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Rhode Island Department of Health logoOctober 2017
Health Connections
Public health news, advisories, and updates for licensed providers

                     James McDonald                Utpala Bandy                Dr. Clyne 

From the Director...


Dear Colleagues,

What memories come to mind for you when answering the question, “What was your favorite book to read when you were a child?” The goal is for reading to be a natural part of everyone’s childhood and education experience. Reading proficiency is a requirement and a necessity for any type of professional career, especially in healthcare. But sadly, it is not the norm for many Rhode Island children. In fact, in 2017, only 40% of third graders in our state are reading at grade level. That percentage drops dangerously low for students with disabilities (10%), Hispanic and Latino students (24%), low-income students (25%), and African American students (26%). These statistics are unacceptable, and that is why Governor Raimondo has charged the Rhode Island Children’s Cabinet (of which I am an active member) with the task that by 2025, we will double the percentage of third-graders who are reading at grade level.
 
Reading proficiently by the end of third grade is a crucial indicator in a child’s development. Students who are competent readers are more likely to perform well in other subjects, and students who do not read at grade level in third grade are four times more likely to drop out of high school. Education is one of the primary social determinants of health that will impact young Rhode Islanders for the rest of their lives.
 
The importance of reading does not begin when a child starts school. Beginning at birth, parents need to talk, read, and sing to their children as much as possible—in whatever language is commonly spoken in the home. This is the critical message we need to share repeatedly with the parents and families that we encounter in whatever setting we work. Talking, reading, and singing regularly, from day one, stimulates optimal levels of brain development and helps to assure that children enter kindergarten ready to learn. We need to encourage all parents and families that talking, reading, and singing to children can take place anytime and anywhere, not just stories before bedtime.
  • When you are in the car, sing along with songs on the radio or read street signs and billboard advertising.
  • Read food labels while you are making breakfast or lunch.
  • While you are doing errands, talk to your children about what you are thinking about doing next on your to-do list, and why you have those errands to run.
 
Assuring children are reading at grade level benefits us all. We want all children to have equal access and opportunities to become productive members of society. We want all children to succeed in whatever profession they choose. The impact on society as a whole cannot be under-estimated. For every student who does not complete high school, it costs about $260,000 in lost earnings, taxes, and productivity. Plus we know that a child who does not graduate from high school is at risk of living at least seven years less than someone who graduates from college.
 
The Children’s Cabinet has joined Rhode Island KIDSCOUNT and United Way in their Rhode Island Reads initiative. I invite all healthcare professionals to support and join our efforts to help all children become proficient readers:
  • Beginning at birth, urge parents and families to talk, read, and sing to their children as much as possible—in whatever language is commonly spoken in the home.
  • Remind parents of the importance of keeping up with regular doctor’s visits for babies and toddlers, especially the ones that include important developmental screenings.
  • Refer children who may have developmental challenges to the resources and services they need.
  • Participate in Reach Out and Read Rhode Island, a program that incorporates books into pediatric care and encourages families to read aloud together. Learn more about the Rhode Island chapter at www.rorri.org
  • Download and distribute parent tip sheets from www.readingrockets.org. The fact sheets are available in 11 languages and for seven life stages – infants, toddlers, pre-K, kindergarten, grade one, grade two, and grade three.
  • Check out the Rhode Island Children’s Cabinet website, www.kids.ri.gov to get the English and Spanish.
  • Learn about and support Rhode Island Reads at www.rireads.org.
 
Thank you for everything you do, and will continue to do to help Rhode Island children read and succeed.
 
Sincerely,

Nicole Alexander-Scott, MD, MPH
Director of Health


FOR ALL CLINICIANS

 

Proper Medication Disposal

One challenge of assuring prescription medications are not misused or diverted is agreement on a standard method for proper disposal of unused medications (prescription and over-the-counter). In the federal government’s article Prescription Drug Use and Misuse in the United States: Results from the 2015 National Survey on Drug Use and Health, it showed that 54% of people who abused opioids purchased, were given, or stole them from a friend or relative. It has become increasingly important that healthcare providers educate their patients about the proper way to dispose of any unused medications – opioids included. The FDA recommends flushing unused opioids. Opioids can also be discarded in the regular trash if they are crushed and mixed with coffee grounds or kitty litter or can be brought to a drug-disposal site.
 
One study, Prescription Opioid Analgesics Commonly Unused After Surgery, reviewed six other studies involving 810 patients. The authors looked at multiple possible outcomes, including filling a prescription but not taking some or all of it, to examine trends in opioid use. The study found between 42% and 71% of opioid pills went unused.  Very few patients (4% to 30%) planned to dispose of their unused medications or actually disposed of them. Only 4% to 9% planned or actually used FDA-recommended disposal methods.
 
