Senate Health and Welfare Chair Julie Raque Adams, a Republican moderate from Louisville, had a banner session

Sen. Julie Raque Adams

By Melissa Patrick
Kentucky Health News

The term "public servant" comes to mind when state Sen. Julie Raque Adams starts talking about being a legislator, especially when she mentions the Senate Health and Welfare Committee, which she chairs.

"I love it," Adams said. "I love every minute of it and I feel very blessed to do this job."

Adams, a Louisville Republican, has chaired the Senate's health committee for three years and calls it "the best committee in the whole legislature."

She added, "It is the committee where you can really touch individuals as well as groups, and that is very important to me. I'm a big believer that if I'm going to take time away from my family to do a job like this, I want to feel as if I'm touching someone, or helping someone or changing someone's situation."

Adams had a banner legislative session. She got a smoking-related bill passed, as well as two pieces of legislation that had been introduced for years, one after it had been vetoed by Gov. Matt Bevin.

"I really felt like I brought a lot of really significant issues to the table and I feel very proud that I was able to get a lot of them passed," she said.

Smoking, mental health and DUIs

Passing any kind of smoke-free legislation in Kentucky has proven to be a monumental task, especially since Bevin has said smoking bans should be local issues.  

Despite polling that says 71 percent of Kentucky adults support a statewide smoking ban and 85 percent support tobacco-free schools, for the first time in six years a smoking ban wasn't even introduced, and a Senate bill to make all Kentucky schools tobacco-free died in the House. 

But Adams, who is often a co-sponsor of anti-tobacco legislation, filed a bill this session aimed at decreasing the state's high smoking rates by requiring all Kentucky health plans, including Medicaid, to provide barrier-free access to all federally approved smoking-cessation treatments. It passed.

"The smoking-cessation bill was tricky only in the sense that most people believed that I was bringing another smoke-free ban because the word smoking was in there," Adams said. The bill leaves the responsibility with smokers, while assuring that they have the tools they need to help them quit, she said. 

Another victory for Adams was the General Assembly's override of Bevin's veto of "Tim's Law," legislation she sponsored that lets judges order mentally ill adults who meet strict criteria into an "assisted outpatient treatment" program, and confine them if they don't comply. This was the fifth year the measure had been introduced.

The legislation is called "Tim's Law" for Tim Morton, a Lexington schizophrenic whose mother had him hospitalized involuntarily 37 times to get him the treatment he needed. He died in 2014. 

Another long-introduced measure that finally passed was House Bill 222, which eliminates "shock probation" for those who kill someone while driving drunk. Adams, who carried the bill in the Senate for Rep. Robert Benvenuti, R-Lexington, said she became involved with the bill soon after she was elected to the House, after learning about a girl who was killed in Seneca Park by a drunken driver who only served two months before being granted shock probation. 

A moderate, and now less of a horse trader

Adams, always the optimist, said most legislators are there to do the "right thing."

"Even though politicians get a really bad rap, particularly nowadays in this toxic environment, I think that most of the people here, along with me, are really here because we are trying to do the right thing. And so I hope that Frankfort does not turn into Washington, D.C., because we are making progress and I think we are helping people."

Asked if  her comments would be different if Democrats were in control, Adams said she has always believed, and still hopes, that lawmakers are all there to serve Kentucky and should be able to work together. She recalled serving two terms under Democratic control in the House before becoming a senator.

"When I was in the House under Speaker Stumbo, I still got some things done and I think the reason is because I was not a bomb thrower," she said. "I was respectful. I worked with them under their structure that they had established. . . . You have to pick and choose your battles."

Adams said it's been easier to get things done in the Senate health committee since Republicans took control of the House because she can prioritize and collaborate on issues with Rep. Addia Wuchner, R-Florence, chair of the House's health committee.

Adams called the change a "breath of fresh air," saying they no longer had to be so secretive or always be dealing in a "horse trade" to get things done. "And so, it's a very positive energy now that I feel in our synergies, in our chairmanships," she said.

Senate Democrats, long in the minority, like Adams. "She treats everybody fairly and I have not found her to use the weight as her chairman to cut people off," said Sen. Julian Carroll of Frankfort, a former governor who is on the health committee. "She does her best to make certain that everybody has an opportunity to be heard. I am extremely complementary of her,"

Sen. Danny Carroll, R-Paducah, also on the committee, added persistence to that list of strengths. He said her persistence with the shock-probation bill and her willingness to have open discussion with him about it over the years helped him to finally vote in favor of it.

