Some hospitals in Kentucky can't find enough nurses; they and nursing colleges work toward short-term and long-term solutions

Highlands Regional Medical Center nursing interns (photo provided)

By Melissa Patrick
Kentucky Health News

While studies show Kentucky will have a surplus of registered nurses in the next decade, right now many of the state's hospitals are struggling to hire enough nurses to care for patients.

“I am hoping this is cyclical," said Susan Ellis, the vice president of patient care services at Highlands Regional Medical Center in Prestonsburg. "But my fear is that this one is much deeper than any of the past nursing shortages that I have seen, and by deeper I mean it is spread much wider.”

Most of the state's critical-access hospitals, which usually have fewer than 20 patients at a time, haven't been hit by the shortage. But at any given time larger Kentucky hospitals may have between a 10 percent and 40 percent vacancy rate, Ellis said.

Highlands is a 184-bed facility that needs about 120 registered nurses in its clinical area and is about 24 short, or 20 percent.

"We are feeling it in our facilities," Ellis said. "And surrounding facilities that I have spoken to, some of their chief nursing officers, they are feeling it too. . . . You really can't run your facility without your registered nurses; they are at the patient's bedsides."

Chandler Medical Center, University of Kentucky (UKHealthCare)

The University of Kentucky, which operates a 569-bed hospital that largely serves Central and Eastern Kentucky, has also struggled with the shortage of nurses.

"I think most of the folks in Lexington who are trying to hire registered nurses would share a similar perspective," said Colleen Swartz, the chief nurse executive at UK HealthCare. "For example, as recently as three years ago, which would put us in that 2013-14 time-frame, we would post a registered nurse position and get 20 applications for it, but right now we have positions that we have posted and re-posted and had no applicants."

Kentucky has about 45,500 full-time employed RNs, whose average annual salary is about $60,000, according to the federal Bureau of Labor Statistics. The Kentucky Board of Nursing website reports 69,337 active RN licenses in the state.

The latest Kentucky Occupational Outlook to 2024 report said the state would need an additional 16,047 full-time registered nurses between 2014 and 2024, or a 36 percent increase from the estimated 45,086 in the 2014 workforce to the projected need of 61,133. "Health-care-related occupations are expected to grow at such a high rate primarily because of Kentucky's aging population," the report said.

By 2030, one in five Americans will be 65 or older, the U.S. Census Bureau predicts. The National Council on Aging says 80 percent of older adults have at least one chronic health condition, and 68 percent have at least two.

Peter Buerhaus, a health-care workforce expert at Montana State University, agreed that the aging population will increase the need for new nurses, but added that states should also pay attention to their retiring RN workforce because more than one-third of RNs are likely to retire over the next 10 years.

"One million nurses who are over the age of 50 are going to be retiring, and with that retirement goes an awful lot of knowledge and skill and experience," Buerhaus said. "It is a major, major quantitative and qualitative change in nursing." He added that health reform and the primary-care provider shortage, which is expected to worsen over the next 10 years, will also drive the need for more nurses.

Retirement does not appear to be as big a problem in Kentucky as in most states. The average age of a Kentucky nurse is 40; the national average is50.

UK College of Nursing students practice (photo provided)

Swartz said UK HealthCare didn't have any immediate concerns about losing nurses to retirement, but said the hospital has worked with its older nurses to figure out how to best manage the large geographic footprint of the facility as it has grown.

"There are nurses who have been here, say 20 years," Swartz said. "You just can't replace the judgment and the knowledge and the critical thinking that they have through those years of experience. It's priceless to us."

Buerhaus said there isn't a nursing shortage from "a big macro national perspective," but that some areas of the country, especially rural areas, are experiencing a shortage. "It is an uneven picture across the country."

Buerhaus noted that his research, published in the journal Nursing Outlook, forecast that Kentucky, as part of the East South Central region of the U.S., is expected to have "substantial growth" in its number of full-time registered nurses between 2015 to 2030.

“What this suggest to me is that in the East South Central part of this country we are going to have fewer older nurses who are going to retire and a stronger growth of young people coming in," he said about his research findings.

A 2014 U.S. Department of Health and Human Services report says that nationwide there will be a surplus of 340,000 full-time equivalent registered nurses in 2025, and a surplus of 16,500 in Kentucky.

However, another report by Georgetown University, which it says uses a study methodology based on nursing demand and "active supply," says that by 2020, the nation will have a shortage of about 193,000 nursing professionals by 2020.

Whatever forecast is correct, that doesn't affect today's shortage of nurses in Kentucky, which is forcing hospitals and nursing schools to find creative ways to fill those vacancies.

Staffing solutions and challenges

Both Highlands and UK HealthCare said shortages and a need for specialty trained nurses have caused them to start using agency nurses again.

Agency nurses, also called travel nurses, take short-term contracts that allow them to easily take time off or move around. Their contracts are usually for three months at a time.

"We have not used travel nurses in probably five to seven years," said Ellis, of Highlands. "Their expense is higher than normal. . . . When you think for one nurse, you could potentially be paying double," adding that this added cost "can actually put a small facility on the edge."

Swartz said UK HealthCare had not used agency nurses for more than a decade, but they now make up almost 2 percent of their nursing workforce, mostly in specialty areas where it takes time to train someone.

“We have a rigorous screening process we go through before we accept anyone in that agency kind of format, but honestly we've had some really clinically strong nurses come through who we've been able to utilize during this period where we've been unable to hire ourselves," Swartz said.

