Nichols told Adams.

A few weeks later, Adams met that guy. It was Craig, who had been referred to Cardiac Rehab after his surgery. In these cases, a patient is generally referred to the rehab service closest to their home.

When Adams received the referral details and realized who the patient was, she knew to call Andy. That local connection was important because Adams and Nichols had an instant trust. Their conversation was the beginning of a coordinated effort to help Craig.

It is not unusual for the cardiac rehab staff to make accommodations for patients, but because of his cognitive abilities, Craig posed a new kind of challenge.

“It’s pretty individual for everyone,” says Adams of the Cardiac Rehab program. “We’ve had competitive athletes and people who have never stepped on exercise equipment in their lives. You’ve got to make it work for all of them.”

Making it work for Craig was personally important to Adams, who has a close relationship with a nephew who has special needs.

Cardiac Rehab at Mary Greeley usually involves small classes of people going through a prescribed set of exercises while wearing heart monitors. Rehab can last several weeks. Could Craig handle this? Should he receive treatment on a one-on-one basis, or be part of a regular group? Would being in a group be too busy for him, too much stimulation?
Nichols assured Adams that Craig could handle it all.

“The goal is to progress the exercise without making it too difficult,” says Adams. “Craig does a lot of active outings and we wanted to make sure he could get back to doing those things without Friendship Ark staff having to constantly worry that they were pushing him too hard.”

Recovery Plan

It was decided that Craig would benefit from being part of a regular rehab class. A slightly shortened 12-session course of treatment was planned. Because he had had falls at home, it was also decided to limit Craig to seated equipment. FAH coordinators Cassie Shivers and Chelsea Apland attended classes with Craig. They provided encouragement and helped cardiac rehab staff work with Craig.

“We would ask him ‘Are you OK?’ ‘Is this too hard?’ ‘Is this really easy?’ ‘Does your chest hurt?’ ‘Is it hard to breathe?’ Yes or no questions for the most part,” Adams says. “We couldn’t have done it without his helpers.This really was a team effort, with our staff working closely with staff from Friendship Ark to make sure Craig got what he needed.”

Friendship Ark staff echoed those sentiments.

“In the 10 years I’ve been with Friendship Ark and working with Craig, this was the most exemplary health care experience he’s had,” says Nichols. “The cardiac rehab staff
paid very close attention to him and got more out of him than any medical professional ever has since I’ve known him.”

In October, Craig finished his therapy. “We wanted him to feel like part of the group, and he did,” says Adams. “Other patients would ask him how he was doing and they cheered when he graduated. I loved seeing that. It was really sweet.”

Craig is back home at Friendship Ark, keeping busy with regular outings, or crocheting and jigsaw puzzles. Did he enjoy his cardiac rehab experience? You already know that answer. It’s a big smile and, “Yeah.”

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Helping others has always been a passion for Carroll native Jamie Waller. It’s why she pursued a career in nursing at Iowa Central Community College in Fort Dodge and it’s why she participated in a three-week mission trip to Tanzania in Africa following her freshman year of nursing school.

“After going to Africa, I discovered that nursing was my true passion in life,” Waller said. “It confirmed my interest in serving others and solidified my decision to become a nurse.”

Today, Waller is a registered nurse and six-year veteran of St. Anthony Regional Hospital in Carroll. She works on the medical, surgical and pediatric floor and often serves the role as charge nurse. But her commitment to serving others extends beyond her daily shifts.

In November 2016, newlyweds Jamie and her husband, Cory, ventured to Haiti with Grace4Haiti, a medical mission group based in Omaha. The couple joined the team’s 15th trip with the purpose to work in a hospital setting, perform medical services, prepare patients for surgery, assist surgeons, and care for patients in a hospital.

Jamie shares that she grew both personally and professionally from the experience.

“We saw many, many patients in the clinic every day and performed small procedures in the clinics if able,” Waller said. “I realized on this trip that we have many luxuries we take for granted here in the in U.S. – things as simple as running water and electricity in every health care facility, and features as complex as all of the technology and supplies we have available. It was an eye-opening experience.”

Yet, most memorable of all, Jamie recalls two premature infants the medical mission workers saved during their stay.

