Sarah Jane Tribble, KFF Health News
Wed, 04 Oct 2023 09:00:00 +0000

CLARKSVILLE, Tenn. — On a hot July morning, customers at the Dollar General along a two-lane highway northwest of Nashville didn't seem to notice signs of the chain store's foray into mobile health care, particularly in rural America.

A woman lifted a child from the back of an SUV and walked into the store. A dog barked from a black pickup truck before its owner returned with cases of soda. Another woman checked her hair in a convertible's rearview mirror before shopping.

Each went right by a sign exclaiming “Quick, Easy Health Visits,” with an image of a mobile clinic.

Just after 10 a.m., registered nurse Kimberly French arrived to work at the DocGo mobile clinic parked in the store's lot. She checked her schedule.

“We don't have any appointments so far today, but that could change,” French said. “Last night we didn't have any appointments and three or four people showed up all at one time.”

Dollar General, the nation's largest retailer by number of stores, with more than 19,000, partnered with New York-based mobile medical services company DocGo to test whether they could draw more customers and tackle persistent health inequities.

Deploying mobile clinics to fill care gaps in underserved areas isn't a new idea. But pairing them with Dollar General's ubiquitous small-town presence has been heralded by investment analysts and some rural health experts as a way to ease the health care drought in rural America.

Dollar General's latest annual report notes that about 80% of the company's stores are in towns with populations of fewer than 20,000 — precisely where medical professionals are scarce.

Catering to those who want urgent or primary care, the mobile clinics take private insurance as well as Medicaid and Medicare. The company's website says DocGo's self-pay rates start at $69 for patients without insurance or who are out of network. DocGo officials said Tennessee patients may be charged different rates but declined to provide details.

On the ground in Tennessee, primary care doctors and patients are skeptical.

“Honestly, they don't really grasp, I don't think, what they're getting into,” said Brent Staton, a family medicine doctor and the leader of the Cumberland Center for Healthcare Innovation, a statewide organization that helps small-town family care doctors coordinate care and negotiate with insurers, including Medicare.

Michelle Green manages the popular Sweet Charlotte grill about 10 miles south of Dollar General's most rural test site. Green, who was handing out hamburgers and hand-cut fries during a Saturday rush, said she hadn't heard of the mobile clinic. She said with a shrug that Dollar General and health care clinics “don't go together.”

“I wouldn't want to go to a health care clinic in a parking lot; that's just me,” Green said, adding that someone might go if “you're sick and you can't go anywhere else.”

Bumps in the Road

The Clarksville-area pilot, which launched last fall, is in a federally designated primary care shortage area for low-income residents.

About 1,000 patients have been seen in the company's clinics, either at Dollar General sites or community pop-up events, and some became repeat visitors, according to DocGo. Payment is taken outside on a mobile device and, once inside, patients meet with an on-site staff member, like French, and connect via telehealth on an iPad screen with a physician assistant or nurse practitioner.

The clinic rotates between three Dollar General pilot sites each week. The stores are in the Clarksville area and, early this summer, the van stopped going to the most rural site, near Cumberland Furnace, because of low utilization, according to company leaders. DocGo moved that location's time slot to busy Fort Campbell Boulevard in Clarksville.

“We do try for months in a given area to see where it makes sense and where it doesn't,” former DocGo CEO Anthony Capone said in a July interview. “Our goal is to align the supply we have with the demand of the local community.”

Capone, though, said he thought the pilot would work in rural areas when insurers are signed on to refer their members to the mobile clinic. DocGo recently announced a deal with Blue Cross Blue Shield of Tennessee.

Capone abruptly resigned on Sept. 15 after the Albany Times Union reported he lied about having a graduate degree.

Dollar General stores have a “tremendous opportunity” to have “a major impact on health there and really bond themselves as a member of the community,” said Tom Campanella, the healthcare executive-in-residence at Baldwin Wallace University, who has managed mobile clinics in rural places.

Near tiny Cumberland Furnace, south of Clarksville, William “Bubba” Murphy stopped on his way into a Dollar General, paused to wave and holler hello to friends getting out of their cars, and shared that multiple family members — his sister-in-law, nephew, and niece's boyfriend — used and liked “the little clinic on wheels.”