Highlands Regional Medical Center (website photo)

Highlands also offers a sign-on bonus and an incentive program for employee referrals, but Ellis said traveling-nurse agencies also offer this incentive and have lured several of her nurses away.

"And just like I'm trying to use my staff to recruit nurses, the travel companies actually use their staff to recruit staff to travel. And we have lost individuals in our organization who wanted to go travel because they hear about this bright, shiny money travel adventure and they sign on," she said.

In addition, Highlands is planning to hire four internationally trained nurses, who would commit to working there for two years. Ellis said they would be paid the same as the current staff, but the hospital would be responsible for their recruiting costs, including immigration fees upward of $15,000 per RN.

"I think it is another way to help the problem, and let's say I'm cautiously optimistic," she said.

But Fran Feltner said, "I'm not sure it is the answer." Feltner is director of UK's Center of Excellence in Rural Health, which focuses on improving health-care provider shortages in Appalachia.

Feltner said she understood why hospitals use internationally trained nurses, but also said they can create a language barrier to care for patients and families who already may struggle with health literacy.

Highlands has also revived its nurse-intern program as a recruiting tool. This paid "shadowing" program, which includes 14 student interns from the local nursing school, pairs an intern with a registered nurse in a department of the student's interest, in hopes they will join Highlands upon graduation.

The program seems to be working, at least for Samantha Thomas, who will graduate in May with an associate degree in nursing from Big Sandy Community and Technical College in Prestonsburg. Thomas said she joined the internship program to explore working in the intensive care unit and plans to continue working there after graduation.

"I think it's a really great way for Highlands to recruit nurses because once we work there, then we will want to stay," she said. "I think I'll stay there for at least two years until I'm really comfortable with my skills -- and I may stay there forever."

Highlands may be on to something.

UK's Swartz, who was chief nursing officer at Clark Regional Hospital in Winchester, said that while it is often hard to recruit nurses to rural areas, once they hire on, they are often "so committed to that facility and to the people there, it was very much a service orientation to that community."

Swartz said UK HealthCare doesn't offer signing bonuses or incentives for employee referrals, but does have an aggressive recruiting program that touts their "amazing benefits package."

Appalachian Regional Healthcare, an 11-hospital system that serves Eastern Kentucky and West Virginia, is reported to have severe nursing shortages, with around 177 RN job openings listed on its website, as well as many for licensed practical nurses. ARH also offers a $5,000 signing bonus for qualified full-time RNs and a $2,000 incentive to employees for referring an RN who is hired. To further meet the "dire need for nurses in Eastern Kentucky," ARH has formed a partnership with Galen College of Nursing, a private nursing college, at ARH Hazard, which opened for its first class of associate-degree students in March.

ARH opted to not answer questions on the subject.

Partners in education

Through a strategic partnership, Swartz said UK's College of Nursing has increased its number of graduates from 80 to 200 over the past five or six years to help the hospital meet its staffing needs.

"But honestly right now, we can probably take another doubling of class size," she said. "The last several years we hired almost 600 nurses every year because of the growth phases that we've been in."

Swartz said the hospital has had to become more "intentional and deliberate" in planning for recruitment, strategically timing the openings of floors in its new pavilion with graduation dates.

Many nursing-education programs find it hard to expand because they have aging faculty, who must be doctoral-prepared, and non-competitive pay, not to mention limited clinical access for training and student/faculty ratios that are mandated by the state. UK's College of Nursing just posted five open faculty positions.

Another staffing challenge is that many nurses come immediately out of nursing school with their sights already set on the next job, such as nurse-midwife or nurse practitioner. Swartz said it is not unusual for UK HealthCare to turn over 12 to 15 nurses each year who leave to become certified registered nurse anesthetists.

The American Association of Colleges of Nursing says that in 2014, entry-level Bachelor of Science in Nursing programs turned away 50,681 qualified applicants. This has been common in Kentucky.

There is also a push for nurses with associate degrees, who make up 60 percent of Kentucky's registered nurses, to get baccalaureate degrees. The state has 15 BSN programs and 40 asscoate-degree programs.

UK College of Nursing graduates (photo provided)

UK Nursing Dean Janie Heath said the Institute of Medicine recommends that 80 percent of the nursing workforce should be educated at the baccalaureate level by 2020, because there is growing evidence that links nurses with higher education levels to better health outcomes for patients.

"Kentucky, as well as the rest of the country, is moving the needle, but we are not going to make that 2020 mark," Heath said.

Technology may help. The UK nursing college moved its RN-BSN program fully online in the fall of 2015, after research found that most RNs in Kentucky have easy access to computers and the internet.

And as many hospitals in the state do, both Highlands and UK HealthCare offer tuition reimbursement for employees who further their education.

Patricia "Pat" Burkhart, professor and associate dean of undergraduate faculty affairs at UK's nursing college, said faculty are working on innovative ways to further develop the nursing workforce, with a focus on second-degree students and second-career military medics.

"What they have wanted is more fast pace," Burkhart said. "Where our traditional students want their summers off, second degree, which we are calling second-career medics or second-degree students, want to get it done as quick as they can and want to go through the summer, so we are looking at a different model now for them."

Looking to the future, Health said nursing schools must make sure they are educating students to have primary-care competencies, so they can manage individuals, families and communities.

Resiliency and Retention

Heath said UK's College of Nursing is working hard to make sure its graduates have the skill sets they need to work in today's complex environments, whether urban or rural, putting top priority on helping them learn to be resilient.

"Science is there," Heath said, "that if we are not taking good care of ourselves, we can't take good care of our patients, our families, our communities."