Here are some resources to share with patients on safe disposal of unused or expired medications:
  • US Food and Drug Administration’s (FDA) website includes information on proper disposal of medications.
  • The Rhode Island Resource Recovery Corporation’s (RIRRC) website has a list of police departments in the state that have medication return drop boxes.
  • Some retail pharmacies have drug take-back containers; however, not all pharmacies can take back all medications. Patients should call the pharmacy to ask what medications they can accept. 
 

Alert: Prescription Fraud

Numerous provider practices have reported to RIDOH that they have received unsolicited faxes from out-of-state pharmacies asking for permission to fill prescriptions for compounded medications or for diabetic testing supplies. In many cases, a fax listed four or five prescriptions stating the need for refills to be authorized. These faxed prescriptions are often sent by a marketing company, and a compounded prescription may cost more than $1,000 to fill.
 
RIDOH urges all provider practices to verify any prescription refill requests with a patient’s medication history and/or medical record. If medical records cannot validate a refill request, providers should call the patient to verify the request. Please report any prescription fraud to RIDOH Board of Pharmacy Chief Compliance Officer Scott Campbell at 222-7892.

 

New STD Ad Campaign Targets High-Risk Individuals

RIDOH launched a multimedia advertising campaign the week of October 23 to address the surge in sexually transmitted diseases (STDs). As RIDOH reported in an August 22 provider advisory, a surge in the number of new diagnoses of STDs, including chlamydia, gonorrhea, and syphilis, were identified in 2016. These trends in Rhode Island mirrored national trends.
 
The ad campaign targets high-risk populations and includes messages about STD prevention and testing that will be shared on social media sites such as Facebook, Instagram, and YouTube, as well as popular dating and “hook up” apps, such as Tinder, Grindr, and Scruff. Patients may begin referencing messages from this campaign and providers could see an increase in requests for STD counseling or testing. Please review the provider advisory outlining what providers can do and resources for clinicians.
 
RIDOH is also revamping patient-centered STD web pages and has launched an enhanced, interactive condom-finder map showing Rhode Islanders where they can get free, RIDOH-supplied condoms at community partner sites throughout the state. See RIDOH’s healthcare provider STD web page for more information.



Flu Vaccination Campaign Kicks Off In Rhode Island

As October draws to a close, flu-vaccination season is well underway. Getting a flu shot every year is the easiest and best way to protect against the flu. Last year, Rhode Island had the highest flu vaccination coverage rate in the nation for people six months and older at 55.4%. However, this means that almost half of Rhode Islanders were not vaccinated. Anyone six months of age and older should get a flu shot, but it is especially important for high-risk individuals to be vaccinated as they are more likely to develop serious complications or to be hospitalized from the flu. High-risk individuals include anyone age 50 or older; pregnant women; healthcare workers; and people with weakened immune systems or long-term, chronic medical conditions such as diabetes, asthma, heart disease, and cancer.
  • CDC recommends vaccination before the end of October, if possible.
  • Although FluMist is not available again this year, it is critical for providers to give a strong recommendation for the flu shot to all parents. Please remind parents that any discomfort their child may experience from getting a flu shot is extremely mild compared to symptoms of the actual flu, which can be deadly.
  • All healthcare workers are strongly urged to be vaccinated. At certain healthcare facilities in Rhode Island, healthcare workers are required to either be vaccinated against the flu annually, or wear surgical masks when the Director of Health declares flu to be widespread in the state (requirementsummary of requirement).
  • School-based influenza vaccination clinics began on October 2. Insurance information will be collected from adults and students who are insured; however, no one will be turned away for lack of insurance. Most evening clinics are open to family and community members.
  • Right now, influenza activity in the United States is low. Learn more about CDC’s influenza surveillance efforts.
  • Resources
 

SIM Supports Provider-Patient Engagement On End-of-Life Care

The State Innovation Model (SIM) Test Grant is funding two new patient engagement projects aimed at helping providers and patients navigate difficult conversations surrounding end-of-life care.

The first project is a Complex Care Conversations Training program facilitated by Hope Hospice and Palliative Care. A three-year initiative, the project will focus on education and training to increase providers’ ease and effectiveness in establishing care conversations with patients who are dealing with serious, progressive illness. The overarching goal of this initiative is to increase engagement among providers, patients, and families in advance-care planning and to improve the health literacy of patients and families around goals of care and treatment options in the face of advanced illness. The strategy to achieve this will be to train generalist care providers throughout Rhode Island on advance care planning and complex care conversations. This model, developed by palliative education pioneer Dr. David Weissman, has been shown to increase conversations between clinicians and patients with advanced illness and their families and has enhanced patient and family satisfaction.

