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Health Care

Under Pressure

A changing healthcare landscape has doctors feeling stressed, unsatisfied, and burned out like never before — and that could have dire effects on patient care. That’s why the industry is focused on diagnosing the problem and prescribing remedies.

Every day, patients rely on doctors to tackle their chronic health and wellness issues and make them feel better.

But what if it’s the doctors feeling miserable? Or stressed-out, anxious, and overwhelmed? Unfortunately, that’s happening constantly.

Burnout among physicians has become so pervasive that a new paper recently published by the Harvard T.H. Chan School of Public Health, the Harvard Global Health Institute, the Mass. Medical Society, and the Mass. Health and Hospital Assoc. deems the situation no less than a public health crisis.

“A Crisis in Health Care: A Call to Action on Physician Burnout,” as the document is titled, includes a number of strategies aimed at curbing the prevalence of burnout among physicians and other care providers, including improvements to the efficiency of electronic health records (EHRs), proactive mental-health treatment and support for caregivers experiencing burnout, and the appointment of an executive-level chief wellness officer at every major healthcare organization (much more on all of these later).

But the report also details just how extensive the problem is, and why it should be a concern for patients. In a 2018 survey conducted by Merritt-Hawkins, 78% of physicians said they experience some symptoms of professional burnout — loosely described in the survey as feelings of emotional exhaustion, depersonalization, and/or diminished sense of personal accomplishment.

Physicians experiencing burnout are more likely than their peers to reduce their work hours or exit their profession. And that’s concerning in itself; the U.S. Department of Health and Human Services predicts a coming nationwide shortage of nearly 90,000 physicians, many driven out of practice due to burnout.

“The issue of burnout is something we take incredibly seriously because physician well-being is linked to providing quality care and favorable outcomes for our patients,” said Dr. Alain Chaoui, a practicing family physician and president of the Massachusetts Medical Society. “We need our healthcare institutions to recognize burnout at the highest level, and to take active steps to survey physicians for burnout and then identify and implement solutions. We need to take better care of our doctors and all caregivers so that they can continue to take the best care of us.”

Dr. Alain Chaoui

Dr. Alain Chaoui

 “We need to take better care of our doctors and all caregivers so that they can continue to take the best care of us.”

While some have pointed to the passage of the Affordable Care Act (ACA) in 2010 — the most significant recent change in the American healthcare landscape — as a stressor, the roots of the crisis date further back, the report notes. For example, EHRs, mandated as part of the 2009 Reinvestment and Recovery Act, have dramatically changed the way doctors allot time to their jobs. And the 1999 publication of the Institute of Medicine’s “To Err is Human” report, highlighting the prevalence of medical errors, directed new attention to the need for quality improvement, physician reporting, and accountability — and brought heightened pressure.

In the past, the report notes, some have proposed ‘self-care strategies’ — such as mindfulness or yoga — as a response to burnout and presented some evidence of limited success with such approaches. However, physicians typically don’t have time to fit such coping strategies into their routine. They also don’t really address root problems.

“Such an approach inaccurately suggests that the experience and consequences of burnout are the responsibility of individual physicians,” it continues. “This is akin to asking drivers to avoid car accidents without investing in repairing and improving hazardous roads. Simply asking physicians to work harder to manage their own burnout will not work.”

Digital Dilemma

As the report noted, a broad consensus has formed that a major contributor to physician burnout is dissatisfaction and frustration with EHRs, which have become ubiquitous in recent years. While the goal of transitioning to electronic records has been to improve quality of care and patient communication, the results have been mixed at best.

“The growth in poorly designed digital health records and quality metrics has required that physicians spend more and more time on tasks that don’t directly benefit patients, contributing to a growing epidemic of physician burnout,” said Dr. Ashish Jha, a VA physician and Harvard faculty member. “There is simply no way to achieve the goal of improving healthcare while those on the front lines — our physicians — are experiencing an epidemic of burnout due to the conflicting demands of their work. We need to identify and share innovative best practices to support doctors in fulfilling their mission to care for patients.”

As Dr. Atul Gawande, a Massachusetts surgeon, writer, researcher, and CEO of the nonprofit healthcare venture formed by Amazon, Berkshire Hathaway, and JP Morgan Chase, recently described it, “a system that promised to increase physicians’ mastery over their work has, instead, increased their work’s mastery over them.”

That’s because the patient encounter is now dominated by the demands of the EHR, undermining the crucial face-to-face interaction that has long been at the core of a satisfying doctor-patient encounter, the report notes, adding that, “for many physicians, EHRs impose a frustrating and non-intuitive workflow that makes excessive cognitive demands and detracts from, rather than reinforces, the goals of good patient care.”

Dr. Ashish Jha

Dr. Ashish Jha

 “The growth in poorly designed digital health records and quality metrics has required that physicians spend more and more time on tasks that don’t directly benefit patients.”

In addition, the quantity of mandatory documentation imposed by EHRs — due to regulatory and payer requirements — means physicians typically spend two hours doing computer work for every hour spent face to face with a patient, including numerous hours after work. And they’re frustrated by spending so much time on administrative tasks they feel have little to do with actual patient care.

One promising solution, according to the report, would be to encourage software developers to develop a range of apps that can operate with most, if not all, certified EHR systems.

Improved EHR usability is, in fact, required by law. The 21st Century Cures Act of 2016 mandates the use of open health care APIs (application programming interfaces), which standardize programming interactions, allowing third parties to develop apps that can work with any EHR. This would allow physicians, clinics, and hospitals to customize their workflow and interfaces according to their needs and preferences, promoting rapid innovation and improvements in design.

Another promising but less-developed approach to reducing the HER burden on physicians, the report notes, is the development of artificial intelligence (AI) technologies to support clinical documentation and quality measurements.

Mind Matters

The report spends plenty of time on mental health, and for good reason.

“It is clear that one can’t have a high-performing healthcare system if physicians working within it are not well,” it notes. “Therefore, the true impact of burnout is the impact it will have on the health and well-being of the American public.”

To that end, it calls on hospitals and other healthcare organizations to improve access to, and expand, health services for physicians, including mental-health services — while reaching out to doctors and encouraging them to take advantage of such services in order to prevent and manage the symptoms of burnout.

That’s easier said than done, of course, as a stigma still exists around seeking help for mental-health issues.

“Physician institutions — including physician associations, hospitals, and licensing bodies — should take deliberate steps to facilitate appropriate treatment and support without stigma or unnecessary constraints on physicians’ ability to practice,” the report argues.

Last year, the Federation of State Medical Boards (FSMB) adopted a policy reconsidering ‘probing questions’ about a physician’s mental health, addiction, or substance use on applications for medical licensure or renewal, as the existence of such questions may discourage physicians from seeking treatment. “To the extent that such questions are included,” the report says, “those questions should focus on the presence or absence of current impairments that impact physician practice and competence, in the same manner as questions about physical health.”

The FSMB is also calling for state medical boards to offer ‘safe-haven’ non-reporting to applicants for licensure who are receiving appropriate treatment for mental health or substance use. Such non-reporting would be based on monitoring and good standing with the recommendations of the state physician health program (PHP).

Speaking of which, Physician Health Services Inc. (PHS) — a charitable subsidiary of the Massachusetts Medical Society that serves as the PHP for Massachusetts physicians — intends to reach out in a broader way to physicians and hospitals to encourage doctors dealing with burnout and behavioral-health issues to seek appropriate and confidential care.

“Many PHPs in other states have expanded their outreach,” the report notes. “Hospitals and other healthcare institutions should complement and support this effort by acknowledging physicians’ concerns with seeking mental healthcare and clearly identifying avenues and opportunities to receive confidential care, particularly for residents and trainees, who are at a vulnerable stage of their careers.

Finally, the report calls for the appointment of executive-level chief wellness officers (CWOs) at all healthcare organizations. “CWOs must be tasked with studying and assessing physician burnout at their institutions, and with consulting physicians to design, implement, and continually improve interventions to reduce burnout.”

“Patients do not like being cared for by physicians who are experiencing symptoms of burnout, which is significantly correlated with reduced patient satisfaction in the primary-care context. Evidence further suggests that burnout is associated with increasing medical errors.”

The key responsibilities of the chief wellness officer, in addition to acting as an advocate and organizational focal point, may include studying the scope and severity of burnout across the institution; reporting findings on wellness and physician satisfaction as part of institutional quality-improvement goals; presenting findings, trends, and strategies to CEOs and boards of directors; and exploring technological and staffing interventions like scribes, voice-recognition technology, workflow improvements, and EHR customization to reduce the administrative burden on doctors, just to name a few.

CWOs could benefit physicians not just in hospitals, the report continues, but across health systems, and in affiliated practices. “Departments, units, and practices can survey for burnout, begin to identify their areas of focus and barriers to success, and collectively develop solutions. The CWO can help lead this process and provide best practices and other supports.”

Lives in the Balance

In the end, physician burnout is a problem with many triggers, which is why the authors of “A Crisis in Health Care” encourage a multi-pronged approach to counter it. But it’s also an issue with many potential consequences, not just for doctors and their employers.

“Patients do not like being cared for by physicians who are experiencing symptoms of burnout, which is significantly correlated with reduced patient satisfaction in the primary-care context,” the report notes. “Evidence further suggests that burnout is associated with increasing medical errors.”

Dr. Steven Defossez, a practicing radiologist and vice president for Clinical Integration at the Massachusetts Health and Hospital Assoc., said hospitals in the Commonwealth place a high priority on the safety and well-being of patients, so combating burnout will continue to be an area of focus.

“In particular, we recognize the need to further empower healthcare providers and support their emotional, physical, social, and intellectual health,” he said. “This report and its recommendations offer an important advance toward ensuring that physicians are able to bring their best selves to their life-saving work.”

Joseph Bednar can be reached at [email protected]

Health Care

Progressive Course

Laura Hanratty

Laura Hanratty says the number of BCBA students has probably doubled since 2012, a clear sign of growing need for such trained individuals.

In many cases, Alyssa Clark says, progress — in whatever way it is measured — comes slowly.

But in most all cases, it does come, and when it does, it quickly reminds her why she chose this career path — not that she ever really forgets.