Burkhart said, "We are seeing students coming in who are graduates that are looking for work-life balance, so much more than our generation." She said the industry isn't adjusting "fast enough" to this changing attitude.

Heath said it's important for health-care facilities to create healthy environments as a way to retain nurses, suggesting the need for policies and practices that let nurses know they are supported, including things like building inter-professional relationships, or even as simple as providing pet therapy for the staff. Studies show that healthy work environments create better health outcomes for patients, she said.

"It's the simple things," she said. "Things like abusive behavior, bullying, screaming, yelling is not tolerated in this environment. You know, when you've got that coming out from the top -- of zero tolerance of inappropriate behavior -- that didn't cost a thing."

Burkhart added, “I think we all knew that we needed a caring environment for our patients, but I think [what] we are now being responsive to is that caring environment needs to translate to the staff as well, whether it is respectful discourse, or confidentiality, or the little things that show that you care about your staff, just the way we are asking staff to care about patients. Every patient, every time.”

An example of this philosophy in action is St. Joseph Martin, a critical-access hospital with 25 beds that employs about 45 RNs and is part of KentuckyOne Health. It has been selected as one of the best places to work among small employers in the annual Best Places to Work in Kentucky list for the past three years.

Billie Turner, the hospital's chief nursing officer and vice president of patient-care services, said it doesn't have a nursing shortage because it has a great place for nurses to work: "I strongly feel that it is a good work environment, more so than anything else, that helps us with retention."

This article was produced as part of the Health Care Workforce Media Fellowship of the Center for Health, Media & Policy, New York, N.Y. The fellowship is supported by a grant from the Johnson & Johnson Foundation. Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Media at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

Support for statewide smoking ban rises to 71%

Seventy-one percent of Kentucky adults favor a statewide smoking ban, up 17 percentage points since the Kentucky Health Issues Poll began asking the question in 2011.

Opposition to such a smoke-free law fell six points in 2016 alone, from 31 percent to 25 percent.

The proposal received bipartisan support, with 76 percent of Democrats, 68 percent of Republicans and 72 percent of independents reporting they favored it. Former smokers also showed support in strong numbers, although nonsmoker support was the highest at 85 percent, according to a news release from the Foundation for a Health Kentucky, which sponsors the poll with Interact for Health of Cincinnati. But two of every five smokers also favored it.

"The fact that 41 percent of current smokers see the value in a statewide smoke-free law may mean that the messages about the dangers of second-hand smoke are getting through," foundation President and CEO Ben Chandler said in the release.

Local anti-smoking ordinances protect about one in three Kentuckians from exposure to second-hand smoke, according to the Kentucky Center for Smoke-free Policy, and about half of Kentucky children are protected by smoke-free policies in school buildings. In 2011, 27 communities had passed smoke-free ordinances. To date, 46 cities and counties have enacted such ordinances, according to a news release. Nationally, 27 states and the District of Columbia have enacted smoke-free laws.

Comprehensive smoke-free laws prohibit smoking in most public places, including workplaces, public buildings, offices, restaurants and bars.

Most adults in every region of Kentucky favor such a law, the poll found. The strongest support, 82 percent, is in the Bluegrass region. Lexington was the first city in the state to enact a smoke-free law.

"The single most effective thing we can do to improve Kentucky's health is to reduce our smoking rates," Chandler said. And the most efficient way to do that is to enact smoke-free laws, which also protect nonsmokers from tobacco smoke."

He noted that Kentucky has the nation's highest smoking rate among adults, 26 percent. "Not coincidentally, we die at a higher rate from cancer than any other state," Chandler said. "We also have some of the highest rates of heart-disease mortality, COPD and asthma."

The state House passed a statewide smoking ban in 2015, but its takeover by Republicans after the election of a Republican governor has dimmed prospects for such a law. Gov. Matt Bevin has said it is a matter for local governments, not the state.

Young, white, lower-income and lesser-educated men have greatest increase in heroin addiction, study finds

Young, white men with lower education and income levels have experienced the greatest increase in heroin use and addiction, a study has found.

Men 25 to 44 accounted for the highest heroin-related death rate (13.2 per 100,000) in 2015, a 22 percent increase from the previous year, according to the federal Centers for Disease Control and Prevention.

Silvia Martins, the lead author of the new study, told Lindsey Bever of The Washington Post that increases in heroin use and addiction may be related to several factors, including prescription opioid abuse and market forces that favor cheaper alternatives to pills.

"We saw that most of them had already used prescription opioids," Martins, associate professor of epidemiology at Columbia University, told Bever. "We saw that in 2001-02, only 36 percent of white heroin users reported they had already used prescription opioids before. Now, more than half of them — 53 percent of them — said they had used prescription opioids before. So we believe there is a link to the prescription opioid epidemic. Other potential reasons for that are the fact that heroin has become cheaper in recent years in the U.S."

The study, published in the academic journal JAMA Psychiatry, looked at data from two nationally representative household surveys from 2001-2002 and 2012-2013, analyzing responses from nearly 80,000 respondents. It showed that the number of people who reported using heroin at some point in their lives has climbed over the decade from 0.33 percent of the adult population to 1.61 percent, or roughly 3.8 million Americans. The number of those who met the criteria for heroin use disorder, or addiction, more than tripled from 0.21 percent in 2001-2002 to 0.69 percent in 2012-2013, according to Bever.

Synthetic opioids, including heroin and fentanyl, are the main cause of overdose deaths across the U.S., according to the CDC. More than 33,000 people died of opioid overdose in 2015. Nearly 13,000 people died last year from heroin overdose alone.