The second project, an Advance Care Planning Training Program facilitated by Healthcentric Advisors and the Improving End of Life Care Coalition, will promote effective collaboration among patients, families, community organizations, legal services, and providers to enhance patient engagement in end-of-life care decision-making. Implementation of the project involves three components:
  • Consumer education and outreach, including targeted engagement of the Latino community through a partnership with Progreso Latino and faith communities;
  • Cross-cutting provider education and outreach; and
  • An Advance Care Planning group medical visit pilot project for Medicare beneficiaries.
Both projects seek to build a culture that normalizes advance-care planning and end-of-life conversations for providers, patients, and their families as well as reduce unwanted healthcare utilization in the final years of life.
Providers interested in enhancing their ability to engage patients and families in informed decision-making and improve care coordination are encouraged to participate in one of these training programs. For more information, email Betsy Kerr, and  for more information about SIM and its programs, visit the SIM webpage.
 
 

Effects of Smoking and Smoking Cessation During Pregnancy on Adverse Birth Outcomes in Rhode Island, 2012–2014

Rhode Island data show that one in 12 Rhode Island women who delivered a live infant during 2012-2014 smoked in the last three months of pregnancy, and there were significant disparities among populations in prenatal smoking prevalence. These new data can be strategically used by providers to communicate the benefits of quitting, increase motivation to quit, and engage pregnant smokers in supportive services that help them quit and stay quit.
 
Download the complete Health by Numbers article to learn about how smoking risks during pregnancy affect Rhode Islanders and how clinicians can support smokers who are pregnant in their quit journey. The article also contains free resources for clinicians and patients.
 

Help Pregnant Smokers Quit for Good: Free Cessation Services Available

QuitWorks-RITM invites all clinicians to refer smokers who are pregnant for free, telephonic cessation counseling services. There is no cost for clinicians or patients to participate. All clinicians will receive follow-up reports from QuitWorks-RI counselors for patients who participate. All services are sponsored by RIDOH.

QuitWorks-RITM is also available to anyone of any age who wants to quit smoking. Interested individuals can participate at no cost and may also be eligible for free nicotine replacement therapy (NRT) as gum, patch, or lozenge in two-week supplies while supplies last. Submit patient referrals electronically or by fax. Need free promotional materials for the 2017 Great American Smokeout on November 16? Click here!

 

CDC and RIDOH Update Zika Clinical Guidance

On July 24, the Centers for Disease Control and Prevention (CDC) released updated guidance for healthcare providers who care for pregnant women and babies with possible Zika virus exposure. This action was taken in response to the declining prevalence of Zika virus disease in the Americas and the emerging evidence indicating prolonged detection of Zika virus immunoglobulin (IgM) antibodies. As the prevalence of Zika virus disease declines, the likelihood of false-positive test results increases, and IgM results cannot reliably distinguish between current and previous infections. These guidelines emphasize a shared decision-making model between the provider and the patient. CDC has updated materials and RIDOH’s Center for Acute Infectious Disease Epidemiology (CAIDE) has compiled this information and its updated Zika testing tables into an online packet that may be downloaded.

 

Upcoming Educational Opportunities


Single-Payer Systems: Why They've Failed So Far and How They Can Succeed
November 1, 5:30 p.m.
LOCATION: Alpert Medical School, 222 Richmond St., room 160, Providence
This program features guest speaker John McDonough, DrPH, MPA. Dr. McDonough  is a Professor of Public Health Practice at Harvard School of Public Health, a former Senior Advisor on National Health Reform to the US Senate, and the former Executive Director of Health Care for All.
Register online.

Temas Familiares Conference: Practical Ideas for Raising and Educating Children
November 4, 8 a.m. - 12:30 p.m.
LOCATION: Juanita Sanchez Educational Complex, 182 Thurbers Ave., Providence
This half-day conference will feature keynote speaker Javier Torres.
REGISTRATION: This program is free and is open to anyone who is interested. Register online.

Screening and Addressing Suicide Risk for Patients and Families in Pediatric and Adolescent Primary Care
November 7, 7:30 a.m. - 8:45 a.m.
LOCATION: Thundermist Health Center Conference Room, Wakefield
Primary care physicians constantly report a lack of confidence in their ability to assess and intervene for youth suicidality. Physicians will learn how to properly assess patients for suicide risk using screening tools. Participants will also learn about the local community resources available to providers and their patients. Co-presented by Jennifer Jencks, PhD; Assistant Director of the Access Center at Bradley Hospitals and Jeffrey Hill, MS; Program Manager for RIDOH's Violence and Injury Prevention Program; Providers can attend via live webcast or in person
REGISTRATION: Register online through Alpert Medical School's Office of Continuing Education.
 