"She has a very good ability to convince and to make adjustments where they need to be adjusted and to compromise where that needs to be done," Carroll said.

Julian Carroll vounteered, "I consider her, by the way, to be one of the more independent members of her caucus in that she seems to be her own boss without question. She doesn't always agree with leadership and sometimes she votes against leadership."

Adams was the only Republican senator to join all Senate Democrats in voting against HB 281, which would have stripped the power from the attorney general (now a Democrat) to file civil lawsuits or handle appeals on behalf of the state, and instead award those powers to the governor (now a Republican).

"I think there is a time sometimes to toe the party line," she said, "and there are times where my constituency expects me to be an independent voice, and so I try to meet all of those expectations." She said she absolutely is a Republican, and is pro-life.

Adams is less conservative on some issues than most Republican senators, and was the only GOP co-sponsor of a bill to add sexual orientation and gender identity as protected classes under the state civil-rights law.

The civics teacher

"I love first of all being a voice for those who are voiceless because if you look at so many of the issues we deal with, they are not that interesting to a lot of people and they are difficult and they are sad and they are hard, and I almost think it takes a mom to be that person who steps up for some of those other moms," Adams said.

"And one of the biggest eye-openers for me is the lack of knowledge of how the political process works. . . . I love to take people and I say, 'Here's how it works, and let me hold your hand and let me take you through this process and then maybe we'll see if we can get something done.' I never make any promises, but I always tell them, 'I'll listen and I'll help you and I will be your advocate and we'll navigate this together."

Adams said she has surprised some constituents with how far she will go, having good ideas put into bill form for review. "I'll e-mail it back to them and they will say, ' Oh my gosh, you mean my idea is actually in bill form?' . . . I think the best ideas come from the people that you represent."

And they can come from anywhere. "My husband sometimes won't let me go to the grocery store because he says Kroger is my campaign headquarters," Adams said. "Every line, they are like 'Hey, I've been meaning to call you about this.'"

Looking ahead

Looking ahead to the 2018 legislative session, Adams said topics on the horizon include medical marijuana, creating real access to cannabidiol oil in Kentucky, finding more ways to address addiction and recovery, and gun violence.

She said some are surprised when she talks about gun violence as a public-health issue, a view not commonly held by many Republicans.

"I truly think that the violence that we are experiencing in our state, and particularly  in Louisville, rises to the level of a public-health issue," she said. asked if she was talking about gun-control measures, she said, "I think we need to have that conversation."

Work requirements for Medicaid expansion would affect relatively few people; most are already working or would be exempt

By Melissa Patrick
Kentucky Health News

Requests by Kentucky and other states to require "able-bodied" Medicaid beneficiaries to work or pursue work still haven't been approved, but the expectation is that they will be soon.

"We are still in negotiations with CMS on our 1115 Medicaid waiver and feel optimistic about the ultimate outcome," state Cabinet for Health and Family Services spokesman Doug Hogan said in an e-mail.

Medicaid Commissioner Stephen Miller told Lisa Gillespie of Louisville's WFPL Radio that he expects to know about the changes by the end of June, with expectations that it will be approved, and that the goal is to put the new system in place Jan. 1, 2018.

Kentucky's waiver proposes that the state be allowed to charge small, income-based premiums and would require "able-bodied" recipients to either work, volunteer or take job training, gradually increasing in hours to a maximum of 20 hours a week after one year, among other things.

Under the Obama administration, the U.S. Department for Health and Human Services said such a provision does not fit the program's goals to promote health coverage and access.

But under the Trump administration, HHS officials sent a letter to the nation's governors "urging states to alter the insurance program for poor and disabled people by charging them insurance premiums, requiring them to pay part of emergency-room bills and prodding them to get jobs," notes Amy Goldstein of The Washington Post. Support for work requirements was also included in the Republican health-reform bill that did not come to a vote.

What states have applied for work requirements?

Kentucky, Indiana, Pennsylvania and Arizona have waiver requests pending that include work requirements. All but Indiana's would require a certain amount of work, typically 20 hours, or another approved activity, and does not seek a work requirement.

Indiana's request would require a referral to a work-search program. The Hoosier State also has pending a request for renewal of its earlier waiver, which was drafted with the help of a consultant, Seema Verna, who is now head of the Centers for Medicare and Medicaid Services. She also helped draft the Kentucky request and has recused herself from its consideration.

Indiana, Montana and New Hampshire have a voluntary work-program referral, but only for people covered by expanded Medicaid. Arkansas is seeking changes to its waiver to include a work requirement, but has not submitted a proposal.