President Donald Trump signed an executive order on Wednesday creating a commission to cope with the escalating epidemic. The commission, which will be led by Republican New Jersey Gov. Chris Christie, will work to "combat and treat the scourge of drug abuse, addiction, and the opioid crisis," the White House said in a statement.

Public Health Week is a time to think about immediate challenges and the long-term health of Kentucky and its communities

April 3-9 is National Public Health Week. Why should you care? The reasons are many.

"Have you eaten at a restaurant lately? Did you brush your teeth this morning?  If so, the Department for Public Health has touched your life," state Health Commissioner Hiram Polk writes in a column for Kentucky newspapers. He notes that his agency "doesn’t only inspect the conditions of restaurants you visit, but also worked to make Kentucky the first state to add fluoride to your water to help protect your teeth."

Dr. Hiram Polk

Polk, an internationally renowned surgeon, says his top priority as commissioner is the heroin epidemic, "a crisis unlike any we have ever faced in public health." His agency "has focused on establishing and expanding preventive programs beginning with early childhood education (K-3) stressing the negative consequences of alcohol, drug and tobacco use, and educating our children about the positive outcomes associated with good nutrition and exercise. We have also launched a mobile pharmacy traveling statewide dispensing Narcan, an overdose antidote, and testing Kentuckians for hepatitis C and HIV, both of which are increasing challenges in our communities largely due to drug addiction."

The definition of public health has expanded in recent years, going beyond environmental health and clinical services to a broader concern for the overall health of communities, states and the nation. Kentucky has one of the lowest health rankings among the states, so "We must also tackle the underlying causes of poor health and disease risk," says the University of Kentucky College of Public Health.

"Those causes are rooted in how and where we live, learn, work and play. It’s the child who goes to school hungry and can’t take full advantage of the education that leads to a healthier, more productive adulthood. It’s the low-wage worker who must choose between losing much-needed income and staying home with a sick child. It’s the family that struggles to find nutritious, affordable food anywhere in their community. It’s the student who can’t walk to school because there are no sidewalks. . . . If we partner across public and private sectors to ensure decisions are made with people’s health in mind, we can build healthier communities."

Medical examiner quits, then stays; was in dispute over resources, autopsy delays, hiring of former legislator to run office

Photo illustration from WKYT-TV

Dr. William Ralston quit his job as the state's chief medical examiner Friday "over frustrations involving personnel decisions and financial concerns for his office," then agreed to stay after the state initially said his resignation was accepted, reports Miranda Combs of Lexington's WKYT-TV.

The Lexington Herald-Leader reports Ralston and Justice Secretary John Tilley "came to an agreement for Ralston to stay as chief medical examiner sometime around 6 p.m., Jimmy Pollard, a consultant for the Kentucky Coroners Association said. Mike Wynn, spokesman for the Justice and Public Safety Cabinet confirmed that Dr. Ralston is not leaving his position."

The back-and-forth came a few days after a letter the coroners' group sent Gov. Matt Bevin a certifed letter "saying economic challenges and unpaid bills are putting death investigations in jeopardy while the state hired an unqualified administrator to run the state medical examiner’s office," Combs reports.

Katie Stine (H-L photo)

Former state Rep. Katie Stine of Northern Kentucky was hired two weeks ago as executive director of the medical examiner's office. "Pollard said the hiring of Stine, who is being paid $80,000 a year and is eligible for $27,222 from her legislative pension, was the final straw for Ralston, who had been fighting for more funding for the medical examiner’s office for months," Morgan Eads and Daniel Desrochers report for the Herald-Leader. Pollard said Stine is not qualified to oversee the office.

Lyon County Coroner Ronnie Patton, president of the coroners' group, told Bevin in the letter, “The state has not paid its bills or provided funds to hire doctors and support staff, but can hire administrative personnel with no previous knowledge of the medical examiner’s program’s operation, at a tremendous salary.”

Fayette County Coroner Gary Ginn told the Herald -Leader that a shortage of medical examiners has delayed cases for some time. "With fewer examiners, it’s taking longer for county coroners to receive completed autopsy reports. And, as the number of heroin deaths has increased, Pollard said, coroners and the medical examiner’s office have more pressure to determine cause of death so U.S. attorneys can prosecute drug dealers," the newspaper reports.

"Autopsies related to homicide cases have been prioritized so as not to delay investigations, but waiting for autopsy reports in accidental death cases can affect families, Ginn said. County coroners are unable to sign death certificates until autopsy reports are completed. Until death certificates are signed, families are often unable to begin taking care of matters like life insurance or property transfers."

More health bills pass as legislative session ends; one would require doctor's OK to play student athletes after concussions

By Melissa Patrick
Kentucky Health News

Several more health-related legislation passed in the final two days of the General Assembly's session.

House Bill 524, sponsored by Rep. Addia Wuchner, R-Florence, to prevent and reduce human trafficking, passed without dissent in both chambers and now awaits action from Gov. Matt Bevin.

As often happens in the final hours of a legislative session, some unrelated measures were tacked onto the bill, including non-controversial legislation to more clearly define "serious physical injury" in child-abuse cases involving children under 13.

Several other health-related bills passed in the last days of the session and await action from the governor. Bills passed after the veto period are not eligible to be overridden by the General Assembly, so Bevin's decision on these bills will be final. They include:

HB 333, sponsored by Rep. Kim Moser, R-Taylor Mill, would limit most painkiller prescriptions to a three-day supply for acute pain, and change how synthetic-opioid traffickers are prosecuted.