Clark was talking about her work as a board-certified behavior analyst, or BCBA, as those with the requisite credentials are called. She works in a few area elementary schools with students in grades K-4. Some are on the autism spectrum, but all of them are defined with an industry term of sorts: social/emotional, which means they have behavioral issues, usually brought on by trauma in their backgrounds — poverty, divorce, or being in foster care, for example.

“Sometimes, progress is slow in coming, but even the little things you see … kids might have that one good day after several bad ones,” she told BusinessWest. “And to be able to see that and know that you could make a difference in that kid’s life and help them…”

She didn’t actually finish the sentence, because she didn’t have to. The satisfaction that comes with such work is clearly apparent. And it is one of many reasons why applied behavior analysis (ABA) is becoming an increasingly popular career path within the broad spectrum of healthcare, and also why programs such as the master’s in ABA program at Elms College in Chicopee, which Clark graduated from recently, were created and continue to see growth in enrollment.

“Every kid that we work with should go through an analysis to determine why problem behaviors are occurring, and then treatment based on that analysis helps address those behavioral concerns.”

But the biggest factor is growing need within the community, said Laura Hanratty, assistant professor and director of both the ABA and ASD (autism spectrum disorders) programs at Elms.

“It’s definitely a growing field,” she said, noting that, when she sat for the certification exam in 2012, there were roughly 10,000 BCBAs in this country; now, there are perhaps twice that number.

Why? The ever-growing number of people diagnosed with autism is a big factor, she said, adding that there are many theories surrounding this surge, but the prevailing one is that there is simply more awareness of the condition and, therefore, more early diagnosis.

But the nature of applied behavior analysis, and the tremendous rewards, as Clark described, are also a factor in the growing popularity of this profession.

When asked to elaborate, Hanratty said there is a good deal of science, some of it rigid in nature, in this field. But there are also large amounts of creativity, and this blend of ingredients appeals to many people looking to enter the broad realm of healthcare.

“What we try to teach our students to do is become a scientist practitioner,” she went on, adding that there is much that goes into that phrase. “Every kid that we work with should go through an analysis to determine why problem behaviors are occurring, and then treatment based on that analysis helps address those behavioral concerns.

“We know that attention and rewards help increase behaviors,” she went on. “So what our students do is take that science side, but then then get really creative and personalize with our kids.”

This ability to be creative is what appeals to Rachel Reyes, currently enrolled in the Elms master’s degree program and working part-time with young people through a company called Positive Behavior Supports Corp. (PBS). She has one client, a 4-year-old with autism she sees three times a week.

“I’m working one-on-one with a child a lot, and that’s what I love most about this work,” she said, adding that she aspires to become a BCBA. “I get to see them grow, I get to see their progress, and I get to know them; I build a relationship with them first so they they’ll trust me.”

For this issue and its focus on healthcare, BusinessWest takes an in-depth look at the ABA offering at Elms. In the course of doing so, we’ll explain why the program, and the careers it can lead to, have attracted people like Clark, Reyes, and many others.

Down to a Science

When asked how she got onto the path to becoming a BCBA, Clark said a single course on applied behavior analysis she was taking during her undergraduate work at the Elms opened her eyes and changed her career focus.

Alyssa Clark

Alyssa Clark, seen here at the Applied Behavior Analysis International Conference in San Diego earlier this year, says there are many rewards from her work as a BCBA.

“I was in the speech language pathology program,” she recalled. “They mentioned applied behavior analysis; that one class really stuck with me. I knew I always wanted to work with this population of kids, whether it was kids on the autism spectrum or kids with disabilities. So I looked into it more and I saw the behavior side of things, and I loved it.”

Reyes tells a somewhat similar story. She was doing undergraduate work at Westfield State University, studying special education. She had come to the conclusion that she didn’t want to teach and took an introductory course in ABA.

“Prior to creation of this program, there was a master’s in autism spectrum disorders, which was also behavior-analytics-focused, but a little more broad. What we found is that most people who are coming into the program are really interested in the behavior-analysis side, so that’s where most of our students are now.”

“The professor was great — when she would teach, everything was amazing,” she recalled. “I thought about things some more, went to her office, and asked if there were any graduate programs in the field, because I realized that this is what I wanted to do. She told me about Elms.”

Hanratty said many of the students now in the ABA program arrive via a somewhat similar experience, and this helps explain the creation of the master’s program, which accepted its first cohort in 2017.

“Prior to creation of this program, there was a master’s in autism spectrum disorders, which was also behavior-analytics-focused, but a little more broad,” she explained. “What we found is that most people who are coming into the program are really interested in the behavior-analysis side, so that’s where most of our students are now.”

Rachel Reyes, a student in the Elms ABA program

Rachel Reyes, a student in the Elms ABA program, says she enjoys working one-on-one with children.

Students enter the program with a wide diversity of backgrounds, she went on, adding that there are many with a psychology or communications sciences background, who took their undergraduate focus on speech disorders and shifted it to behavioral analysis.

But there are others with backgrounds in education, sociology, social work, and other fields.

“We also get some students who earned their bachelor’s degree in … whatever, and then found a passion for working with kids with autism,” she went on, adding that enrollment in the master’s program fluctuates, but it averages about 17. The smaller size of the cohorts — and the classes themselves — appeal to many students because of the one-to-one support from faculty members.

As she mentioned earlier, ABA is a blend of science and creativity that addresses a range of recognized behavioral issues in people of all ages.

“ABA is based on basic science principles,” Hanratty explained. “We take the basic principles of behavior and apply them to promote changes in behavior among children with autism or behavior concerns. Our students get to take that science and apply it.”

Practitioners use reinforcement — giving some kind or reward or positive contingency — for appropriate behaviors, as well as strategies for reducing inappropriate behaviors.

When asked for an example, she cited a research project she worked on with several of her students, including Clark. Together, they gave a presentation on their work at the Applied Behavior Analysis International Conference in San Diego earlier this year, and also at the Berkshire Conference for Behavioral Analysis.

The project involved one young person exhibiting problem behaviors, said Hanratty. “We did an analysis and found that kids were engaging in severe problem behavior usually to gain some control over their environment — they want to take a break from adult-led activities and just have time to do their preferred activities.

“We taught the kids to ask for control, and then we would reward that, with them being able to have ‘their-way’ time,” she went on. “We gradually started saying, ‘you can’t have your way right now; it’s adult time, and you need to do X,Y, and Z.”

Eventually, the students would come to understand that they can’t always have ‘their-way’ time when they asked for it, and would acquiesce to adult-led activities without immediate reward or reinforcement.

Such progress was noteworthy, because these were students who were engaging in severe problem behaviors, said Hanratty, adding that they would (note the past tense), when asked to do an instruction, aggress toward adults and engage in self-injurious behaviors.

“We were making really impactful outcomes for families,” she told BusinessWest. “It was very rewarding work.”

And just one example of how to blend science and creativity, she went on, adding those attracted to this work now have a number of attractive career options.

These include work in school systems and specifically in special-education classrooms, but also, and increasingly, in the home, working with both children and their families. Others open their own private practices or conduct research. With a doctorate, which some go on to attain, they can teach in the field.

Meanwhile, many students, like Reyes, are finding work in the field, or, in this case, the home, as they’re earning their master’s degree.

“I’d love to stay in the home; I love the home setting,” she said, adding that she enjoys working with not only the child, but the family as a whole.

Bottom Line

Such sentiments, such passion for this demanding yet rewarding work, help explain the growth of the ABA field and programs like the one at Elms.

As Hanratty and her students noted repeatedly, applied behavior analysis is indeed an intriguing blend of science and creativity, a rare mix that is gaining the attention of people from diverse backgrounds and putting them onto the path of becoming a BCBA.

And also opening doors to a wide mix of fulfilling careers.

Health Care

Healthy Development

Baystate Health & Wellness Center in Longmeadow held a grand-opening and ribbon-cutting ceremony on Feb. 25. The $11 million, 54,000-square-foot medical office building offers primary and specialty care, as well as services like Baystate Reference Laboratories and Baystate Radiology and Imaging.

State legislators present Baystate leaders, including President and CEO Mark Keroack (center), citations on the grand-opening occasion

State Sen. Eric Lesser and Keroack share a moment before the event

State Sen. Eric Lesser and Keroack share a moment before the event

The ribbon-cutting ceremony

The ribbon-cutting ceremony

Dr. Elizabeth Boyle chats with state Rep. Angelo Puppolo

Dr. Elizabeth Boyle chats with state Rep. Angelo Puppolo

The back entrance to the new facility at 21 Dwight Road

Health Care

Game Plan

By Mark Morris

James Ferry, certified aging life care manager at Coaching Caregivers Inc.

James Ferry, certified aging life care manager at Coaching Caregivers Inc.

Many adults take on the role of caregiver for an aging parent, but few are prepared for what’s actually involved in taking on that all-important assignment.

What starts out as a trip to the grocery store or a ride to the doctor’s office can, and very often does, become overwhelming when the parent has a medical crisis or other event where their needs suddenly change.

“It often begins with a hospitalization,” said James Ferry, who manages Coaching Caregivers Inc. in Northampton. “Let’s say your mom is admitted for a urinary-tract infection. After a short stay at a skilled-nursing facility, your family is told that she can no longer stay home alone.”

If the family is local, he went on, an adult child, usually a daughter, typically tries to be the caregiver. But as she tries to balance her mother’s care needs with holding down a job and taking care of her own family, burnout inevitably sets in.

And that, unfortunately, is the time when many families usually reach out for help.

“They come to me when they’re exasperated,” said Ferry, a certified aging life care manager with more than 25 years of experience and an advanced degree in social work. He sees his role as someone who helps navigate the complexities of elder care to relieve the family’s burden and develop a course of action that provides a quality life for the elder parent.

He’d rather get involved before people become exasperated, but human nature often precludes that from happening. Regardless of when he does get involved, the goal is the same — to come up with a care plan that works for both the elder parent and the caregiver.

It’s an art and a science, he says, that brings many rewards.

The Big Picture

In order to develop a plan, Ferry starts by doing an assessment.

“I’ll visit the elder in their home and ask them to tell me their family story,” he explained. “At the same time, I’m listening for what’s going on emotionally and with their mental processing. Then we might take a tour around the home to see how they maneuver in that environment, how safe it is, and how realistic is it for them to remain in the home.”