“We don't have to go to town and fight all that traffic,” he said. “They come to us. That's a wonderful thing. It helps a lot of people.”

Over on busy Fort Campbell Boulevard in Clarksville, Marina Woolever, a mother of three, said she might use the clinic if she didn't have insurance. Natural health professional Nichole Clemmer glanced toward the clinic and called it a “ploy” to make more money.

Jefferies lead equity analyst Corey Tarlowe, who follows discount retailers, said the clinics will help “democratize” access to health care and simultaneously boost traffic to Dollar General stores.

With its rapid growth in recent years, Dollar General has faced accusations that its stores kill off local grocery stores and other businesses, reduce employment, and contribute to the creation of food deserts. More recently, the U.S. Labor Department said the chain “continues to discount safety” for employees as it has piled up more than $21 million in federal fines.

Crystal Luce, senior director of public relations for Dollar General, said the company believes each new store provides “positive economic benefits,” including new jobs, low-cost products, and its literacy foundation. On the federal fines, Luce said Dollar General is “committed to providing a safe work environment for its associates and shopping experience for its customers.” The company declined to provide an interview.

The DocGo pilot, she wrote, is intended to “complement” the DG Wellbeing initiative, which is a corporatewide push. Dollar General wants to increase “access to basic health care products and, ultimately, services over time, particularly in rural America,” Luce wrote.

States away, DocGo is under fire for a no-bid contract to provide housing, busing, and other services for asylum-seekers in New York. State Attorney General Letitia James is investigating complaints levied by migrants under the company's care. In August, DocGo officials said claims aired by sources in a New York Times article that first reported the problems were “not reflective of the overall scope and quality” of the services the company has provided.

The company's pilot with Dollar General is “supported with funding from the state of Tennessee,” DocGo's Capone said during the company's first-quarter earnings call. The Dollar General partnership is cited in quarterly grant reports DocGo's Rapid Reliable Testing LLC submitted to the state, according to records KFF Health News obtained through public information requests.

In the grant filing, DocGo listed Dollar General along with other organizations as “trusted messengers” in building vaccine awareness.

Dollar General declined to respond to a question about its involvement in the grant. Instead, Luce stated, “We continue to test and learn through the DocGo pilot.”

‘Relational Care'

The goal of the $2.4 million grant, funded by the Centers for Disease Control and Prevention and distributed by the Tennessee Department of Health, is to administer covid-19 vaccines. In a written response provided by DocGo's marketing director, Amanda Shell Jennings, the company said, “Dollar General has no involvement with the TN Department of Health grant funding or allocations.”

The grant covers storage and maintenance of covid-19 vaccines on the DocGo mobile clinics, Jennings' statement said, adding that, as of September, DocGo has held 41 vaccine events and provided 66 vaccines to rural Tennesseans.

Lulu West, 72, was visiting a friend at the Historic Cumberland Furnace Iron Museum when she stopped to consider the mobile clinic. West said she would rather go to her primary care doctor.

“When you say mobile clinic outside a Dollar General it just kind of has a connotation that you may not be comfortable with. You know what I mean?” she said.

That kind of response doesn't surprise Carlo Pike, a doctor who for years has practiced family medicine in Clarksville. He said he's not worried about the competition because providing primary care is about developing relationships.

“If I can do this relationship right,” Pike said, “maybe we can keep you from getting a [blood] sugar of 500 [mg/dL] or from Grandpa climbing up a ladder and trying to fix something he has no business with and falling off and breaking his leg.”

Staton said the Cumberland Center for Healthcare Innovation, his accountable care organization, has saved Medicare and Medicare Advantage companies more than $100 million by focusing on preventive care and reducing hospitalizations and emergency visits for patients.

“We're just small rural primary care docs doing our jobs with a process that works,” Staton said. In another interview, Staton called it “relational care.”

DocGo surveyed its patients and found that 19% of them did not have a primary care physician or hadn't seen theirs in more than a year. In the written responses Jennings provided, DocGo said it follows up with every patient after the initial visit, offers telemedicine support between visits, and provides ongoing preventive care on a regular schedule.

But despite its outreach, DocGo struggled to get a foothold in rural Cumberland Furnace.