One afternoon several of the mission team members walked to the beach during a short break from the hospital. As they were walking back, additional group members met them with the urgent message that an abandoned, premature baby had just been dropped off at the hospital.

“Luckily, we had the biggest group at the hospital that week, because at the same time this baby was struggling to breathe, another mother was having a scheduled C-section,” Waller said. “Once we delivered the baby via C-section, we knew right away the baby was not 40 weeks along. We had to cardiopulmonary resuscitate the baby for a short while and perform other medical techniques for this child to survive.”

At St. Anthony Regional Hospital, Jamie Waller (left) is a preceptor for nursing student Morgan Neary.

Within hours, the medical team had both babies stabilized and transferred them to a nearby hospital, a couple hours away. The infants were transported in the missionaries’ vans, because there is no organized ambulance service in Haiti.

“I truly felt the difference our team was making in that moment to help those babies,” Waller said. “We used the resources and skillsets we had available to provide great care. Had our team not been there, I don’t believe they would have lived.”

Waller is grateful for the support of St. Anthony, which provided supplies and a mission trip support fund to match her employee vacation hours.

“St. Anthony’s generous donations were an invaluable asset for our trip,” Waller said. “We used many supplies while there. Every little bit counts and each donation helps to lessen the burden of providing health care in Haiti. The vacation match program also helped my husband and me financially with the trip. It meant the world to us.”

Jamie encourages others to partake in the same types of endeavors. She and Cory are leading by example, returning to Haiti in April with the hopes of spending more time in orphanages to show their support of Haitian children and continuing the relationships they built in November.

“I felt God’s presence many times while there – whether it was getting to know the people around me or guiding my hands while working with patients,” Waller said. “I truly believe that everything happens for a reason. My husband and I went on this trip to serve God and show love to other parts of the world by hugging someone that needs a hug or providing life or death care to a newborn baby. I am incredibly blessed and grateful for the opportunity to help others.”

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Iowa’s Certificate of Need (CON) regulations were first enacted in 1977 for the express purpose of providing for the orderly and economical development of health care services, thereby avoiding unnecessary duplication of services, controlling the growth of overall health care costs and ensuring the stability of community hospitals. Since that time, these regulations have been re-examined multiple times and each time the same conclusion was reached: Iowa needs Certificate of Need.

Now the Iowa Legislature is considering a bill that, if enacted, would repeal significant portions of the CON program, putting community-based health care at risk. Here are some of the reasons why Iowa hospitals are supporting CON:

CON ensures access to health care services

  • CON repeal will reduce access by destabilizing local health care systems.
  • Without CON, services that keep hospitals financially healthy will be stripped away by for-profit, out-of-state, investor-owned organizations that selectively perform services simply because those services are likely to create the most income.
  • These niche providers would leave the financial burden on hospitals to provide 24/7/365 emergency care, to provide care for patients with complicated conditions and patients with Medicaid or no insurance.

 CON supports rural communities

  • States without CON have seen hospitals close, especially in rural areas.
  • Rural Iowa is uniquely susceptible to losing essential health care services. CON criteria and safeguards ensure health care systems are financially stable and that health care options exist throughout all of Iowa.
  • In many counties, rural hospitals are among the largest employers, bolstering Iowa’s rural economy, attracting and retaining young professionals and families and bringing high-quality jobs where they are most needed.

CON promotes quality health care services

  • CON criteria ensure new facilities operate with patient volumes that are sufficient to provide high quality services.
  • CON criteria ensure excess capacity does not lower volumes in a manner that compromises patient safety.
  • CON criteria result in consideration of the quality services available in the community.

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(This article was provided by Kaiser Health News.)

Elizabeth Cosgrove, left, helps Yolanda Solar, 73, who suffers from depression, organize her medications during a home visit on Nov. 3 in San Antonio. Cosgrove is a community outreach worker at a transitional care clinic run by the University of Texas Health Science Center at San Antonio. (Bahram Mark Sobhani for KHN)

Elizabeth Cosgrove, left, helps Yolanda Solar, 73, who suffers from depression, organize her medications during a home visit on Nov. 3 in San Antonio. Cosgrove is a community outreach worker at a transitional care clinic run by the University of Texas Health Science Center at San Antonio. (Bahram Mark Sobhani for KHN)

Yolanda Solar has battled a life-threatening disease for more than three decades. The disease nearly killed her last summer and Solar, a 73-year-old grandmother, was rushed to the hospital by ambulance.