After the assessment, Ferry develops a care plan to best meet the elder’s needs. The plan can range from a few basic services on an as-needed basis to a more substantial plan that provides daily services.

Arranging for help with even simple tasks can provide great relief for the family, he added. “There’s a big difference between having nothing and having a person in place for grocery shopping, doctor’s appointments, or just to walk the dog.”

For more intensive needs, Ferry will often recommend a plan that functions like assisted living, but takes place in the person’s home and still allows for family to be involved.

He refers to this type of plan as a “split-shift approach” in which a caregiver arrives in the morning around 8 a.m. to help the elder client with bathing, getting dressed, and eating breakfast. Then the caregiver will make lunch, clean up after lunch, and leave. The client has the afternoon to themselves to watch TV, catch up with friends, or take a nap. The elder can be alone during this time because they will have a lifeline-type device in the event of an emergency.

A second caregiver arrives around 5 p.m. to prepare dinner, do the cleanup afterward, and help get the client get ready for bed.

“With a plan like this, you can cover the whole day with only seven or eight hours of care,” he explained. “This approach is much less expensive than an assisted-living facility and provides a much higher quality of life for the client.”

This type of plan reflects the current trend of ‘aging in place,’ where services that were once provided in a facility are now delivered in the home. In recent years, home-healthcare agencies have seen strong growth because their services can cost much less than an admission to a long-term-care facility. In addition, studies have shown that people enjoy better quality of life when they can stay in their home and follow their own schedule.

In addition to health concerns, caring for an aging parent also involves financial, legal, and other issues. During this time, family dynamics can bring out a whole new level of stress. “If a family member has a resource agenda, such as the parent’s house or some cash, they could potentially subvert a plan of care because they see it as less going to them.”

Ferry’s role in these situations, he explained, is to be a facilitator who helps the family reach common ground and remind everyone of what’s best for their parent.

Age-old Concerns

The need for the services provided by Coaching Caregivers and similar businesses is sure to increase as more people than ever before are living longer in retirement. According to the U.S. Census Bureau, a 65-year-old couple has a 50% chance of one of them living to age 93, and a 20% chance that one of them will reach age 97.

“I work with a lot of people in their 90s who need some help, but clearly do not need a nursing home,” Ferry said, noting that, 25 years ago, far fewer people lived past age 90.

When an aging parent is living a vital and independent life, it’s easy to avoid an elder-care discussion, but he said that’s the time to do it. As difficult as it is to start the conversation with a healthy parent, Ferry said it’s much easier than waiting for a crisis when significant decisions about care must be made under stress.

“When people are desperate for help, they don’t have the capacity to shop around. Instead, they listen to the first person who can offer a solution,” he noted, which may not be in the elder’s best interest.

Ferry counsels people to ask many questions before selecting a caregiver. “Try to get a sense of their reputation. Are they looking out for your parent, or are they steering you to the business they are in?”

There are many professionals who consider themselves care managers, he added, but may represent the interests of an agency or an insurance company. His advice, simply put, is to look for someone who will objectively represent the client’s interests. Once a care plan is in place, he explained, he then takes on the role of ‘consumer advocate’ for the client to make sure they get the services they were promised.

“Professionals like me have no bias for a particular course of action,” he told BusinessWest. “I have relationships with many home-care and assisted-living agencies, as well as other professionals I can recommend. My only interest is what’s best for my individual client.”

Health Care

Lean — But Not Mean

Mark Fulco in the ‘Mission Control’ room at Mercy Medical Center.

Mark Fulco in the ‘Mission Control’ room at Mercy Medical Center.

‘Lean.’ ‘Six Sigma.’ ‘Gemba walks.’ These are terms and phrases, used traditionally on manufacturing shop floors, in relation to continuous improvement initiatives and efforts to take waste out of processes. Today, they’re being heard more in the healthcare realm, and especially at Mercy Medical Center, where efforts are ongoing to improve efficiency without impacting quality of care.

The sign on the door says ‘Mission Control.’

That’s a play on words, obviously. There’s a definite nod to NASA and its famous control room, where decisions were made, and moonshots were choregraphed. But that word ‘mission’ takes on a different, higher meaning at Mercy Medical Center, part of Trinity Health Of New England. The hospital was founded more than 125 years ago by the Sisters of Providence, and its mission to care for the region’s population, and especially those who are traditionally underserved, has been paramount and in most ways more important than the bottom line.

But these days, the mission is being carried out in a different way, said Mark Fulco, president and CEO at Mercy, who recently marked a year at the helm. He noted that, in many ways, the hospital, and the Trinity system on the whole, are taking cues from the auto industry and other business sectors and taking a Six Sigma approach to healthcare — a lean approach, one that manifests itself in a number of ways.

But the major focus is on making the medical center more efficient in ways that will reduce costs without sacrificing quality.

“It’s been a watershed for us, because it has changed our work and has helped us focus on key metrics to drive efficiencies.”

“It’s been a watershed for us, because it has changed our work and has helped us focus on key metrics to drive efficiencies,” said Fulco, adding that the hospital’s efforts to become leaner are reflected in everything from reduced wait times in the ER to an increase in the number of discharges over last year by staffing up more beds; from reducing the overall cost of each discharge by roughly $1,100 to cutting back on travel by using videoconferencing technology.

Overall, Mercy and the Trinity system are eliminating waste whenever possible, creating efficiencies in every department, and constantly looking for ways to improve service without impacting quality of service.

This work extends all the way down to the medical center’s printers and copiers, the number of which has declined noticeably over the past year or so.

“We’ve gone very much paperless,” Fulco explained. “We had two big meetings this morning, and instead of printing out huge packets of information, we did it electronically and on large monitors.

“It’s unbelievable what a color copy costs these days, and when you produce lots of color copies with charts and graphs, it costs a lot of money,” he went on. “So we’ve actually taken printers away and put codes on some of our printers so departments are accounting for every color copy they make.”

This focus on lean practices and accountability brings us back to the room behind the door bearing the sign that says ‘Mission Control’ and its co-called ACE (achieving clinical excellence) boards that track progress in specific areas.

They are part of what is now known as the Trinity Health Management System, or lean daily management, an operating philosophy, if you will, that we’ll explore in greater detail later.

It also brings us to the large conference room, also known as the Patient Safety and Flow Room, a few hundred paces away. Here, each day at 8 a.m. (no one is typically late, because if they are, they have to walk into a room filled with people who were on time), as many as 50 people gather for what are known as ‘huddles.’

These are strategy sessions where issues are discussed, problems are identified, and solutions generated, said Fulco, who offered an example.

“We have several huddles every morning, and one of them is our ‘tier 3 huddle,’ where we bring together leaders from across the entire hospital,” he explained. “The very first thing we talk about is patient safety or problems that came up the night before, or safety catches — like if something was a near-miss — because we want to know, first and foremost, what we need to do to be better and keep patients safer.

“That’s our early-warning system,” he went on. “And at the meeting, if we have a detected infection, we report it, and then we talk about what we can do to prevent another case like that from happening.”

For this issue, BusinessWest looks at Mercy’s broad efforts to employ the principles of Six Sigma and become, in keeping with its mission, lean but certainly not mean, at least in a very literal sense.

Work in Progress

They’re calling it the ‘29-minute pledge.’

That number is significant because of its specificity, meaning it’s not the ‘30-minute pledge,’ a much rounder number to be sure.

It refers to the maximum time it will take for someone visiting Mercy’s Emergency Department to see a physician or physician’s asistant, and this pledge is due to be launched in the coming weeks and announced with billboards and other forms of advertising.

“We’re pledging a door-to-provider time, in our emergency room, of 29 minutes,” Fulco explained, adding that the program has essentially been rolled out already, but the billboards won’t be going up for another few weeks. “We chose 29 minutes because it represents an average of what we can hold out as a pledge; there are times when we’ve averaged 16 minutes.”

The 29-minute pledge is a another example of Mercy’s efforts to improve quality of service while also becoming more efficient and taking cost out of the equation, said Fulco, noting that it is one of many initiatives put in place during what has been a very intriguing and challenging (he would use that word early and quite often, and usually with at least one ‘really’ in front of it) first year at the helm — and year for all those who provide healthcare.

He would sum it all up, sort of, by saying, “I knew what I was getting into — I knew it was challenging; it’s just been more work than I expected — not in a bad way, but in a good way, because it’s been a labor of love.”

What he was getting into is a very demanding climate for not just Mercy but all healthcare providers, one in which reimbursements for services provided, especially from public payers including Medicaid and Medicare, do not really come close to covering the cost of those services.

This disparity is especially large in the broad realm of behavioral health, Fulco noted, adding quickly that, through its facilities at Providence Behavioral Health Hospital, the Trinity Health system is the region’s leading provider of such services.

And these are services that are, from a purely bottom-line perspective, losing propositions, again because the cost of care is not being met by those paying for it. And while Providence and the Trinity system have always been mission-driven, there comes a point where the losses being incurred cannot be sustained, said Fulco, adding that this reality explains why there were inevitable cutbacks at Providence, and in other departments under the Mercy/Trinity umbrella as well.

Mission Control is part of an effort to bring the principles of Six Sigma to Mercy Medical Center.

Mission Control is part of an effort to bring the principles of Six Sigma to Mercy Medical Center.

“We had to make some tough decisions — the status quo simply doesn’t work,” he explained, adding that among these decisions were staffing reductions at Providence (most employees were offered other positions within the system) and cutbacks within or elimination of some departments at Mercy, including the Hearing Center.

While the cutbacks and staff reductions garnered the largest headlines regarding the Mercy system in 2018, a considerable amount of work going on behind the scenes to make the system more efficient, more responsive, and, yes, leaner — efforts like the 29-minute pledge — were perhaps more newsworthy.

As he talked about them, Fulco said these initiatives accurately reflect a system-wide operating philosophy being implemented by Trinity Health Of New England’s recently appointed CEO, Dr. Reginald Eddy, a former emergency-room physician.

“He really gets it,” said Fulco. “He gets it from a care perspective, and he has a strong sense of urgency that he’s really instilled in us in terms of doing it right, doing it well, and doing it quick, not just from a patient perspective, but from a business sense.”

Tracking Improvement

As he talked about the Trinity Health Management System, Fulco said it is focused on quality metrics, or what he called ‘people-centered metrics,’ which are carefully monitored with an eye toward continuous improvement.