Lottie Stokes, the president of the community center in Cumberland Furnace, said DocGo's team had “called and asked to come down here.” Stokes said she would rather use the local emergency medical technicians and firefighters, who she knows are “legit.”

Her father-in-law, Bobby Stokes, who's nearly 80 years old, said he used the mobile clinic before it moved locations.

His wife couldn't breathe. They pulled into the parking lot and climbed onto the van.

“We wasn't in there five minutes,” he said. “They done the blood pressure test and what they need to do and put her in the car and said, ‘Get her to the hospital, to the emergency room.'”

The DocGo staff, he said, did not ask for payment: “Nothing.”

“They were more concerned with her than they were with I guess getting their money,” he said, adding that his wife is doing well now. “They told me to get there, and I took them at their word. My car runs fast.”

KFF Health News correspondent Brett Kelman contributed to this report.

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By: Sarah Jane Tribble, KFF Health News
Title: What Mobile Clinics in Dollar General Parking Lots Say About Health Care in Rural America
Sourced From: kffhealthnews.org/news/article/mobile-clinics-docgo-dollar-general-parking-lots-tennessee/
Published Date: Wed, 04 Oct 2023 09:00:00 +0000

Did you miss our previous article…
https://www.biloxinewsevents.com/more-schools-stock-overdose-reversal-meds-but-others-worry-about-stigma/

Rae Ellen Bichell and Virginia Garcia Pivik
Tue, 03 Oct 2023 09:00:00 +0000

Last year, a student fell unconscious after walking out of a bathroom at Central High School in Pueblo, Colorado. When Jessica Foster, the school district's lead nurse, heard the girl's distraught friends mention drugs, she knew she had to act fast.

Emergency responders were just four minutes away. “But still four minutes — if they are completely not breathing, it's four minutes too long,” Foster said.

Foster said she got a dose of naloxone, a medication that can rapidly reverse an opioid overdose, and gave it to the student. The girl revived.

Forty-five miles away in Colorado Springs, Mitchell High School officials didn't have naloxone on hand when a 15-year-old student overdosed in class in December 2021 after snorting a fentanyl-laced pill in a school bathroom. That student died.

Colorado Springs' school district has since joined Pueblo and dozens of other districts in the state in supplying middle and high schools with the lifesaving medication, often known by one of its brand names, Narcan. Since passage of a 2019 state law, Colorado has had a program that allows schools to obtain the medicine, typically in nasal spray form, for free or at a reduced cost.

Not all schools are on board with the idea, though. Though more districts have signed on since last year, only about a third of Colorado districts had enrolled in the state's giveaway program at the start of this school year. And within the dozen counties with the highest drug overdose death rates in the state, many school districts had not signed up in the face of ongoing stigma around the need for the overdose reversal medication.

The federal Substance Abuse and Mental Health Services Administration recommends that schools, including elementary schools, keep naloxone on hand as fatal opioid overdoses rise, particularly from the potent drug fentanyl. And 33 states have laws that expressly allow schools or school employees to carry, store, or administer naloxone, according to Jon Woodruff, managing attorney at the Legislative Analysis and Public Policy Association, which tracks naloxone policies across the country.

Among those, about nine states require at least some K-12 schools to store naloxone on-site, including Illinois, whose requirement goes into effect in January. Some states, such as Maine, also require that public schools offer training to students in how to administer naloxone in nasal spray form.

Rhode Island requires all K-12 schools, both public and private, to stock naloxone. Joseph Wendelken, a spokesperson for the Rhode Island Department of Health, said in the past four years naloxone was administered nine times to people ages 10 to 18 in educational settings.

In early September, the medication also became available over the counter nationally, though the $45 price tag per two-dose package has some addiction specialists worried it will be out of reach for those who need it most.

But the medicine still isn't as publicly widespread as automated external defibrillators or fire extinguishers. Kate King, president of the National Association of School Nurses, said reluctance to stock it in schools can stem from officials being afraid to provide a medical service or the ongoing cost of resupplying the naloxone and training people to use it. But the main hang-up she's heard is that schools are afraid they'll be stigmatized as a “bad school” that has a drug problem or as a school that condones bad choices.

“School districts are very careful regarding their image,” said Yunuen Cisneros, community outreach and inclusion manager at the Public Education & Business Coalition, which serves most of the state's school districts. “Many of them don't want to accept this program, because to accept it is to accept a drug addiction problem.”