HB 78, sponsored by Rep. Jim Duplessis, R-Elizabethtown, to require providers of standard mammograms to notify patients if they have "dense breast tissue" when appropriate, because such tissue can hide cancers. The intent of the notice is to allow patients to decide with their provider if they need further screening.

HB 241, sponsored by Rep. John Sims, D-Flemingsburg, would require written clearance from a physician for a coach to play a student-athlete who has been diagnosed with or is suspected of having a concussion.

House Concurrent Resolution 48, sponsored by Walker Thomas, R-Hopkinsville, urges the U.S. Food and Drug Administration to withdraw its proposal to reduce the levels of N-nitrosonornicotine, or NNN, a carcinogen, in all smokeless-tobacco products sold in the U.S. Thomas's district is a home of dark tobacco, used in smokeless products, and Hopkinsville has a plant that makes such products.

Bevin has signed a bill to establish review panels for malpractice cases. SB 4 was controversial, pitting lawyers against doctors such as the sponsor, Sen. Ralph Alvarado, R-Winchester. It passed the House 51-45, with 11 Republicans joining 34 Democrats in voting no, even after substantial changes sought by opponents.

Under the new law, three physicians will say whether a suit against a health-care provider has merit before it could be filed in court. An attorney will chair the panel but not have a vote. The judge in the case would decide whether the panel's opinion could be admitted as evidence.

Also of note, the General Assembly overrode Bevin's veto of SB 91, which will allow judges to order mentally ill adults who meet strict criteria into an "assisted outpatient treatment" program, and confine them if they don't comply.

April is Sexual Assault Awareness Month; advocates honored, Green Dot training program gets national recognition

April is Sexual Assault Awareness and Prevention Month, so the state Cabinet for Health and Family Services and the Kentucky Association of Sexual Assault Programs held a ceremony in the state Capitol rotunda in late March to recognize several people's prevention and advocacy efforts.

A state news release said Lt. Gov. Jenean Hampton read a proclamation from Gov. Matt Bevin noting that Kentucky has higher-than-average rates of sexual violence, and Glenna Bevin presented the awards. “Their accomplishments are not only uplifting survivors, they are saving lives,” the first lady said.

Four Kentuckians received Sexual Assault Awareness Month awards: Michelle Kuiper, for her legislative activism and using her voice as a survivor; Maj. John Harvey of the Kentucky National Guard for his work with the guard's sexual assault prevention and response programs; Lt. Carolyn Nunn of the Louisville Metro Police Department; Laura Kinney of the Women’s Crisis Center in Northern Kentucky.

KASAP Executive Director Eileen Recktenwald said she’s seen major progress in prevention efforts and community engagement. “Initiatives to combat sexual violence may include counseling, school- and business-based prevention programs or just a supportive conversation,” she said. “We are much more open about supporting survivors and not accepting high-risk behaviors.”

Recktenwald said an approach invented at the University of Kentucky was the subject of a study published in the American Journal of Preventive Medicine. Green Dot teaches a communal method for bystanders to get involved in a safe and responsible way when witnessing possible sexual violence or coercion.

The study found that in Kentucky high schools that didn’t receive the training, sexual violence — including harassment, stalking and dating violence reported by students — remained steady or went up overall, while in schools that received the training, incidents of sexual violence decreased by as much as 50 percent.

“Green Dot is teaching teenagers to be empowered -- to interrupt a risky situation or to say something to a teacher,” Recktenwald said. “Through training young adults, we are increasing mindset that sexual violence is unacceptable.”

For more information about the sexual assault prevention programs and services and Sexual Assault Awareness and Prevention Month, go to http://chfs.ky.gov/dcbs/dpp/violenceprevention.htm or http://www.kasap.org/SAAM.html.

Kentucky's last abortion clinic says Bevin is trying to shut it down, gets restraining order

Without even having a hearing, a federal judge has ordered the state Cabinet for Health and Family Services not to close Kentucky's only remaining abortion clinic.

"The order issued Friday by U.S. District Judge Greg Stivers follows a lawsuit by EMW Women's Surgical Center in Louisville seeking to block the state's effort to close the clinic over alleged deficiencies in its license," reports Deborah Yetter of The Courier-Journal. "Stivers said in his order that prior notice is not necessary in a case where facts 'clearly show' that harm, irreparable injury or damage will occur before a hearing can be held. . . . He said the clinic's lawyers had shown 'a strong likelihood of success on the merits' of their claim."

Cabinet spokesman Doug Hogan said officials were "surprised and disappointed the court entered a temporary restraining order without input from the cabinet and without first ascertaining the status of communications between both parties." Hogan added, "EMW's license was never in immediate jeopardy. The cabinet had informed counsel for EMW no final decision would be made regarding the abortion facility’s license until the administrative due process hearing required by Kentucky statutory law was complete."

The cabinet has alleged "technical" deficiencies in EMW's transfer agreements with local hospitals and an ambulance service, a condition state law sets for a license to perform abortions. It said the clinic could be closed Monday, April 3. That would make Kentucky the only state with no legal abortion services.

EMW said in its lawsuit, filed Wednesday, that its license is not deficient and that Gov. Matt Bevin is trying to abolish legal abortion in Kentucky. "The abortion clinic has had its agreements with the University of Louisville Hospital and Mercy Ambulance on file with the cabinet for several years," the Lexington Herald-Leader reports.

"Two other abortion providers ceased operations over the past year following enforcement actions by the Bevin administration," Yetter notes. "Planned Parenthood of Indiana and Kentucky suspended offering abortions at its clinic in downtown Louisville, and EMW closed a small, part-time office in Lexington . . . after the state refused to issue it a license. Planned Parenthood has appealed the state's action against its license."