As an example, he cited the infection rate, a key issue — and major challenge — for all hospitals.

“Our infection rate has remained below target and below what’s expected for a hospital like Mercy, and is, in fact, one of the 20 lowest infection rates across all the 94 or 95 Trinity hospitals,” he said, using infections from urinary catheters as an example of how Mercy tracks issues and addresses problems.

“Our goal is to be an ‘A,’ and we’re not stopping until we get there, and then we have to stay there, which becomes progressively more difficult.”

Steps such as these have a trackable impact on quality, as measured in a number of ways and by a number of entities, said Fulco, noting that Mercy’s Leapfrog score — its rating based on surveys undertaken by the Washington, D.C.-based Leapfrog Group, improved from ‘C’ to ‘B’ in 2018.

“Our goal is to be an ‘A,’ and we’re not stopping until we get there, and then we have to stay there, which becomes progressively more difficult,” he explained. “But we’ve improved by one whole grade, which is a significant step forward.”

But while quality is certainly an important benchmark, so too is cost, said Fulco, adding that the ultimate goal is to not only improve the overall level of quality but reduce the cost of providing care as well.

“On the cost side, because we’ve been more efficient and we’ve tried to tease out unnecessary expense — and there are several buckets of expense, from labor to non-labor — we have reduced the cost per case by more than $1,100 from last November [2017] to this November,” he said. “And when you multiply that by the 1,400 or so discharges we had, that’s a savings of more than $1.5 million.”

With that, he went to his desk to retrieve the current average cost per discharge, $6,850, a number he had handy, and for a reason — it is carefully tracked, and its downward movement is a source of pride within the system.

It’s been accomplished through a number of means, he said, starting with staffing changes (none at the bedside) that result from consolidation in some areas, such as billing, that are made possible by synergies with the regional Trinity team, thus reducing overhead costs.

Further savings have been achieved on supplies, he said, returning to efforts to go paperless when possible, and also such things as travel expenses.

“We work with people; if they’re printing too much, we take steps to reduce that volume,” he said. “It doesn’t sound like much, but it adds up when you’re saving 50 cents or 75 cents on a print; it adds up over time. And it doesn’t contribute anything to patient care, so we’d rather put the money into patient care than into paper.”

As for travel, it has been cut back as well, he said, noting that meetings between the Mercy team and the system team are now staged electronically. “Instead of having our people drive to Hartford or their people drive here, we’re using technology,” he told BusinessWest.

Huddling Up

As he offered a tour of the Mission Control room, Fulco started by referencing several large charts, called A3 charts, on the wall. Each one outlines an individual’s primary strategic aims, and they are part of the hospital’s lean daily management system.

“An A3 is putting our key objectives and measures all on one page,” he said, referencing his own A3, while noting that the charts track progress toward meeting those specific aims and goals, as laid out in an action plan. “We track this every week; we look at this every week. Every member of the leadership team has one of these.”

And when problems arise at those huddles, as he noted several times, everything is measured.

That goes for efforts to address recognized problems or issues as well, he went on, referring to other charts and the four letters ‘P,’ ‘D,’ ‘C,’ and ‘A,’ which stand for ‘plan,’ ‘do,’ ‘check,’ and ‘act,’ the four stages of tackling a problem, as Fulco identified them.

“This is flowing constantly; it’s changing every day,” he said, adding that the PDCA cycle, as it’s called, was created to generate action on a specific matter and keep things moving.

From Mission Control, the tour moved to the Patient Safety and Flow Room, where there was a comparatively small huddle going on (this was late afternoon). For the 8 a.m. huddles, those assembled have an agenda and start with safety, and move on to a daily operating summary and then performance reports — how well the hospital is doing with patient satisfaction, for example. Next is a round-robin session, at which feedback is sought on problems that have been identified.

But the tier 3 huddle is actually the second step in the process, said Fulco, noting that there are huddles on the departmental level as well. Matters arising at those sessions then come before the larger group, and there is then a Gemba walk. That’s a Japanese term that translates, loosely, into going to the front lines to see what’s going on, to hear from the people involved and come to understand the problem; it is similar in many ways to the concept known as MBWA — managing by walking around.

“A Gemba walk is daily rounding — we’re not sitting in our office or around a conference-room table; where going to see things where they really happen. We’re talking to people who are doing the work, and we’re doing some accountability checks,” said Fulco. “From 8:30 to 9:30 we take that walk, and from there we go to the Mission Control room and do an accountability huddle.

“It’s about getting close to the people,” he went on, “and finding out how we, as leaders, can help them.”

To emphasize these points, he concluded the tour in the Emergency Department, where are charts similar to those in both Mission Control and the Patient Safety and Flow Room.

They track things like wait times and numbers of patients who left without being seen — presumably because the wait times were too long — said Fulco, adding that subsequent huddles and PDCA charts identified the causes of those problems and tracked the success of steps taken to address them.

Healthy Outlook

Gemba walks. PDCA cycles. Huddles. A Mission Control room. These names, acronyms, and places all help explain how, while the mission hasn’t changed at Mercy Medical Center and Trinity Health Of New England, the process of carrying out that mission certainly has.

The emphasis today is on continuous improvement and being lean — without impacting the quality of care being provided at the bedside. As Fulco said repeatedly, in this environment, everything is measured, or charted, and progress is marked daily.

There is considerable work still to be done — this process never actually ends, he said — but progress can be seen in the ER, on the bottom line, and on the charts in the Patient Safety and Flow Room.

It could be seen as paper as well — only they’re using much less of it these days. That’s just part of the process of running lean.

George O’Brien can be reached at [email protected]

Health Care

A Widening Problem

Steve Conca says it can be difficult for people to ask for help losing weight and getting fit, especially if they’re discouraged by all the attempts that didn’t work.

Steve Conca says it can be difficult for people to ask for help losing weight and getting fit, especially if they’re discouraged by all the attempts that didn’t work.

It’s gratifying, Steve Conca said, when people ask for help managing their weight — especially if nothing has worked before.

“When people come to us, they have a laundry list, and sometimes we’ll even write it on the whiteboard — ‘tell me all the stuff you’ve tried that didn’t work,’” said Conca, who owns Conca Sport and Fitness in West Springfield.

“They go on and on about different things, whether it’s a training method or a diet — you name it, they’ve tried it, and it didn’t work. And we draw the line and say, ‘we don’t to be the next thing on that list of 15 things that didn’t work. It stops right here.’”

But that’s easier said than done, he told BusinessWest, because weight loss is more than a numbers game — even when the numbers seem so overwhelming.

“It’s a lifestyle change. It’s mindset, it’s accountability, it’s exercising the right way. It’s eating healthy again and not just counting points. You’ve got to take it one step at a time and get your mind right.”

“It’s a lifestyle change. It’s mindset, it’s accountability, it’s exercising the right way. It’s eating healthy again and not just counting points,” he said. “You’ve got to take it one step at a time and get your mind right — and make sure the effort and exercise you’re going to put in are designed for you specifically, and will work for your body and your metabolism.”

Even people who lose weight, whether through traditional diet and exercise or surgery, often have trouble in the months and years following their initial success, said Dr. Yannis Raftopoulos, director of the Weight Management Program at Holyoke Medical Center.

“The challenge is, how do they maintain this weight in the long run?” he said. “Most practices today aren’t looking to change the person. That’s what we do here, and we have a higher success rate and a better chance to maintain the weight loss. But that’s hard to do. We have seen great successes, but it’s labor-intensive, time-consuming, and a lot of resources are needed.”

And it starts with a decision to take that first step, Conca noted.

“When someone calls and says they need help, that’s a vunerable position they put themselves in. When they come in and sit down, that’s one more big step that can also be another vulnerable spot,” he said. “We take that very seriously that you’re looking to trust us with your health, fitness, and well-being. That’s a huge responsibility, and we take it seriously.”

Wrong Direction

It’s an important responsibility, too, in a country that’s been going in the wrong direction, fitness-wise.

“There’s something that’s dramatically not right,” Conca said. “As a people, we’re getting less active, and we’re eating a much poorer grade of food than we did 20 or 30 years ago.”

Those trends are starting at an early age. According to the latest data from the National Health and Nutrition Examination Survey, produced by the Centers for Disease Control and Prevention (CDC), the percentage of children ages 2 to 19 who are obese increased from 14% in 1999 to 18.5% in 2015 and 1016. In the Pioneer Valley, 25% of children are considered obese.

Dr. Yannis Raftopoulos says treatments for obesity are myriad, and crafted on a patient-by-patient basis.

Dr. Yannis Raftopoulos says treatments for obesity are myriad, and crafted on a patient-by-patient basis.

“That means they have a body-mass index that puts them at increased risk as they enter adulthood for diabetes, high cholesterol, heart disease, gallbladder disease, asthma, and bone and joint problems. Already, we are seeing more and more youngsters developing type II diabetes, which is commonly developed by overweight adults,” said Dr. Chrystal Wittcopp, medical director of Baystate General Pediatrics, who oversees the Pediatric Weight Management Program at Baystate Children’s Hospital.

“The growing rate of childhood obesity in our country is alarming. Being overweight poses a serious threat to the health of America’s children, and as a society, we must make a concerted effort to decrease its prevalence not only in the Springfield area, but across the country,” she added, noting that obesity carries psychosocial consequences that can also hinder these children academically and socially.

Of even greater concern, there was a large increase in obesity — up to 14% from 9% — in the youngest population of those 2 to 5 years of age.

“My philosophy is, I try to change the patient’s lifestyle. If you want any chance to be successful, you have to change the logistics, how they operate every day.”

Conca sees it, too. “Overall, kids are moving not as efficiently as they were years ago. When we were growing up, kids were outside crawling, jumping, running around, and their bodies developed much differently than the kids now if they’re not forced into a structured activity. Instead, many of them are glued to a phone or a tablet. It’s a generational thing, and we’re seeing it not only on the activity level but the nutrition level as well. Kids don’t appreciate their bodies as much as they should because things like exercise and sleep and nutrition aren’t talked about.”

He recalled talking to an older woman whose infant grandchild’s first word was ‘Dunkin’ Donuts’ — which isn’t as odd as it sounds because the child’s parents were always making fast-food runs.