That's the wrong way to think about it, King said. “We really equate it to our stock albuterol for asthma attacks, our stock epinephrine for anaphylactic reactions,” she said.

Colorado health officials could not say how often naloxone had been used on school grounds in the state. So far this year, at least 15 children ages 10 to 18 have died of fentanyl overdoses but not necessarily in schools. And in 2022, 34 children in that age group died, according to the state Department of Public Health and Environment. That included 13-year-old José Hernández, who died in August 2022 from a fentanyl overdose at home just days after starting eighth grade at Aurora Hills Middle School. His grandmother found his body over the bathroom sink in the early morning.

With the arrival of this new school year, supplies of naloxone are on hand for kids in more Colorado schools. Last year, state lawmakers appropriated $19.7 million in federal aid to the Naloxone Bulk Purchase Fund, which is accessible to school districts, jails, first responders, and community service organizations, among others.

“It's the most we've ever had,” said Andrés Guerrero, manager of the state health department's overdose prevention program.

According to data provided by Colorado's health department, 65 school districts were enrolled in the state program to receive naloxone at low or no cost at the start of the school year. Another 16 had reached out to the state for information but hadn't finalized orders as of mid-August. The remaining 97 school districts either didn't stock naloxone at their schools or sourced it from elsewhere.

Guerrero said the districts decide whom to train to administer the medicine. “In some cases, it's just the school nurses. In some cases, it's school nurses and the teachers,” he said. “And in some cases, we have the students as well.”

In Durango, the 2021 death of a high schooler galvanized students to push for the right to carry naloxone with them to school with parental permission — and to administer it if need be — without fear of punishment.

It took picketing outside a school board meeting to get permission, said Hays Stritikus, who graduated this spring from Durango High School. He's now involved in drafting legislation that would expressly allow students across the state to carry and distribute Narcan on school grounds.

“The ultimate goal is a world where Narcan is not necessary,” he said. “But that's just not where we live.”

Some health experts disagree that all schools should stock naloxone. Lauren Cipriano, a health economist at Western University in Canada, has studied the cost-effectiveness of naloxone in secondary schools there. While opioid poisonings have occurred on school grounds, she said, high schools tend to be really low-risk settings.

More effective strategies for combating the opioid epidemic are needle exchange sites, supervised drug consumption sites, and medication-assisted treatment that reduces cravings or mutes highs, Cipriano said. But those approaches can be expensive compared with naloxone distribution.

“When the state makes a big, free program like this, it looks like they're doing something about the opioid epidemic,” she said. “It's cheap and it looks like you're doing something, and that's, like, political gold.”

Denver Public Schools, the largest school district in Colorado, started stocking naloxone in 2022, said Jade Williamson, manager of the district's healthy schools program.

“We know some of the students are on the forefront of these things before older generations,” Williamson said. “To know where to find it, and to access it when needed through these adults who've trained, whether that's a school nurse or a school administrator, I think it brings them some sense of relief.”

The state's seven largest districts, with more than 25,000 students each, all participate in the state program. By contrast, a KFF Health News analysis found, only 21% of districts with up to 1,200 students have signed up for it — even though many of those small districts are in areas with drug overdose death rates higher than the state average.

Some school districts figured out a path to getting naloxone outside of the state program. That includes Pueblo School District 60, where lead nurse Foster gave naloxone to a student last year.

The Pueblo school district gets naloxone at no cost from a local nonprofit called the Southern Colorado Harm Reduction Association. Foster said she tried signing up for the state program but encountered difficulties. So she decided to stick with what was already working.

Moffat County School District RE-1 in Craig, Colorado, gets its naloxone from a local addiction treatment center, according to district nurse Myranda Lyons. She said she trains school staffers on how to administer it when she teaches them CPR.

Christopher deKay, superintendent of Ignacio School District 11Jt, said its school resource officers already carry naloxone but that the district enrolled in the state program, too, so that schools could stock the medication in the nursing office in case a resource officer isn't around.

“It's like everything — like training for fire safety. You don't know what's going to happen in your school,” said deKay. “If the unthinkable happens, we want to be able to respond in the best way possible.”