Big drug bill heads to governor's desk; has harsher penalties and limits most prescriptions for acute pain to 3 days

By Melissa Patrick
Kentucky Health News

A bill that would limit most painkiller prescriptions to a three-day supply for acute pain, and change how synthetic-opioid traffickers are prosecuted, flew through the legislative process in the final days of the 2017 General Assembly. It now awaits action from Gov. Matt Bevin.

Rep. Kim Moser
photo: LRC Public Information

House Bill 333, sponsored by Rep. Kim Moser, R-Taylor Mill, would limit painkiller prescriptions such as oxycodone and morphine to a three-day supply if prescribed for acute pain, but has a long list of exceptions such as chronic pain, terminal illness and severe trauma.

"We really want prescribers to stop and think before they write that prescription for 30 Percocet or Lortabs or any narcotic, to change the mindset that opioids are the first line of treatment for pain because it may not always be necessary," Moser said in a phone interview. She is director of the Northern Kentucky Office of Drug Control Policy.

"We know that we had 3.5 billion doses of opioids prescribed in Kentucky last year and that is enough for 79 pills per man, woman and child. That's huge," Moser said. "We also know that 80 percent of heroin addicts started with either a legitimate pain prescription or opioids in tablet form, some sort of stolen medication or diverted medication."

The bill also expands jail time for the illegal possession and importing of heroin, fentanyl, carfentanil and fentanyl derivatives; increases penalties for trafficking; creates a felony offense for those who misrepresent a controlled substance as a legitimate prescription drug; and adds heroin, fentanyl, carfentanil and fentanyl derivative trafficking to aggravated trafficking in a controlled substance.

The Senate made changes to the bill to increase penalties for heroin and fentanyl, and removed the provision that enabled addicts to avoid the increased penalties, sometimes called the "peddler distinction."

The bill now requires that any transfer of heroin, fentanyl, carfentanil and fentanyl derivative to another person is a Class C felony for a first offense, with a five- to 10-year sentence and no parole eligibility until half of the sentence is served. A second or subsequent offense would be considered a Class B felony, with a term of 10 to 20 years.

Currently, "An addict caught sharing under two grams of these drugs in this way would be charged with a Class D felony with a one- to five-year sentence, with parole eligibility after serving 20 percent of the sentence" for a first offense, Ashley Spalding writes for the Kentucky Center for Economic Policy.

Writing in opposition to the changes, Spalding says the amended version of HB 333 will "lock up more addicts for longer periods of time and be ineffective in addressing the state’s addiction problems, it would be very costly for the already overburdened criminal-justice system."

Spalding argues that the changes will cost money, adding to the $30 to $35 million estimate for a similar bill (Senate Bill 14) that was not heard in the House. Spalding said it will cost more because the estimate for SB 14 assumed those trafficking in amounts of under 2 grams could be paroled after serving 20 percent of their sentence.

Moser said that without this provision, the Senate wasn't able to get enough votes to pass the bill: "They wanted zero tolerance."

She added, "This was a tough compromise for me because I really believe that you need to be able to get help for the folks who are in the cycle of addiction and not just have them stuck in this revolving door of the criminal justice system," she said, adding that prosecutors will still have discretion to determine trafficking charges.

"The real danger that we've seen is the addition of fentanyl and carfentanil with the heroin, and that's what is killing people," Moser said. "And so that's why it was important for me to pass a bill that had the distinction for fentanyl and carfentanil in it."

She said Senate Republican leaders are committed to working with the criminal justice system to continue researching whether this is the best way to handle trafficking, and whether this is best for individuals stuck in the cycle of addiction.

The bill also adds fentanyl derivatives as a Schedule I drug, meaning they have no medical use, and allows drugs to be raised to higher schedules as needed. It has language that will result in better communication between the Cabinet for Health and Family Services, its Office of Inspector General, medical licensing boards and the state Office of Drug Control Policy about prescription-drug use in the state.

The bill also excludes cannabidoiol, a non-hallucinogenic marijuana extract, from the definition of marijuana under state law if the products are approved as a prescription medication by the U.S. Food and Drug Administration. 

The bill passed out of the House 96-1 on February 28. A month later, on the next to the last day of the session, around 11 p.m., it passed out of the Senate Judiciary Committee. And on March 30, the last day of the session, it passed out of the Senate 29-9 with some changes, which the House accepted by a vote of 80-6.

Mixed reviews in the Senate

Several Senate Democrats were frustrated that such an important bill was rushed through the Senate.

"This bill could have been discussed. It's got major policy components. We could have had testimony and heard from the stakeholders affected in a public forum with civil discourse and the ability to ask questions. We didn't have that for this bill and that pains me a bit," said Sen. Robin Webb, a lawyer from Grayson, who voted against the measure.

Webb said patients with legitimate pain problems who can't get legitimate treatment "are going to go to the street, and they are going to pursue illegal means. We've seen it. We see it in our communities. I hear it in my office from time to time. And then we are upping the penalties for these individuals, when some are driven [by] legitimate sources of pain remediation."

Senate Democratic Leader Ray Jones of Pikeville said he cast a "difficult" vote for the legislation because he wanted the fentanyl and carfentanil provisions, but he agreed with Webb and said he didn't like the three-day limit. He and several other lawmakers suggested that provision should have been in a separate bill.