When Solar was discharged one week later, she received bad news: She would have to wait until March to see a doctor.

Waiting seven months for treatment would be unthinkable if Solar had cancer or heart disease. But Solar suffers from severe depression, and waiting that long for help is typical — and potentially dangerous.

Although San Antonio has earned widespread praise for its success in keeping people with mental illness out of jail, patients here routinely wait months to see psychiatrists, who are in short supply across the country. The number of available psychiatrists who specialize in the care of the elderly or children is even smaller.

Without routine medical care, patients like Solar, who tried to kill herself in August with an overdose of pills, can quickly deteriorate. Many return to the emergency room. Some don’t survive.

But Solar was luckier than most.

Emergency room (ER) staff made an appointment for her at a transitional care clinic at the University of Texas Health Science Center at San Antonio, which annually treats up to 1,500 patients with serious mental illness until they can find regular care. The clinic helps the mentally ill avoid winding up in the ER, where round-the-clock activity and confusion is ill-suited to the needs of patients who are already agitated, suicidal or psychotic.

Communities like San Antonio are increasingly focused on reducing emergency room use by people with mental illness. In addition to being chaotic, emergency rooms are among the most expensive places in the health system to get urgent care.

Patients like Solar end up in the ER because they can’t find care in the community, and emergency rooms can’t legally turn anyone away. The mentally ill can be stranded in the ER for hours, days or even weeks with minimal treatment, because doctors deem them too disabled to discharge, but can’t find them an inpatient psychiatric bed, which would allow patients to get more intensive care.

More than half of emergency room physicians said their local mental health system has gotten worse in the past year, according to a survey of 1,716 members of the American College of Emergency Physicians, released in October. Seventy-five percent of ER doctors said on their last shift, they saw at least one psychiatric patient who needed to be hospitalized.

“The emergency department becomes the de facto dumping ground for all mental health patients,” said Gillian Schmitz, a San Antonio emergency physician.

The number of ER patients with a mental illness grew from 4.4 million in 2002 to 6.8 million in 2011, an increase of 55 percent, according to a 2016 study in Health Affairs. About 836,000 Americans a year go to the emergency room after harming themselves, according to the Centers for Disease Control and Prevention. Nearly 43,000 Americans committed suicide in 2014 — more than are killed annually in car accidents.

The American College of Emergency Physicians devoted much of its annual meeting in October to patients with psychiatric crises.

Everyone suffers when people with mental illness are stuck in limbo in the ER, Schmitz said. Other patients face longer waits for care and hospitals lose money. That’s because insurers pay emergency rooms only for their initial encounter with a patient, but not for time spent waiting for an inpatient bed.

“Every hour we are holding a psych patient,” Schmitz said, “is lost revenue that hospitals could be earning on other medical patients.”

Elizabeth Cosgrove, right, helped 73-year-old Yolanda Solar make a reminder to take her medication that Solar put on her dresser. Cosgrove is a community outreach worker at a transitional care clinic run by the University of Texas Health Science Center at San Antonio. (Bahram Mark Sobhani for KHN)

Elizabeth Cosgrove, right, helped 73-year-old Yolanda Solar make a reminder to take her medication that Solar put on her dresser. Cosgrove is a community outreach worker at a transitional care clinic run by the University of Texas Health Science Center at San Antonio. (Bahram Mark Sobhani for KHN)

Personalized care

Solar’s story also shows the progress that people with mental illness can make when they receive prompt and comprehensive care. She has not returned to the ER since beginning treatment in August.

Hospital staff scheduled her appointment at the transitional care clinic through a web-based computer system before she left the hospital. Like most patients, Solar was seen within a few days.

Solar now meets regularly with a psychiatrist, who manages her medications, and a counselor to discuss her fears.