Kentucky's proposed requirement would apply only to people covered by the Medicaid expansion and would not apply to people who are judged to be "medically frail" or are primary caregivers.

Policy arguments for and against

Work requirements would be a fundamental change in the 52-year-old Medicaid program, MaryBeth Musumeci of the Kaiser Family Foundation writes in an issue brief that looks at the work rules proposed by each of the states in their Medicaid waivers, and considers key policy issues around such request.

Arguments for work requirements center around whether a person thinks Medicaid is a "cash welfare program or one that provides health insurance," Musumeci writes. However, changes in the program since it was created in 1965 have separated it from the welfare system. For example, eligibility is no longer linked to whether a person is on food stamps, and the Patient Protection and Affordable Care Act expanded Medicaid to those who earn up to 138 percent of the federal poverty line, moving beyond pregnant women, seniors or those with disabilities.

Proponents of work requirements say being in the workforce will help people become healthier, and say Medicaid expansion has been a disincentive for some members to work, partly because a job could raise their income above the 138 percent limit. However, a recent analysis of Ohio’s Medicaid expansion found that most expansion enrollees who were unemployed but looking for work reported that Medicaid enrollment made it easier to seek employment.

Even supporters of the requirements have concerns, Musumeci reports. Some fear they would discourage people from signing up for Medicaid, steering them to emergency rooms for routine care. Others are concerned that the requirements will only be effective when the economy is strong.

Opponents of the work requirements say that health insurance is necessary for good health, which is a pre-condition to work, and that these requirements create a barrier to health coverage, Musuimeci writes.

Many adults on Medicaid already work

Most Medicaid beneficiaries are working already, and those who aren't would likely be exempted under the expected waiver.

"Nearly eight in 10 Medicaid adults are in working families, and most (59%) are working themselves without being required to do so as a condition of coverage," Musumeci reports.

The Kentucky Center for Economic Policy reports that "over half of all Medicaid eligible Kentuckians who gained health insurance between 2013 and 2015 held a job," according to the Census Bureau's American Community Survey. The vast majority of those gains came from Medicaid expansion.

Most working Medicaid recipients in low-wage jobs, and most are in jobs that don't offer health insurance, such as farming or food service, Musimeci reports.

"Even when excluding Supplemental Security Income beneficiaries, most Medicaid adults who are not working report a major impediment in their ability to work, with 35% citing an illness or disability that prevents them from work," she writes. "Others are taking care of home or family (28%), in school (18%), looking for work (8%), or retired (8%)."

In conclusion, Musumeci writes, "Conditioning Medicaid eligibility on meeting a work requirement likely would apply to a small number of people, given that most Medicaid beneficiaries who can work already are doing so."

Bevin slows down effort to close Ky.'s only remaining abortion clinic; his efforts have led to the closure of two others

Gov. Matt Bevin has scaled back his effort to close Kentucky's only abortion clinic, agreeing to renew its license until a lawsuit challenging the effort is resolved. Bevin's lawyers and the attorneys for EMW Women's Surgical Center of Louisville filed the agreement with U.S. District Judge Greg Stivers, who is expected to approve it.

"The legal wrangling started recently when the state told the clinic it was out of compliance with state laws related to its agreements with a local hospital and ambulance service," reports Bruce Schreiner of The Associated Press. "That spurred the federal lawsuit claiming the state's move was unconstitutional and accusing the state of violating Kentucky law by not giving proper notice of action against the clinic's license."

The state indicated that the clinic could be closed as quickly as Monday, April 3, but Cabinet for Health and Family Services spokesman Doug Hogan said that was never the state's intention because the clinic had a right to a due-process hearing.

"Two other clinics, one in Louisville and the other in Lexington, have stopped offering abortions in the past year after enforcement actions by the Bevin administration, leaving EMW as the state's sole abortion provider. One, Planned Parenthood of Indiana and Kentucky, is appealing the state's refusal to issue a license for it to provide abortions at its clinic in downtown Louisville," Deborah Yetter reports for The Courier-Journal.

The state alleged that the EMW's agreements with an ambulance service and a hospital were "deficient," Yetter reports. "Its inspectors had approved them last year when the clinic got its annual license. EMW, in its lawsuit, said its transfer agreements comply with state law. But its lawsuit goes further in challenging the requirement, saying such agreements are not necessary and should be struck down." It says that complications from abortion are rare, that the procedure is one of the safest, and that ambulance and hospital services are readily available.

"The transfer agreements also are part of the dispute between Planned Parenthood and the state over its license," Yetter notes. "The state has refused to accept its agreement with two hospitals and an ambulance service, a decision Planned Parenthood has appealed."