"That ties the hands of doctors. Those decisions should be up to the physicians," said Jones, a lawyer. "If physicians follow the current law and current standards of care, they will be able to prescribe to meet patients needs without any concern of proliferation of drugs."

Sen. John Schickel, R-Union, applauded the bill. He said the Senate had tried to pass bills to increase trafficking penalties for heroin for the past six years, since the passage of a bill that reduced prison time for the state's low-risk, non-violent drug offenders, but he said they had all died in the House when it was led by Democrats.

"A lot has been said about treatment, and I believe in treatment, but we have to keep in mind that we are, at least the majority party is, the party of personal responsibility and where I come from, people are sick and tired of hearing excuses for people dealing in heroin. Killers, murderers dealing in heroin and then those same traffickers claiming to be victims. I'm sorry, they are not victims, they are criminals and they need to be punished," said Schickel, a retired law enforcement officer.

Republican Sen. Ralph Alvarado, a Winchester physician, said he could not have voted yes for the bill without the exceptions to the three-day rule for painkillers. He said guidelines for prescribing pain medication and other controlled substances are so stringent that he, like many other physicians, have chosen to not prescribe them, which has left many of his patients in a lurch.

However, Alvarado also said it's time to reduce the number of pills on the street, and for that to happen, physicians and patients must change how they think about pain and recognize that the goal might be comfort instead of being "absolutely pain free." He said to really decrease the number of pain pills prescribed, insurance companies must stop using pain evaluation as a condition of reimbursement.

Without dissent, General Assembly overrides governor's veto of bill allowing courts to require outpatient mental-health treatment

Mental-health advocates lobbied for "Tim's Law" outside the
state Senate chamber on March 29. (Photo by Melissa Patrick)

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – Cheers of celebration rang in both the Senate and House chambers as lawmakers overrode Gov. Matt Bevin's veto of a bill meant to end the revolving door between jail, hospitalization and homelessness for those with severe mental-health conditions.

Senate Bill 91, or "Tim's Law," would allow judges to be able to order mentally ill adults who meet strict criteria into an "assisted outpatient treatment" program, and confine them if they don't comply.

The legislation is called "Tim's Law" for Tim Morton, a Lexington man with schizophrenia who was hospitalized involuntarily 37 times by his mother because this was the only way she could get him the treatment he needed. Morton died in 2014.

Dozens of mental health advocates, dressed in red, lobbied lawmakers in support of the measure as they made their way to the Senate chambers, where it returned from the governor's office because it originated there.

"This is the culmination of so many hours and minutes and days of work and prayer and people pulling together," Sheila Schuster of the Kentucky Mental Health Coalition said with tears of joy in her eyes. "And to have come back from what looked like a defeat and now we are celebrating a victory --it made me think about what the families and the people who struggle with mental illness go through, that up and down, into the valley of despair and then back up again. It's just wonderful. It's just fabulous."

Advocates of the long-sought bill rode the legislative roller-coaster all week. First, they anticipated a signing of the bill into law by the governor, only to learn that he had vetoed it; then they quickly shifted into a whirlwind of advocacy to encourage lawmakers to override the veto; and finally enjoyed a celebration.

The bill had passed the House without dissent, and with only three "no" votes in the Senate. Without any debate in either chamber, the override votes were 35-1 in the Senate and 91-0 in the House.

Various versions of the bill have been filed in the General Assembly since 2013; this year's version has more stringent requirements.

It says a judge can only order outpatient treatment in cases where the person has been diagnosed with a serious mental illness; has been involuntarily hospitalized for mental illness twice in the past 12 months; and doesn't recognize their diagnosis or treatment needs. The person can only be ordered into treatment after a mental-health professional certifies that the law's requirements have been met.

The law will not be implemented until the state secures funding for it. Advocates have explained that the state cannot file for federal funding until the program is in place. It remains to be seen if the state will do that, in light of Bevin's opposition to the law.

Bevin''s veto said that while "well intentioned," the law "would set a dangerous precedent that would threaten the liberty of Kentucky citizens. . . . It would allow the Commonwealth to restrict the liberty of individuals based on nothing more than a finding that they are 'unlikely to adequately adhere to outpatient treatment on a voluntary basis.' Not only would this permit the restriction of liberty for individuals who have not committed crimes and do not pose a threat to anyone, but it would do so based on speculation about what might or might not happen in the future."

Schuster disagreed, saying that people with severe mental illness don't know they are ill and that this "black robe effect" will help them adhere to treatment long enough to recognize the benefit of it, explaining that while there are some provisions to address this issue that involves involuntary hospitalization, this only last between 72 hours to a few weeks, which she said is not enough time to establish long-term patient stability and more often than not creates a "revolving door" between hospitalization, incarnation and homelessness.

Schuster said this approach is an "evidence-based practice" and has been approved by the Substance Abuse and Mental Health Services Administration. Forty-four states have passed some version of this law. She said, "This bill will change the lives of families and people with serious mental illness in Kentucky."

County Health Rankings show troubling trend of more premature deaths, contrasting trends among some counties

By Danielle Ray
Kentucky Health News

The premature death rate is getting worse in 44 of Kentucky's 120 counties and improving in 12 counties, according to a health rankings report released Wednesday.

The figure is calculated using data from 1997 through 2014 and is part of the annual County Health Rankings & Roadmaps, released by the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation.

Experts say the premature death rate is fueled by drug overdoses, which accounted for nearly 1,250 deaths in 2015, according to the Overdose Fatality Report by the Kentucky Office of Drug Control Policy.