A therapist visits her at home to help organize her medications, which include pills for high blood pressure and cholesterol. The visits are paid for through a Medicaid pilot program, which allows staff to provide extra services for up to five patients who are considered “high utilizers” of health care, or patients who are particularly costly to insurers because of repeat trips to the hospital or ER, said Megan Fredrick, the clinic’s program manager.

Patients with serious mental illness, which can cause cognitive changes similar to dementia, often need help with day-to-day tasks, said psychologist Dawn Velligan, project director at the transitional care clinic. Therapists help patients set alarms that remind them when to take their medicines. They work with patients on calendars and organizational skills, so that clients don’t miss appointments.

Through a type of therapy called cognitive adaption training, clinic staff teach basic skills, such as how to shop for groceries or take the bus to a medical appointment, Velligan said.

Only 2.5 percent of psychiatric patients seen at the transitional care clinic return to the ER within three months, compared to 10 percent of patients who aren’t seen at the clinic, Fredrick said.

Without the clinic’s help, Solar said, she would probably have considered suicide again.

“Sometimes, I get pretty, pretty, pretty depressed,” said Solar, who was raised by an alcoholic father. Her depression began, Solar said, during an unhappy marriage.

Yet for years, Solar suffered in silence. The first time she saw a psychiatrist was after her August suicide attempt.

Nationwide, more than half of people with mental illness go without treatment, according to Mental Health America, an advocacy group. The reasons are complex. Many people with mental illness don’t realize they’re sick, or that treatment can help. Some patients lack transportation or money to pay for care. About 17 percent of people with a mental illness in the U.S. are uninsured, according to Mental Health America.

“For many of our elderly Hispanic patients, this is the first time they’ve seen a therapist,” Cynthia Sierra, a clinic counselor. “You’re raised not to talk about your problems with strangers … You can carry years of burdens and trauma.

Unsolved problems

For all its success, the transitional care clinic can’t help everyone.

With an annual budget of $3.5 million — provided by a variety of grants and a fund for Medicaid demonstration projects — the clinic sees just a fraction of those who need help.

“We constantly have to beg for money,” Velligan said.

Although the transitional clinic accepts patients covered by Medicare, Medicaid or private insurance, it can’t accept most uninsured patients.

Psychiatrist Harsh Trivedi describes the program as a “Band-Aid” that fails to address the larger problem of inadequate care for people with mental illness.

“Unfortunately, creating these programs doesn’t actually solve the real access issues,” said Trivedi, chair of the American Psychiatric Association’s council on healthcare systems and financing.

Trivedi notes that the national shortage of psychiatrists means that even well-insured patients often have to wait for care. Although the overall number of physicians increased 14 percent from 2003 to 2013, the number of psychiatrists fell by 10 percent when adjusted for population growth, according to a July study in Health Affairs.

That shortage is projected to worsen over the next decade as large numbers of psychiatrists reach retirement age, said Trivedi, who is also the president and CEO of Sheppard Pratt Health System in Maryland.

Many psychiatrists have stopped taking insurance because health plans pay them too little to sustain a practice, Trivedi said.

To really help more patients, the country needs to rebuild the mental health system, investing both in outpatient care, more hospitals beds and supportive services, Schmitz said. Instead, states have been steadily slashing mental health budgets for years.

“As a society, we’re OK with the fact that someone with depression isn’t able to get care,” Trivedi said. “That double standard allows some of our most vulnerable people to end up in harm’s way.”

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Dwight Dial

As he sits in the kitchen of his Lake City farm home, Dwight Dial is surrounded by items that remind him of his loved ones: a barometer his mother passed down to him from Swedish ancestors, photos on the fridge of children and grandchildren, embroidered wall hangings completed by his beloved wife, Jane. It’s a comfortable room in a sprawling farmhouse, but at the moment, it’s quiet. The only sound in the house is Dwight’s voice as he remembers three people he lost within three years.

His father, Gerald, was a tail gunner in a B-17 bomber during World War II in the European theater. He flew 36 missions and was featured in a book written about the “Flying Fortress.” Gerald rarely discussed his experiences with his family, who only came to realize the dangers he had faced when they read the book. “We told each other we’re lucky to be here!” recalls Dwight.