“She’s distraight about it because it’s not the way she wants her grandkids to be raised, but it’s something that, culturally, a lot of kids are embedded in. And they’re so impressionable at that age.”

When parents choose to eat right and be physically active, Wittcopp added, children are more likely to take note and make those same healthy choices. She said families could encourage each other by walking around the neighborhood together, going on a bike ride, or playing basketball at the park, while limiting time spent in front of the TV and video games, and cooking healthy meals with fresh vegetables, fruits, and whole grains.

“The severe consequences of obesity underscore the critical importance of children and teens to participate in physical activity and to engage in healthy eating habits,” she noted. “Childhood obesity is entirely preventable, and it is up to adults to encourage these healthy habits.”

Plenty of Options

For individuals who are well past those foundational years and frustrated by an inability to get fit, there are plenty of treatment options, Raftopoulos said.

“There are different levels of obesity, and different methods are available based on that,” he told BusinessWest. “For someone mild obesity, surgical options are usually not recommended, though there are some exceptions to that.”

Less drastic options range from classic diet and exercise to medications that restrict appetite, although Raftopoulos isn’t personally keen on those, as they can be expensive, come with side effects, and are not a long-term solution.

“My philosophy is, I try to change the patient’s lifestyle. If you want any chance to be successful, you have to change the logistics, how they operate every day.”

A more dramatic, yet still non-surgical, option is a gastric balloon that is swallowed, inflates, and suppresses the appetite until it’s removed after a few months. Holyoke Medical Center is currently involved in a clinical trial of a more advanced balloon that needs no endoscopic removal, but rather passes into the stool after it deflates.

Then there are the surgical options, specifically gastric bypass and sleeve gastrectomy, both of which drastically reduce the size of the stomach. But, no matter how effective a treatment is, whether surgical or non-surgical, patients face the same challenges afterward.

“Surgery will reduce the portion of the stomach and how much you can eat, but you can gain weight even with a small stomach,” Raftopoulos said. “If surgeons don’t provide the support to change the fundamentals of the patient — if they don’t help you change how you live your life — nothing will be very effective, and you can gain the weight back.”

For people who have struggled with obesity, he noted, there’s a psychological component to maintaining a healthy weight, and one that can be frayed by the stresses of everyday life, from work schedules to parenting obligations to caring for sick parents. That’s why his team works with patients on managing their entire lifestyle — through education and support services — to stay on the right path.

“The problem with how medicine is done today is not seeing the patients holistically,” he said. “Everybody is focused on one thing — ‘oh, your ear hurts? Let’s fix the ear.’ But the ear is connected to something else. And that fragmented mentality affects the patient’s results.”

But when something clicks, Raftopoulis gets excited — not just for that one patient, but for others who may be inspired by their example.

“The more practices do this the right way, and the better results they have, the more people will believe we can help them,” he said. “We need to have more practices do the right thing because there’s a great need.”

Reaping the Rewards

Conca understands the frustration of trying to make a change, and, after a few weeks of poor results, becoming discouraged.

“What they’re doing isn’t working, and after a few weeks, they’re tired and frustrated, and they quit again. Rightly so — if you’re doing something and not getting results, you’re going to stop doing it,” he said.

That’s why he touts his practice’s ‘Fit in 42’ program, an immersive, six-week experience that aims to change not just the number on a scale, but a mindset, through both serious exercise and an emphasis on accountability through activities like daily journaling and connecting with other members, both at the gym and on a private Facebook page.

“That sense of community and connection is so powerful — it’s more powerful than anything we could throw at them exercise-wise,” he went on. “So we have the community component, plus training that works, plus nutrition — there’s no diet, you’re just going to eat good, healthy foods for your body type — and then you see results. We have to show them results.”

It’s a great feeling, he said, when someone trusts him to make a change when nothing has worked before.

“When someone comes in, they have to have a why. From a business perspective, we try to preach that as well. Why are we doing what we’re doing?” he said, before answering his own question.

“People come in, and they’re down in the dumps and just throwing in the towel, saying, ‘I just want to play catch and not hurt, or just roll around on the ground with my kids.’ And it’s really cool to give somebody that. It’s really rewarding.”

Joseph Bednar can be reached at [email protected]

Health Care

The Eyes Have It

Dr. Camille Guzek-Latka

Dr. Camille Guzek-Latka shows a patient an image of her eye and any signs of disease that might be present.

When people think of diabetes, they might think of complications like cardiac disease, but they may not consider what elevated blood-sugar levels can do to their eyes over time. In truth, regular vision exams are a must for diabetics, who are at higher risk of certain conditions, including diabetic retinopathy, that can seriously damage one’s vision. Like diabetes itself, the key to minimizing the risk is often simply diligent lifestyle management.

It’s no secret that diabetes is a growing problem in the U.S., with more than 30 million Americans suffering from this condition that affects blood-sugar levels and leads to a host of complications, from heart disease and stroke to kidney disease, foot ulcers, and eye damage.

It’s that last one that often catches people off guard, said Dr. David Momnie of Chicopee Eyecare.

“A few red flags do go up when we examine patients with diabetes,” he said, explaining that a diabetic eye exam always includes a careful examination of the retina through a dilated pupil, looking for a condition known as diabetic retinopathy (more on that later).

“We also carefully examine the iris for tiny vessels that don’t belong there. We call this condition neovascularization. And we also also look for changes in the lens of the eye, called cataract, and for signs of glaucoma, as both of these conditions occur more frequently in people with diabetes.”

According to the American Diabetes Assoc., about one-fourth of people with diabetes are undiagnosed, which is problematic on many levels, one of which is that diabetics need to have their eyes checked more often — at least once a year — than the general population.

“What’s alarming to us is seeing more young adults and people in their 20s and 30s with type 2 diabetes. The culprit is invariably weight. It’s a global phenomenon as people are spending more time indoors and less time being physically active.”

And, as noted, it’s a condition that’s becoming more prevalent. In Massachusetts alone, diabetes incidence has risen from 3.9% of all residents 25 years ago to about 9% today.

The day BusinessWest visited Chicopee Eyecare early in the afternoon, Dr. Camille Guzek-Latka said she had already seen four patients that day with diabetes — unsurprising because, as a practice that has been around for decades, many patients are older.

“People are living longer, so it’s not surprising to see more people in their 70s, 80s and even 90s diagnosed with diabetes,” Momnie said. “But what’s alarming to us is seeing more young adults and people in their 20s and 30s with type 2 diabetes. The culprit is invariably weight. It’s a global phenomenon as people are spending more time indoors and less time being physically active.”

Yet, not all overweight people develop diabetes, he added, so there are obviously other factors involved — in some cases, there are genetic reasons why the beta cells of the pancreas stop producing enough insulin.

Dr. David Momnie says a key part of seeing diabetic patients is educating them about lifestyle factors that go into their eye health.

Dr. David Momnie says a key part of seeing diabetic patients is educating them about lifestyle factors that go into their eye health.

“Since the likelihood of developing complications of diabetes like cardiovascular, kidney, and eye problems increase over time,” he added, “young people developing diabetes are more likely to have these problems down the road.”

But with early detection, Guzek-Latka said, patients have a good chance of holding off many of the complications, including eye damage, because they can get a head start on controlling their blood sugar with medications and lifestyle changes.

“We tend to spend a little more time with our diabetic patients,” Momnie added, “because we need to have a frank discussion about lifestyle changes like weight control, a well-balanced diet, and quitting smoking.”

I Can’t See Clearly Now

When diabetes does cause eye damage, it’s often in the form of a disease called diabetic retinopathy, which is caused when too much sugar circulating in the blood damages the tiny retinal blood vessels in the retina, which is like the film of a camera.

“Elevated glucose levels cause damage to blood vessels. The most vulnerable vessels, the ones that show the earliest damage, are the smallest ones that lie farthest from the heart, such as those that supply the fingers, toes, kidneys, and eyes,” said Dr. Andrew Lam, an ophthalmologist at New England Retina Consultants, as well as an attending surgeon at Baystate Medical Center.

Diabetic retinopathy, he explained, is the leading cause of blindness in adults aged 20 to 74. “Treating this condition can be one of the most fulfilling, and frustrating, conditions that a retinal specialist encounters.”

“Elevated glucose levels cause damage to blood vessels. The most vulnerable vessels, the ones that show the earliest damage, are the smallest ones that lie farthest from the heart, such as those that supply the fingers, toes, kidneys, and eyes.”

The two most common eye problems that result from diabetic retinopathy are vitreous hemorrhage and macular edema. Vitreous hemorrhage, or bleeding in the eye, typically results from the formation of neovascular blood vessels in the retina.

“The growth of these vessels is actually the eye’s natural response to the lack of normal blood supply in diabetic eyes, but they are bad because they are apt to leak and bleed,” Lam said, noting that doctors can try to stop the proliferation of neovascular vessels with a laser treatment, and sometimes with injections of a medicine called Avastin.

“But when major bleeding in the eye does occur, it can severely affect a patient’s vision — sometimes taking away almost all the vision,” he went on. “The good news is that our techniques performing vitrectomy surgery to remove the blood are very good, and some of our most grateful patients are those whose vision has been restored after a vitreous hemorrhage has been cleared.”

Diabetic macular edema can be a more frustrating condition to treat, Lam said. This occurs from leaking blood vessels causing swelling in the macula of the eye, the part of the retina responsible for detailed central vision. This in turn causes vision loss and distortion.

Dr. Andrew Lam says diabetic retinopathy is the leading cause of blindness in adults aged 20 to 74 — and it’s increasing in prevalence.

Dr. Andrew Lam says diabetic retinopathy is the leading cause of blindness in adults aged 20 to 74 — and it’s increasing in prevalence.

“If we can reduce or eliminate the edema, the patient’s vision often improves, but this is sometimes hard to do,” he explained, noting that weapons in the battle can include eye injections with medicines such as Avastin, Eylea, or steroids, or even laser treatments.

“But the problem is that these treatments don’t always work that well, or for very long,” he went on. “Some patients respond quickly and do well, but others have persistent macular edema and blurry vision, even after repeated treatments.”