 

FOR PHYSICIANS

 

Prescribing Opioids For Acute Pain? Consider Using Do not fill after date

A message from James McDonald, MD, MPH
Chief Administrative Officer for the Board of Medical Licensure and Discipline


If you prescribe opioids for acute pain to a patient who is new to the prescription of opioids, regulations limit the initial prescription to no more than 20 doses and no greater than 30 MME/day.(1) Every effort should be made to utilize alternatives to opioids, when possible. 
 
It is important to remember that when you prescribe a schedule II opioid, the prescription is valid for 90 days.(2) The Vicodin or Percocet prescription that you prescribed in good faith for an acute injury, can be filled by your patient any time in the next 90 days – even if it is not filled immediately as you anticipated. Keep in mind that most patients do not understand the power or potential risk associated with an opioid prescription. Patients must be educated in a manner that resonates with them about the risks and the benefits.(3) If prescribing opioids, the practitioner will advise patients specifically about adverse risks of taking alcohol or other psychoactive medications (e.g., sedatives and benzodiazepines), tolerance, dependence, addiction overdose or death if acute or long-term use.
 
Prescribers should also know it is common for opioid prescriptions given after a surgical procedure to remain unfilled or go unused(4) or not be appropriately discarded. Many patients have unused opioids kept somewhere in their home, and the unused medication creates a clear risk for misuse. Prescribers should document in the medical record that a patient is advised to appropriately dispose of any unused medication. The FDA recommends flushing unused opioids, although they also can be discarded in the regular trash if they are crushed and mixed with coffee grounds or kitty litter or they can be brought to a drug-disposal site.(5) Documenting that you educated your patient about safe disposal and storage is also a regulatory requirement: Acknowledgment that it is the patient's responsibility to safeguard all medications and keep them in a secure location; and educate patient regarding safe disposal options for unused portion of a controlled substance.(6)
 
If you prescribe an opioid for acute pain, consider, as a best practice, writing Do not fill after date on the prescription.  For example, if you decide to prescribe an opioid for a fracture, write on the prescription Do not fill if not filled within three days of date written – or simply insert a specific date after which the prescription should not be filled. If the medication is not filled immediately, it is likely that it is being filled for an unintended purpose and may be diverted or misused. If the medication you prescribed is diverted or misused, you are responsible for that prescription. Writing a Do not fill after date stipulation protects the patient, your reputation, and your license.
 
1. Pain Management, Opioid Use and the Registration of Distributors of Controlled Substances in Rhode Island. http://sos.ri.gov/documents/archives/regdocs/released/pdf/DOH/8564.pdf
2. Controlled Substances. State of Rhode Island: Department of Health, www.health.ri.gov/healthcare/medicine/about/controlledsubstances/
3.www.health.ri.gov/regulations/?parm=Addiction+and+Overdose  Pain Management, Opioid Use and the Registration of Distributors of Controlled Substances in Rhode Island. Section D http://sos.ri.gov/documents/archives/regdocs/released/pdf/DOH/8564.pdf
4. Bicket, MD Mark C. “Unused Prescription Opioids After Surgery.” JAMA Surgery, 2 Aug. 2017, jamanetwork.com/journals/jamasurgery/article-abstract/2644905?utm_source=Silverchair_Information_Systems&utm_campaign=FTM_07312017&utm_content=news_releases&cmp=1&utm_medium=email.
5. Safe Disposal of Household Medical Waste. State of Rhode Island: Department of Health, www.health.ri.gov/healthrisks/householdmedicalwaste/.
6.www.health.ri.gov/regulations/?parm=Addiction+and+Overdose  Pain Management, Opioid Use and the Registration of Distributors of Controlled Substances in Rhode Island. Section D
 


FOR ORAL HEALTH PROFESSIONALS

 