After the war, Gerald returned to the farm and married Alice Ann. Together, they raised seven children and tended the land. When he was 85, a lifetime of smoking resulted in a diagnosis of chronic obstructive pulmonary disease (COPD) and emphysema. In 2009, he began to utilize Community Hospice at Stewart Memorial Community Hospital (SMCH) in Lake City. Hospice is a special kind of care that brings terminally ill patients and their families comfort, support and compassion in a manner that respects and cherishes the dignity and uniqueness of each individual. When cure is no longer possible, hospice can provide highly skilled care to patients and their families in the familiar surroundings of their own home or residence, including nursing homes.

Dwight recalls, “The nurses would come to the house to take care of him. My parents were very private, but I think my folks shared more of their personal lives with them than they did with their children.” He was impressed with the level of care his father received at the hands of the hospice team. “At one point, my father decided to stop going to see his doctor for checkups. The nurses communicated with his physician who then made a housecall. Together they decided to let mom continue to take care of Dad in their home with the help of the hospice nurses. When he passed on December 6, 2013, his last words to mom were ‘I’m glad you kept me at home.’”

In May 2011, Dwight and Jane were visiting their son in Alabama who was preparing for his third tour of duty in Iraq. They were playing with their grandson when Jane suddenly said to Dwight, “Something’s not right inside.” When the couple returned home Jane made an appointment with her primary care provider Nancy Flink, certified physician assistant. Tests revealed that Jane had ovarian cancer. Dr. Marc Miller performed surgery in June and Jane, a long-time Nutrition Services Director at SMCH, began chemotherapy at the hospital that felt like home.

On August 28, 2013 the couple celebrated their anniversary with dinner, margaritas and laughter. Dwight recalls that it was their last meal together. A few days later, Jane was taken to Des Moines to receive care from her oncologist where she stayed until October. When she was able to return to her home, she opted to do the next round of chemotherapy at the Lake City hospital, entering the hospice program at the same time. “Everyone at the hospital worked to make sure Jane was comfortable. The maintenance crew brought a hospital bed, then went and got a new mattress for it, while Bethany Morrow made sure Jane had new sheets and anything else she needed. Friends came to sing Christmas carols for us and later hung Valentine’s cards all over the walls,” says Dwight.

The hospice team helped with bathing Jane and medications. They trained Dwight on how to care for her ileostomy and how to give her nutrients through a port after she was unable to digest food. Dwight pauses for a long moment, “Jane passed away on December 26, 2013, 20 days after her father-in-law. She didn’t want to go before Dad and she didn’t want to go on Christmas day. That morning she said to me, ‘I made it.’” Softly, Dwight continues, “I told her it was okay for her to go, and she went.”

A few months passed and Dwight continued to farm. In June 2014, his mother, Alice Ann was diagnosed with breast cancer. Dr. Miller performed a mastectomy, but the disease had spread into her lymph nodes. “My mother was very strong. She went home and convalesced for a few weeks on her own and then began a series of 29 radiation treatments. After she completed 20, I took her to California to see her sister. When we returned she completed the last nine.”

Before Thanksgiving that year, Alice Ann acquired an infection and was hospitalized for 100 days. Dwight decided to take her home to his house where he could care for her. “The wound nurse showed me how to clean and pack her wound. The hospice nurses were also there to help care for Mom.” Throughout 2015, Alice Ann was in and out of the hospital but on December 5 she returned to the hospital for the final time. She told Dwight, “As soon as I’m well enough, I’m going to go to Shady Oaks.”

She reached that goal on December 9. “The hospice team was involved in mom’s care at the hospital and the nursing home,” says Dwight. “The communication, care and support flow so well from the SMCH hospice team. They bent over backwards to make the process as easy as possible for the family.” Alice Ann passed away on December 31, 2015.

Dwight is grateful for the care shown to Gerald, Alice Ann and Jane, “Hospice gave my loved ones the ability to live out their last days in dignity and love, surrounded by people who truly cared. They became our family during those very critical days. The sincerity this staff has is unquestionable. For the compassion they have for those that are leaving us and for the caregivers, I cannot thank them enough.”

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