Guzek-Latka noted that 7.7 million people in the U.S. had diabetic retinopathy in 2010, a number projected to double to 14.6 million by 2050. Because diabetic retinopathy is progressive and does not cause symptoms until vision loss occurs, she stressed that annual exams are recommended, with more frequent follow-ups if retinopathy is detected. Her practice sends reports on ocular health to the patient’s primary-care physician and schedules appointments with a retinal specialist, like Lam, when necessary.

“One of our problems is that we cannot cure the underlying disease: diabetes,” Lam said. “Still, we fight diabetic retinopathy as diligently and as well as we can. I tell my patients to consider this a life-long battle that requires constant vigilance and sometimes many treatments over time. They must also strive to maintain the best blood-sugar control they can.”

Indeed, he noted, diabetic retinopathy can be managed — and sometimes vision loss can be regained — with treatments, but there is no cure because there is no cure for diabetes itself.

“Early detection, monitoring, and treatment of diabetic retinopathy certainly improve the chance that a patient will enjoy good vision throughout their lifetime,” he continued. “It is important that all diabetics have at least an annual eye exam to detect early signs of retinopathy before it becomes vision-threatening.”

Momnie and his team often use a digital retinal camera to take a picture of any diabetic retinopathy that they find, especially if it’s progressing — and not just because it’s beneficial to them in diagnosing and treating it.

“We also want to get the patient involved in managing their diabetes,” he said. “Seeing the actual damage to their retina is often an incentive to better manage their blood sugars.”

Guzek-Latka agreed. “I find it helpful to show people these pictures because, if you show a person a picture of what’s going on for them, it’s like night and day. It’s a powerful tool not only to document what they’ve got, but to educate them.”

Another instrument for tracking people with diabetic retinopathy is an OCT, which stands for optical coherence tomography, which is a scan that produces a cross-section image of the retina, so they can tell if there is any macular edema. “Any time a diabetic patient has reduced vision, we need to rule out diabetic macular edema, and the OCT gives us that information.”

Early Detection Is Key

Lam said there are many other possible manifestations of diabetes in the eye, including cataracts, neovascular glaucoma, tractional retinal detachment, and optic nerve swelling. These are treated in various ways, sometimes surgically. As the only retina practice in Western Mass., he noted, New England Retina Consultants sees many patients with diabetic retinopathy every day.

Momnie stressed that diabetic eye conditions don’t always present with dramatic symptoms at first. “There are some potentially blinding eye conditions that can develop in people with diabetes without symptoms like blurred vision. And yet, these conditions are treatable if caught early enough.”

Tight blood-glucose control is the key to significantly reducing the incidence and severity of diabetic eye disease, he went on, adding that people with diabetes should discuss with their primary-care physician how to keep their levels in an acceptable range.

Like diabetes itself, some people are at increased risk for developing diabetic eye disease, including women with diabetes who are pregnant, people who have had diabetes for a long time, and cigarette smokers those who simply don’t have their blood sugars under control. African-Americans and Hispanics are also at a greater risk of developing diabetic retinopathy.

Eye appointments for diabetic patients can run slightly over the expected time, Momnie told BusinessWest, but it’s not the exam itself that takes longer. “It’s the time we spend talking to the patient at the end of the exam. We want to discuss prevention with lifestyle changes and the importance of knowing certain numbers like their hemoglobin A1C.”

The A1C is a three-month average of a diabetic’s blood sugar; a reading between 5.7 and 6.4 typically indicates prediabetes, and higher indicates diabetes. “We don’t like to see it above 7.0,” Momnie said. “Generally, the lower the A1C, the better.”

As part of lifestyle changes, Momnie discusses with patients what is known as the glycemic index of carbohydrates, which ranks carb-laden foods by how quickly they break down into simple sugars in the body. Carbohydrates with a lower glycemic index, like oatmeal and whole-wheat pasta, take longer to break down, and are better than foods like potatoes and bread, which have a higher glycemic index. It’s all part of a series of decisions diabetics need to make, he said, to keep their numbers down and complications — like eye damage — at bay.

“Early detection, optimal glucose control, appropriate follow-up care, and timely treatment of diabetic eye disease are key to guarding against loss of vision,” Guzek-Latka said, adding that, occasionally, she will look at someone’s eyes and detect diabetic retinopathy, and then begin asking about other symptoms, and it turns out the patient wasn’t aware they were diabetic. Once they know, however, they can do something about it.

“If you know, you have so much control over what you can do,” she said. “But there are so many people that don’t know they have it that are walking around. If we can catch some of those and steer them in the right direction, that’s a big deal for that individual.”

Joseph Bednar can be reached at [email protected]

Health Care

In the Club

Adam Malmborg says kids don’t usually enjoy going to the dentist

Adam Malmborg says kids don’t usually enjoy going to the dentist, but he’d like to make the experience a little more fun.

Going to the dentist may never rise to the level of fun for most kids, but one local practice is making it a little more enjoyable, by using a point system and prizes to motivate young patients to take care of their teeth — and improve their lives in other ways as well.

Adam Malmborg was a teacher before his current role at Flagship Dental in Longmeadow, so he knows a little something about motivating kids.

“I love working with kids,” said Malmborg, the practice’s hygiene coordinator and marketing assistant, whose mother, Katie, is Flagship’s practice manager and marketing manager. “She wanted a kids club — something to get kids more interested in coming.”

So he did some research — lots of it, in fact — into what dental practices around the country were doing to motivate their young patients to get serious about their dental health — a topic that many, understandably, aren’t that enthusiastic about.

“I used to be a teacher, so I know what kids like,” he told BusinessWest. “Basically, what I created is a points system; they can earn points here in the office, at home, and even at school.”

Indeed, the Flagship Dental Young Explorers Club, as the new program is called, assigns point values to dozens of achievements, from losing a baby tooth (five points) to scoring a cavity-free visit (25 points) to coordinating a dental presentation at their school (a whopping 500 points). Every 50 points wins a $5 gift card from a store or restaurant chain of their choice.

“It helps them get excited about coming to the dentist, because I know a lot of kids are afraid to come to the dentist,” Malmborg said. “I was, too. I hated coming to the dentist. Any type of medical office, I hated even the smell of it.”

His mother, who has worked in dental offices for more than 40 years, notices the difference in attitude.

“They’re happy to come to the office, and that doesn’t always happen. It’s a good little reward for them,” Katie said. “I do the marketing for the office, but Adam has taken on the job of getting kids invested in their dental treatment and getting them motivated. They can earn points for coming in, for their report cards, and for things they can do in the community as well. It’s pretty cool.”

Since the program began in March, a few participants have already scored enough points to win a gift card — the options range from Starbucks, Red Robin, Subway, and Dunkin’ Donuts to Walmart, Target, Amazon, GameStop, and many others — while others have banked their points in a quest for a bigger reward. Either way, Malmborg said, they’re having fun making healthy choices.

“I remember being younger, and it’s like, what do I get for having great teeth?” he asked. “Really, nothing. I get a pat on the back and a new toothbrush. My mother was huge on dental care, so she was like, ‘good job, congratulations.’ But coming from a dental office, that ‘congratulations, you’ve worked really hard, we want to reward you’ makes a bigger impression.”

How It Works

Members of the Young Explorers Club are given a membership card — showing it at an appointment earns two points — and a colorful badge; wearing this to the office earns five points, and uploading a photo onto social media wearing the button at school picks up another 10.

Being on time for an appointment is worth five points, a dental cleaning earns 10 points, X-rays get 15, and, as noted earlier, a cavity-free visit earns 25. “That pushes a lot of the kids to brush their teeth and floss,” Malmborg said.

And good works outside of school are rewarded, too, such as an A grade on a report card (two points), straight As (15 points), celebrating a personal achievement by sending Flagship a photo (15 points; one patient recently snapped a picture of her new puppy), and volunteering for community service (five points per hour). And those are just the tip of the iceberg.

“I just want to show the kids we’re supporting them,” Malmborg said of the community and school aspects of the program, adding that anything that gets children thinking about the dentist in a positive way, even peripherally, is a plus.

Some Tips to Ease
a Child’s Dental Visit

Are your kids reluctant to visit the dentist? The American Dental Assoc. recommends the following tips to make the experience less like — well, pulling teeth.

• Plan ahead. “If families want to avoid the rush to go back to school in August,” said ADA spokesperson Dr. Mary Hayes, “then plan on getting appointments for the beginning of the summer.”

• Encourage age-appropriate dental habits at home. To make cleanings easier, parents should encourage their kids to brush twice a day for two minutes and floss once a day.

• Timing is everything. Avoid cramming in a dentist appointment right after school or camp. “If the child has already been exhausted or had a bad day or had tests, they just don’t have the stamina to make it through the appointment successfully,” Hayes said.

• Make one child a model. If you’ve scheduled back-to-back appointments for your children, there’s a simple way to decide who goes first: choose the child who’s had the most positive experiences at the dentist. “You generally want the ones first who are more successful because the others get to see how it goes,” Hayes said.

• Hungry doesn’t equal happy
. Feed your child a light meal before the appointment. “Hungry people are grouchy people. You want them to be comfortable,” Hayes said. Oh, and bonus points if your child brushes before an appointment. That’s just polite.

• Leave your anxiety at the door. If your heart races at the very thought of the dentist, your child can probably tell. “Kids pick up on parents’ anxiety,” Hayes said. “It’s important with kids, especially at 4, 5 and 6, because I believe the phobic adults are the ones who had bad experiences when they were that age.”

• Keep cool if your child won’t cooperate
. If your child gets upset during her visit, the worst thing you can do is swoop them out of the chair and leave. “The next visit is going to be harder. You still have to help them get through part of the visit,” Hayes said. “Give the dentist every opportunity to turn the visit around.”

He’s not done adding to the reward list, he noted; for example, he intends to add points for getting a cavity filled. The rationale? The cavity may not have been an ‘achievement’ worth celebrating, but doing something about it certainly is. “I’m just trying to give the kids more chances at points.”

During each visit, the hygienist fills out a report card based on the child’s account of school and home activities, which is used to add points to his or her total. The patient also gets a second report card, this one based on the results of the cleaning.

“Parents can take this home and have a discussion with their kids — ‘oh, I see you have moderate amounts of tartar or plaque. OK, what do you think we can do better?’” Malmborg noted. “It’s all about the communication at home between the parents and kids. It’s the same as a school report card — it’s important that parents have something to go by.”