Seat-belt use in Kentucky is about the national average but is lower in rural counties, and our traffic-death rate is high

Only two Kentucky counties, Boone and Kenton, used seat belts at the national average or above in 2012, according to the latest local data available from the Behavioral Risk Factor Surveillance System, an ongoing poll by the Centers for Disease Control and Prevention.

A county-level map from The Washington Post using data from 2012 shows Boone and Kenton counties in yellow, meaning their seat-belt use rate is above the 85.9 percent national average (as reported by people in the survey). A few other counties are in light orange, meaning their rate is between 80 and 85 percent: McCracken, Graves, Calloway, Marshall, Christian, Hopkins, Henderson, Daviess, Warren, Hardin, Jefferson, Oldham, Spencer, Anderson, Franklin, Scott, Fayette, Jessamine, Madison, Campbell, Pendleton and Boyd.

Because seat-belt use is more common in more heavily populated counties, outweighing lesser use in rural counties, Kentucky's statewide seat-belt use rate in 2014 was approximately the national average. However, the CDC says the state's traffic-death rate is much higher than the national average. According to the Kentucky State Police, about two-thirds of people killed in traffic accidents in the state were not using a seat belt.

Kentucky's seat-belt law requires the driver and all passengers to use seat belts, unless the passenger is a child less than 40 inches tall, in which case a child restraint system must be used. Children younger than 7 and between 40 and 50 inches must be in a booster seat, which uses a seat belt.

Foundation plans to be more active against tobacco, since it is the cause of many of Kentucky's health problems

As more Kentuckians favor a statewide smoking ban but the state legislature won't even ban smoking at schools, the Foundation for a Healthy Kentucky says it may become more active in lobbying against tobacco and for tobacco taxes because of the damage it does to the state's health.

Ben Chandler

"We are looking at the possibility of really getting involved in a big way," foundation President and CEO Ben Chandler told Deborah Yetter of The Courier-Journal. "It's just a hugely expensive problem we've got that badly affects the health of our people."

Yetter reports, "Chandler said the health costs of smoking are so huge for Kentucky – about $1.9 billion a year – that the foundation can no longer sit back and let other advocates lobby for changes meant to reduce smoking or improve public health, including a smoke-free law and cigarette tax hike.
The human toll of smoking is deadly in a state with the highest rate of cancer deaths, many linked to smoking, he said."

Chandler noted that an estimated 8,900 Kentuckians die each year from smoking-related causes, more than 10 times as many as die from traffic accidents. "With tobacco, it's a slow process," he said.

The latest Kentucky Health Issues Poll, co-sponsored by the foundation, found that a record 71 percent of Kentucky adults support a statewide smoking ban and only 25 percent oppose it.

The foundation has done relatively little lobbying, because of its nonprofit, tax-exempt status, but it can spend 15 percent of its annual budget on lobbying and stay within federal guidelines.

Chandler said it is ready to support an increase of at least $1 in Kentucky's 60-cents-a-pack cigarette tax. Such an increase would still leave the state short of the national average of $1.69.

The Republican-controlled legislature would normally be unlikely to entertain the idea of such a large tax hike, but Chandler suggested that it could become part of the legislative debate over tax reform, which Gov. Matt Bevin has indicated he wants to consider in a special session, along with shoring up funding of the state's pension systems.

In 2015, when the House was controlled by Democrats, it passed a statewide smoking ban, but the Senate never considered it. Later that year voters elected Gov. Matt Bevin, a Republican who says control of smoking is an issue for local governments, not the state. This year the Senate passed a ban on smoking at schools and school functions, but the bill didn't get a hearing in the House.

Chandler told Kentucky Health News that in addition to advocating such smoke-free measures, the foundation also expects to become more active at the local level, by urging officials to enact or strengthen smoking bans.

The foundation was created in 2001 with the charitable assets of the old Kentucky Blue Cross and Blue Shield mutual insurance company, now part of Anthem Inc. "Chandler, who was Kentucky attorney general at the time and helped create the foundation, said its assets are worth about $52 million," Yetter reports.

After losing the 2003 election for governor as the Democratic nominee, Chandler was elected to Congress from the 6th District, serving until his defeat by Republican Andy Barr in 2012. After a stint as executive director of the Kentucky Humanities Council, he became chief executive of the foundation Sept. 1.

"We want to have an impact on public policy," he told Yetter. "We want to identify things that policymakers can do to get the people of Kentucky to be healthier."

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.