News From RIDOH's Oral Health Program

  • Save The Date: 2018 Rhode Island Dentistry Mini-Residency: Join us for the third annual mini-residency, Communication Tools and Trends. This continuing education opportunity will be held on March 9-10, 2018, at the Crowne Plaza in Warwick. The program is open to all providers and staff and will cover communication topics not typically addressed by the dental team and best practices in communication.
  • Impact of Medicaid Expansion: Read about what RIDOH learned from recent Medicaid data about the impact of the Medicaid expansion on use of services by adults. The Health by Numbers article  was published in the October 2017 issue of the Rhode Island Medical Journal.
  • Dental Assistant Registry: Dental hygienists and dentists should encourage their dental assistant colleagues to enroll in the Rhode Island Dental Assistant Registry. Assistants who sign up can receive Health Connections and additional announcements of value to the dental team. Learn more about the registry in the  October 4 Provider Advisory.
  • Webinar on Oral Health and Substance-Use Disorders: The Substance Abuse and Mental Health Services Administration (SAMSHA) presents a webinar for the dental team entitled Clinical Best Practices for Improving the Oral Health of Individuals with Substance-Use Disorders. The webinar is November 16, 2 p.m. - 3 p.m., and will identify ways the oral health and behavioral health professionals and safety net healthcare systems can integrate oral health into the care of patients with substance-use disorders. Access the webinar online or dial in at 888-456-0283, passcode 6002636.
 

FOR PHARMACISTS

 

Pharmacies Can Now Enter Antagonists Dispensed Into Database

As of October 16, retail pharmacies in Rhode Island will be able to transmit all opioid antagonists dispensed (such as naloxone) to the Prescription Drug Monitoring Program’s (PDMP) database pursuant to RIGL 21-28-3.18. The PDMP database vendor has assured RIDOH that users will not need to do anything differently with the pharmacy’s operating systems. Pharmacies should include all opioid antagonists dispensed along with schedules II-V controlled substances when transmitting.
 
The legislation requires that information regarding opioid antagonists is only viewable in aggregate format and not attributable to individual patients when prescribers or pharmacists request a PDMP report. The database vendor has configured the system to comply with this law, and the data received for opioid antagonists dispensed from pharmacies will be utilized as stipulated in the legislation. Any questions regarding transmission of these data can be directed to PDMP AWARxE technical assistance team at 844-474-4767.


 

FOR NURSES

 

Coming Soon: Important Changes To Nursing Compact

As of January 19, 2018, the Enhanced Nurse Licensure Compact (eNLC) will be implemented.
Rhode Island is not a member of the eNLC. (Only four states – Colorado, New Mexico, Rhode Island, and Wisconsin – are still under the original Nurse Licensure Compact.)
 
Compact nurses who work in Rhode Island and are licensed by a state other than New Mexico, Colorado, or Wisconsin, must apply for a Rhode Island nursing license in order to work in Rhode Island after January 19, 2018. Compact licenses will no longer be valid. If a nurse does not apply for a Rhode Island nursing license and continues to work in Rhode Island, he/she will be subject to disciplinary action, as they will be working without a valid Rhode Island nursing license.
 
In the next month, the National Council of State Boards of Nursing (NCSBN) will send a letter to all RNs and LPNs licensed in Rhode Island about the transition of the compact. As more information is available, it will be shared in future issues of Health Connections. Questions can be directed to Director of the Rhode Island Board of Nurse Registration and Nursing Education Margaret L. Clifton.


 

FOR EMERGENCY MEDICAL SERVICES PROFESSIONALS


FEMA Course Equips Citizens To Manage Until Help Arrives

As with promoting awareness of hands-only CPR, emergency providers should continue to engage with the community about saving lives. As the country tries to heal after the mass shooting in Las Vegas and recover from a hurricane season with such devastation, FEMA’s new community-based program, Until Help Arrives, provides an opportunity for first responders to help citizens learn a skill set that is vital in saving a life.
 
RIDOH’s Center for Emergency Medical Services urges local pre-hospital care departments to reach out to their community and bring this program to cities and towns across the state. The program teaches the proper use of tourniquets and other ways to help those who suddenly become sick or injured. The program also discusses what information should be given to the 9-1-1 dispatcher and how to comfort and reassure victims while waiting for first responders to arrive.
 
First responders with teaching experience are encouraged to offer the training in their communities. There is guidance for instructors online, but there is no formal instructor training required that is required. Program participants will not receive an official certification; however, a locally created certificate of attendance is often presented at the end of the class.
 
Learn more about the Until Help Arrives program and download resources and information.
 

 

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Quick Links

  
Health Connections is brought to you by the Rhode Island Department of Health. Our physician community includes:

Nicole Alexander-Scott, MD, MPH; Director of Health
James McDonald, MD, MPH; Chief Administrative Officer for the Board of Medical Licensure and Discipline
Utpala Bandy, MD, MPH; Director, Division of Preparedness, Response, Infectious Disease, and Emergency Medical Services
Ailis Clyne, MD, MPH; Medical Director, Division of Community Health and Equity

The Health Connections editor is Annemarie Beardsworth.  

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