The rate of premature death is the years of potential life lost before age 75. Every death occurring before age 75 contributes to the total number of years of potential life lost. The state average is 8,900 years, which is 1,200 years worse than the national average.

Van Ingram, executive director of the Office of Drug Control Policy, told Bill Estep of the Lexington Herald-Leader that preliminary for 2016 are about the same as the 2015 numbers, but “It’s hard to celebrate leveling off.”

Beyond the drug issue, the latest County Health Rankings have much more to say. They give each county two scores: one for health outcomes, which include premature death and low birth weight, and one for health factors, such as access to physicians and areas to exercise, children living in poverty, violent crime, long commutes and other environmental dimensions.

The highest ranked counties in health outcomes are Oldham, Boone and Spencer, respectively. Traditionally, counties with the highest rankings tend to surround cities, where there is better access to medical care and exercise opportunities, like parks, and incomes are relatively high. The lowest ranking counties tend to be poor and in rural Appalachia, and this year is no exception: Owsley, Wolfe and Breathitt.

"The rankings show that people living in Eastern and rural Kentucky counties tend to have much poorer health than those in urban Kentucky counties," Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, said in a news release. "The rankings also make it clear that good health is influenced by many factors beyond medical care, including whether we can find and afford healthy foods, whether we can exercise safely in our neighborhoods, whether we have health insurance and if that insurance covers preventive care, and how safe our water is to drink and our air is to breathe."

The report has been released annually since 2011. Since then, some counties have seen big improvements, while others have seen their situations worsen.

Hickman County is one of the success stories. It ranks 23rd, up by 53 spots since the initial report in 2011. Multi-year trends are important, because rankings can vary from year to year, especially in small counties like Hickman; it ranked 73rd in outcomes last year. The county's health-factors ranking has also improved, to 37th from 58th in 2011, with an increase in employment and a decrease in preventable hospital stays.

Carter County has also shown great improvement over the years. It ranked 91st for the first three years of the report, and 90th in 2014, but rose to 82nd in 2015 and 68th in 2016. This year, it ranks 57th, showing improvements in both length and quality of life.

The latest move put Carter County into the second quartile of Kentucky counties. The rankings divide the counties into four groups because the differences among closely ranked counties can be very small, within the error margins for surveys that form part of the basis for the rankings.

Some counties, such as Menifee, have seen improvements in health outcomes despite lagging ion health factors. The county's outcomes ranking bottomed out in 2013, when it placed 111th. It improved to 92nd in 2015 and 79th in 2016, and this year, zoomed to 36th. Somehow it is overcoming bad health factors, in which it ranks 97th. It has a high unemployment rate and a high percentage of children living in poverty.

Similarly, Cumberland County has steadily improved its numbers since 2014, when it reached a low outcomes rank of 107th. It improved to 102nd the following year and 97th in 2016. This year, it ranks 83rd in outcomes. Like Menifee, it still ranks lower (91st) in health factors, with too few dentists and a high number of preventable hospital stays.

Morgan County once had much higher outcome rankings than its neighbors, despite bad heath factors, and now those factors appear to be catching up with it. Morgan's outcomes ranking slipped to 91st from 76th last year and 23rd in 2011. The county's scores for both length and quality of life have steadily declined. The county also has a high unemployment rate and a high percentage of children in poverty.

For every county that moves up in the rankings, another has to take its place. Rockcastle County ranks 100th in outcomes and has experienced a steady decline since 2011, when it ranked 64th, partly due to high marks for quality of life. Since then, the county's rate of premature death has increased and its quality of life scores have decreased. It suffers from a shortage of dentists and mental-health providers, with just one for every 8,500 people, drastically lower than either state or national figures.

View an interactive map of your county's ranking, with details for each measurement, here.

More than half of Kentuckians have a gun in the house,15% are loaded and unlocked; among those with children, 12%

More than half of Kentucky adults have a firearm in the home and 15 percent of those guns are loaded and unlocked, according to a the latest Kentucky Health Issues Poll.

"Gun safety is a public health issue," said Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, a co-sponsor of the poll. "Whether it's a toddler who stumbles across a loaded gun or a teenager showing off to a friend, accidents happen every day. We can prevent these tragedies by keeping guns and bullets in separate, secure places."

The poll, taken Sept. 11 through Oct. 19, found that 55 percent of Kentucky adults had a firearm in or around the home, up from 45 percent in 2011, the last time the poll asked this question.

Asked if they had a loaded gun in the home, one in four of the gun owners said they did. Of those with a loaded gun, 10 percent said it was locked and 15 percent said it was unlocked.

among Kentuckians who had a child in the home, 59 percent also had a firearm there, compared to 44 percent in 2011. Of this group, 35 percent said it was unloaded, 12 percent said it was loaded but locked, and 12 percent said it was loaded and unlocked.

The news release noted that in 2015, 694 Kentuckians and nearly 1,500 children in America died from a firearm injury. Kentucky ranks about 26th in population but 13th in number of deaths from firearms, 15.2 per 100,000 people.

The American Academy of Pediatrics recommends not keeping a firearm in a home with a child, but if you, it says the firearm should be unloaded and securely locked in storage, away from the ammunition.

The poll found that those with higher incomes were more likely to have a firearm in the home than those with lower incomes, around 60 percent compared to 47 percent. And those living in suburbs (63 percent) and rural counties (62 percent) were more likely to have a firearm in the home, compared to those in urban counties (37 percent).

The poll was funded by the foundation and Cincinnati-based Interact for Health. It surveyed a random sample of 1,580 Kentucky adults via landlines and cell phones, and has an error margin of plus or minus 2.5 percentage points.