Speaking of school, the reason coordinating a dental presentation at a school is worth so many points is because it’s an opportunity to spread these messages about proper dental hygiene to as many kids as possible.

“When we meet with the kids at school, we give kids the tools they need to properly take care of their teeth, because some kids don’t have that — they don’t know what to do, or some parents might not be focused as much on it. That’s why we go in and do that.”

Something to Chew On

The Young Explorers Club is a significant aspect of a shift at Flagship to attract more families with children — a change that’s evident just walking into the waiting room, which features a tepee to climb in, a brightly lit fishtank, an interactive selfie station, and pencil-and-crayon activities lining the walls.

“Our patients are primarily older people, and we did the waiting room with the kids in mind,” Malmborg said. “I don’t want to say they have fun going to the dentist, but we want to get kids excited.”

The activities — word searches, coloring contests, and other brain games — earn three points each, and kids are allowed to do three per visit. “It just gets them doing something in the office, because sometimes in the waiting room, anxiety happens, so as long as folks are doing something fun, they’re not as nervous.”

So far, he told BusinessWest, the points program and other kid-friendly touches are working and getting children thinking more about their dental health.

“They come in, proudly wearing their button and showing their membership card. They’re like, ‘Mr. Adam, I did this.’ I say, ‘don’t worry, I’ve got your points.’ We’ve had a couple of kids turn in their points for gift cards, and they’re already ready for their next one.”

As a program that’s fun for the younger set and keeps them focused on good decisions, Malmborg thinks Flagship has settled on a winner. And he’s glad it’s simple to manage, because, while he’s seen other practices outsource a similar program, that isn’t his style.

“It’s a lot of fun,” he said. “It’s more personable when we can communicate with the kids. This way, they’re not getting rewarded by an outside company; they’re getting it from someone they know.”

Joseph Bednar can be reached at [email protected]

Health Care

Recovery Mission

Michael, a three-time resident of Goodwin House

Michael, a three-time resident of Goodwin House, feels he has finally found the strength and resolve to stay on the path to recovery.

Chantal Silloway started using substances at age 12 and eventually battled her way to sobriety at 25; she’s been clean for 32 years. With her background, she knows full well that no two people take the same path to substance use, and likewise, no two take the same path to recovery. This is the mindset, and operating philosophy, she brings to her role as director of the Goodwin House in Chicopee, a place where young men try to piece their lives back together.

Michael (policy allows use of his first name only) remembers that not long after his family moved while he was in middle school, he started “looking up to the wrong people.”

This was a development that would have consequences he says he couldn’t have foreseen.

He told BusinessWest that his descent into substance abuse began when he started drinking with these individuals and smoking some weed, as he put it. Things would only escalate from there.

“I started doing percocets and slowly became addicted to those,” he recalled. “Then I couldn’t afford them anymore, so I was introduced to heroin, and soon developed a real problem … I wasn’t feeling good when I wasn’t using it, and when I was using it, I felt fine.

“I hated life. It was like … I wasn’t even enjoying the fact that I was super young and had so much to look forward to. I didn’t really care anymore, because all I needed was that drug.”

“Eventually, I turned over to the needle, and once I started shooting it, it became a whole different ballgame,” he went on. “It became my life — that became my top priority every day. I eventually spiraled out of control; I dropped out of high school, I started stealing from friends, family … anything I could do to get that fix.”

Michael was offering these flashbacks while sitting down with BusinessWest on the front porch of Goodwin House, a large home on Fairview Avenue in Chicopee. This unique facility, the only one of its kind in the Commonwealth, is a 90-day program providing substance-abuse treatment for males ages 13-17, operated by the Center for Human Development (CHD). Michael says he feels at home here, and he should; this is his third stint here and also his last.

He’ll be aging out of the program soon, but, more importantly, he feels he has, through the help of those at Goodwin House, found the strength and resolve to stay on the path to recovery, with his next stop hopefully being a so-called ‘sober house’ for individuals over 18.

“This is a great success story — we’re very excited for him,” said Chantal Silloway, program director at Goodwin House and someone who can, like many in positions like hers, speak from experience when it comes to substance abuse and recovery.

“I started using substances starting at age 12, and became clean at age 25; I’ve been sober for 32 years,” said Silloway, who has worked for CHD since 2004 in various capacities involving substance-abuse programs. “It’s long been my goal to lead a program like this one.”

With her background, Silloway knows that no two people take the same path to substance use, and, likewise, none take the same path to recovery. Thus, this 90-day residential recovery program focuses on the uniqueness of each young man that arrives at its door, with a view to self-empowerment and the future they choose.

Chantal Silloway says no two people take the same path to substance abuse, or to recovery.

Chantal Silloway says no two people take the same path to substance abuse, or to recovery.

Elaborating, she said that young men are referred to Goodwin House from a variety of sources, including detox facilities, hospitals, the Department of Children & Families, the Department of Youth Services, and parents and guardians themselves. But where they were referred from is not really important, she said. What is, however, is that they arrive with a willingness to help themselves.

Without that, recovery is simply not attainable, she went on, adding that Michael is a good example of this, as we’ll see, and also an example of why many residents make return visits to this facility.

At Goodwin House, a team of clinicians and recovery specialists use evidence-based programs to help residents find and maintain sobriety. Treatment programs include assessment and treatment planning, individual and group therapy, recovery school and/or educational tutoring, vocational and employment-search assistance, recovery meetings, and after-care services and resources.

Often, said Silloway, the path to recovery means getting family members deeply involved in the process, so there is a family-therapy program as well.

Success at this facility is measured in different ways, she went on, adding that while residents do “graduate” from this program and there is a ceremony to commemorate that, there are other milestones, such as ongoing care, accomplishing specific goals that residents have set, and simply becoming ‘stabilized,’ a significant goal in itself.

For this issue, BusinessWest paid a visit to Goodwin House and talked at length with Silloway and Michael. And it is through his eyes, and his thoughts, that we came to understand what happens at this unique facility and how it is helping others change the course of their lives.

Strong Dose of Reality

Flashing back again to those days when heroin was dominating his life, Michael said he needed five to 30 bags of the drug a day, meaning he needed $20 to $80 a day to fuel his habit. And, as he said, he would do anything he had to do to come up with that cash.

Addiction caused him no end of legal problems, and it strained relationships with family and friends to the tipping point and beyond, he went on. But the actual toll was much, much higher.

“I hated life,” he said. “It was like … I wasn’t even enjoying the fact that I was super young and had so much to look forward to. I didn’t really care anymore, because all I needed was that drug.”

Most all of the people who come to Goodwin House are there because they arrived at the same place that Michael did, said Silloway — a place where they probably hated life and didn’t really care anymore. And they needed a way out and a path to a better life.

Helping to provide all that was the motivation for Goodwin House, a facility named after Jim Goodwin, long-time director of CHD. It opened its doors in May 2017.

“Eventually, I turned over to the needle, and once I started shooting it, it became a whole different ballgame. It became my life — that became my top priority every day. I eventually spiraled out of control; I dropped out of high school, I started stealing from friends, family … anything I could do to get that fix.”

The program operated there was created from the ground up by Silloway, and modeled loosely on a similar facility for young girls ages 13-17 in the Worcester area called Highland Grace House.

Residents must have a substance-abuse disorder, and the substances range from marijuana to alcohol to opioids, said Silloway, adding that a resident’s journey there begins with a referral, usually after a stint in detox.

This is a treatment facility and a next step after detox, she told BusinessWest, adding that Goodwin House can accommodate up to 15 young men at a given time. There are a handful there now, and there could and should be more given the state of the opioid crisis in this state and this country, she went on, but there is still a powerful stigma attached to addiction, and this is, unfortunately, keeping many from seeking the help they need.

Residents — that’s the term used to describe those participating in the program — come from across the Commonwealth, noted Silloway. They arrive, as she noted earlier, under different circumstances and with unique backstories.

But the common denominator is that successful recovery must begin with admitting that one has a problem, and possessing a willingness to do something about it — ingredients that are very often missing from the equation.

“We focus on them wanting to be here as opposed to being mandated, and some can be mandated to come,” she explained. “When they get here, they need to have a willingness to work on themselves.”

At Home with the Concept

Indeed, Michael said his first visit to Goodwin House was triggered by his arrest on various charges (he didn’t want to get into any great detail) in November 2017, followed by a stint in detox.

“I was sent here,” he said, putting heavy emphasis on that word ‘sent.’ “I came here for all the wrong reasons; I wasn’t coming here for myself at first, I was coming for the courts.”

With the benefit of hindsight, he believes that first time in detox and his initial visit to Fairview Avenue ultimately saved his life. But he knows now that he when he first arrived, he just wasn’t ready to change — as in change his friends, the places he hung out at, or, most importantly, himself as a person.

This residential treatment program for males ages 13-17 is the only facility of its kind in the Commonwealth.

This residential treatment program for males ages 13-17 is the only facility of its kind in the Commonwealth.

He started using again while he was at Goodwin House, got kicked out of the program, went back to detox, came back to Goodwin House, used again after only a few weeks, and was again kicked out of the program. He went to detox yet again and then to a halfway house in the Boston area, where he was discharged for using. The frustrating cycle continued with one more trip to detox and his third referral to Goodwin House. This time, though, things were different.

Silloway told BusinessWest that those addicted to substances like heroin, other drugs, and even alcohol are essentially in recovery for the rest of their lives. Recovery is a journey, and very often a long and difficult one, she went on, adding that is why it is not considered a failure to relapse and return to Goodwin House a few times, as Michael has.

“As someone’s leaving,” she said, “we say, ‘we hope we don’t see you back here, but if you need us, we’re here.’”

Michael still needed them, and they were there for him when he checked back in over the summer. Only this time, he arrived with a different attitude.

“When I went to detox for the fourth time, I decided I was sick of living that way and knew I needed to make some changes,” he recalled.

And over the course of the past 10 weeks or so, he has made some, and, with the help of the large support network at the Goodwin House, Michael is ready to do something he was never ready to do before — live without drugs.

“I feel like I wanted to make a change — I just didn’t know how,” he said. “But then, I started second-guessing whether I wanted to make that change. I got through that second-guessing, but I’m addict; I’ll always want to use. But now, it’s a matter of what will happen if I use. Am I going to die? Am I going to have more legal issues?

“Now, I’m happy,” he went on. “Before, I didn’t have any emotion — I just got through the day. Now, I can take in the memories that I have; every day, something can happen, and it can turn into a good memory or a bad memory.”

When asked about the long term, Michael said he doesn’t think in such terms. In fact, he doesn’t even take things one day at a time.

“I’m locked in on thought-by thought, minute-by minute,” he explained, “because that last thought can bring you right back to where I was.”

Positive Steps

On Oct. 18, Michael will turn 18. As noted, he will then officially age out of Goodwin House. He’s hoping that his next short-term address will be a sober house, which will be what he called “another stepping stone on the journey to living without drugs.”

He admits to being somewhat nervous, but not scared.

“The way I was brought up was to always want more out of life, to achieve something greater than you’ve already achieved,” he explained. “I want to keep putting one foot in front of the other every day, because I don’t want to take one step forward and two steps back. I did that for such a long time … I don’t want to start this all over again.”

Getting to this point has been a long struggle, but Michael has found the will to change and keep moving forward. The Goodwin House has played a huge role in that, and the goal moving forward is to write more success stories like this.

George O’Brien can be reached at [email protected]

Health Care

Deep Dive

Stacey Kronenberg (right), operations manager at Achieve TMS East

Stacey Kronenberg (right), operations manager at Achieve TMS East, demonstrates the dTMS technique with technician Sara Pittman.

With data in hand showing that its signature treatment — known as deep transcranial magnetic stimulation — has a strong track record in battling depression, Achieve TMS East has seen significant growth in the region. Now it has further reason to be excited, with the technique showing great promise in treating OCD.

Margie Pierce understands the difficulty — and, yet, the importance — of tackling the problem of depression.

“It’s the leading cause of disability worldwide right now,” said Pierce, a licensed clinical social worker and director of operations at Achieve TMS East, a fast-growing chain of behavioral-health practices that employ an innovative approach to treating depression known as deep transcranial magnetic stimulation, or dTMS.

“We’ve had people who were chronically depressed for 20 years have a fabulous response to this, and we’ve had people chronically depressed who have not had a great response,” she told BusinessWest. “We can’t pigeonhole people when they come in, whether they’re going to respond or you’re not. It’s kind of hit or miss, just like with medications. Some people respond to certain medications, and others don’t.”

That said, however, dTMS has proven remarkably effective in most people who undergo it — in many cases, people who have tried a seemingly endless string of medications and therapies with little success. That explains why the organization has grown to 11 offices across Western Mass., with broader geographic expansion planned.

“We can’t pigeonhole people when they come in, whether they’re going to respond or you’re not. It’s kind of hit or miss, just like with medications. Some people respond to certain medications, and others don’t.”

Deep transcranial magnetic stimulation, or dTMS, is a non-invasive technique that applies a series of brief magnetic pulses to the brain, by passing high currents through an electromagnetic coil placed adjacent to a patient’s scalp. The pulses induce an electric field in the underlying brain tissue and activates underactive areas in the brain associated with depression.

Dr. John Zebrun, senior medical officer with Achieve TMS East, said transcranial magnetic stimulation (TMS) was developed in Europe in the 1990s, and the first machine to receive FDA approval in the U.S. was the Neurostar machine, in 2008, which reached two to three centimeters into the brain, unlike dTMS — developed by an Israeli company called BrainsWay — which reaches six to seven centimeters in, and earned FDA approval in 2013.

“It enables you to get deeper into the brain tissue, so the volume of brain tissue is larger,” Zebrun told BusinessWest. “We don’t miss the target, ever, and there’s more stimulation in that area.”

The developers of the original TMS technique, he explained, wanted to discover if there were circuits or networks in the brain tissue they could stimulate to ease clinical depression. They targeted the left prefrontal area, which imaging scans suggested were underactive in patients with depression.

“The thought was to stimulate that area first and get it closer to a normal activity level, and that would help with depression — and it did. And that still is the primary target,” he said, noting that the device produces a magnetic field, not an electric current. “It’s getting groups of neurons in the circuit to fire together. As they get used to firing together, they’re more connected to each other.”

After a standard treatment of 36 sessions, he went on, those neurons become trained to fire normally. Treatment statistics show that 51% of patients who undergo the entire protocol get all the way to remission, while 75% get at least halfway to their goal. About one-third will need repeat, ‘booster’ treatments down the road, while two-thirds don’t.

Dr. John Zebrun says deep transcranial magnetic stimulation gets deeper into the brain than traditional TMS

Dr. John Zebrun says deep transcranial magnetic stimulation gets deeper into the brain than traditional TMS — and shows great promise for OCD as well.

In short, those are great numbers for a depression treatment, Zebrun said, and that success explains why Achieve has grown so rapidly across the region — and promises to become a more widely known name across the Northeast.

Long Time Coming

The breakthrough in TMS occurred in 1995, Zebrun said; that was when researchers first demonstrated that a magnetic field could stimulate the right neurons and get a response.

“So it’s been around a long time,” he said. “It varies from machine to machine, but they’re all operating within a certain range and certain power level to get the antidepressant effects.”

FDA approval was only one key development, however; insurances companies still needed to pay for the treatment if doctors hoped to reach a wide market. Medicare accepted it in 2015, and other payers soon came on board.

The FDA originally approved TMS for patients who had failed to find relief with another antidepressant treatment. “But insurance companies added extra layers, expecting to see about four medication and psychotherapy trials before they give this approval,” Zebrun said. “But a lot of people out there have already been through years of treatment and tried several medications.”

Dr. Thomas Bombardier, an ophthalmologist turned businessman, was involved with launching a chain of Achieve TMS businesses in California, Pierce told BusinessWest, and when he saw the benefits and how patients were responding out west, he decided to bring the model to his Western Mass. stomping grounds, teaming with two other owners to open Achieve TMS East.

Patients are referred to Achieve by their primary-care doctors, therapists, and psychiatrists, and some self-refer after hearing about the practice through social media or friends or family members.

“We’re very open to however they can get into the door to get the help they need,” Pierce said, noting that, while the majority of people who seek out tDMS are good candidates for it, some aren’t, due to medical contraindications, recent seizures, or even metal in the head that could heat up during the treatment. Everyone also gets a psychiatric consult to see if the treatment will be appropriate.

Stacey Kronenberg, operations manager at Achieve TMS East, demonstrated the dTMS technique for BusinessWest on Sara Pittman, a technician with the practice, although at a very low power level. Pittman put on a soft cap followed by the dTMS helmet, and Kronenberg set the device to a single-pulse mode, moving centimeter by centimeter until she found the motor area for Pittman’s hand, which twitched. From this process of ‘mapping,’ she could locate the right area to target for treatment.

The power setting isn’t uniform for each patient, and can be altered by the thickness of the skull, how much sleep the patient got the night before, even how much coffee they drank that morning. The process involves 36 ‘taps’ in two seconds as the neurons are stimulated, followed by a 20-second break, then another 36 taps in two seconds, then a 20-second break — a cycle repeated 55 times, totaling just over 20 minutes.

Initial treatments are run at lower power than later treatments to desensitize the patient to the sensation, which Pittman described as more of an annoyance — like a woodpecker tapping at her head — than anything. “It’s a tolerable discomfort,” Zebrun added. “I wouldn’t say it’s a breeze, but it’s tolerable.”

Margie Pierce

Margie Pierce says some people have come in after battling depression for 20 years — and finally found relief through dTMS.

Some patients pass the time by chatting with the technician, while others choose something to watch on Netflix, on the big TV hung on the wall beside the treatment chair.

“A lot of people, at the end, are like, ‘oh, I’m done already?’ They’re enjoying their conversation or their show,” Kronenberg said. “I think we should work for Netflix. A lot of people come in and are like, ‘I want to get Netflix.’”

That’s because they’re at the office often enough to binge a lot of TV — five days a week for six weeks, in fact, which is how long it takes to train the brain. “A lot of patients don’t want to leave when it comes to the end of their treatment,” she said. They tell us, “I’m so used to coming and seeing you. Who can I talk to now?’”

Beyond Depression

For starters, they can talk to their loved ones, in most cases, about how effective the treatment was. And depression isn’t the only use for dTMS. The FDA recently approved it as a treatment for obsessive compulsive disorder. In fact, dTMS has been successful in trials for OCD in ways that traditional TMS cannot be, because the target area of the brain is deeper than for depression.

“The surface coils [of TMS] would need so much energy to get that deep, it would hurt. The surface area would get too much stimulation rather than area you’re targeting, and you’d risk a seizure. That wouldn’t happen with dTMS,” Zebrun explained.

He said he hopes to reach people who don’t find standard cognitive treatment for OCD effective. “It can devastate one’s life. You can get wound up into some of these compulsions, or your mind can be so caught up and obsessed with obsessive thinking that you can’t focus on anything else. You can’t get through a planned project because there’s too many interruptions from your loops of thought that come in. There’s a wide range of those obsessions and compulsions.”

Even milder symptoms of OCD can really bother people, he added. “They wish they could get rid of these images popping into their head that started from nowhere and have no relation to anything in their lives and are disturbing to them.”

“They’ll say, ‘why wouldn’t you try this? What do you have to lose, except maybe your depression?’ … For most people, it’s going to help.”

Kronenberg also hopes dTMS makes an impact on the lives of these patients, noting that OCD is one of the most thorny issues that therapists tackle. And, much like depression, she added, OCD can be a “hidden” disease because there’s some stigma and shame associated with it.

But there shouldn’t be, Zebrun said, especially when something like dTMS exists, with its strong track record and its minimal side effects, which may include facial muscle contractions and headaches, which are both temporary. Fewer than one patient in 1,000 may experience a seizure — a risk similar to that of taking an antidepressant medication at the maximum dose.

Because it’s tolerable, he added, patients can do it before or after work, or during their lunch break, and return to their normal activities.

And maybe a normal life.

“People who for 20 years were depressed say it’s life-changing for them,” said Anita Taylor, marketing director at Achieve TMS East. “When we hear those kind of stories, we’ll ask them, ‘what would you say to someone thinking about this?’ They’ll say, ‘why wouldn’t you try this? What do you have to lose, except maybe your depression?’ It’s worth it to give it a try, go in wholeheartedly, and, for most people, it’s going to help.” u

Joseph Bednar can be reached at [email protected]