This story was produced with reporting assistance from El Comercio de Colorado.

——————————
By: Rae Ellen Bichell and Virginia Garcia Pivik
Title: More Schools Stock Overdose Reversal Meds, but Others Worry About Stigma
Sourced From: kffhealthnews.org/news/article/schools-narcan-naloxone-overdose-reversal-colorado/
Published Date: Tue, 03 Oct 2023 09:00:00 +0000

Markian Hawryluk and Renuka Rayasam
Mon, 02 Oct 2023 09:00:00 +0000

The way Sheldon Haleck's parents see it, the 38-year-old's only crime was jaywalking. But that March night in 2015, after Honolulu police found him behaving erratically, they pepper-sprayed him, shocked him with a Taser, and restrained him. Haleck became unresponsive and was taken to a hospital. Before his parents could get from their home in Utah to Hawaii, the former Hawaii Air National Guardsman was taken off life support.

“Nobody's supposed to die from something like this,” said Haleck's father, William.

An initial autopsy ruled Haleck's death a homicide and his family filed a civil lawsuit in federal court against the three officers who tried to remove him from the street. The case should have been “one of the easiest wrongful death cases” to win, said Eric Seitz, an attorney who represented Haleck's family.

But the officers' attorneys seized on a largely discredited, four-decade-old diagnostic theory called “excited delirium,” which has been increasingly used over the past 15 years as a legal defense to explain how a person experiencing severe agitation can die suddenly through no fault of the police. “The entire use of that particular theory, I think, is what convinced the jury,” Seitz said.

Haleck's case is just one legal battle in which the theory of excited delirium exonerated law enforcement despite mounting opposition to the term among most prominent medical groups. The theory has been cited as a defense in the 2020 deaths of George Floyd in Minneapolis; Daniel Prude in Rochester, New York; and Angelo Quinto in Antioch, California. It figures in a criminal trial against two police officers involved in the 2019 death of Elijah McClain in Aurora, Colorado, now underway. It has allowed defense attorneys to argue that individuals in police custody died not of restraint, not of a Taser shock, but of a medical condition that can lead to sudden death.

But now, the American College of Emergency Physicians will vote at an October meeting on whether to formally disavow its 2009 position paper supporting excited delirium as a diagnosis that helped undergird those court cases. The draft resolution also calls on ACEP to discourage physicians who serve as expert witnesses from promoting the theory in criminal and civil trials.

“It's junk science,” said Martin Chenevert, an emergency medicine physician at UCLA Santa Monica Medical Center, who often testifies as an expert witness. The theory has been used to provide a cover for police misconduct, he said. “It had an agenda.”

Passing the resolution wouldn't bring Haleck back, but his parents hope it would prevent other families from experiencing their agony. “May that excited delirium die here,” said his mother, Verdell.

Democratic California Gov. Gavin Newsom is considering signing into law a bill passed Sept. 12 that would do much of the same in his state.

“If we don't fully denounce this now, it will be there for the grasping, again,” said Jennifer Brody, a physician with the Boston Health Care for the Homeless Program, who co-authored a 2021 editorial calling on organized medicine to denounce excited delirium. “Historically, we know what happens: The pendulum swings the other way.”

Most major medical societies, including the American Medical Association and the American Psychiatric Association, don't recognize excited delirium as a medical condition. This year, the National Association of Medical Examiners rejected excited delirium as a cause of death. No blood test or other diagnostic test can confirm the syndrome. It's not listed in the “Diagnostic and Statistical Manual of Mental Disorders,” a reference book of mental health conditions, nor does it have its own diagnostic code, a system used by health professionals to identify diseases and disorders.

But the argument's pervasiveness in excessive-use-of-force cases has persisted in large part because of the American College of Emergency Physicians' 2009 white paper proposing that individuals in a mental health crisis, often under the influence of drugs or alcohol, can exhibit superhuman strength as police try to control them, and then die from the condition.

The ACEP white paper has been cited in cases across the U.S., and lawyers who file police misconduct cases said that courts and judges accept the science without sufficient scrutiny.

ACEP's position “has done a lot of harm” by justifying first responder tactics that contribute to a person's death, said Joanna Naples-Mitchell, an attorney who worked on a Physicians for Human Rights review of excited delirium. The term has also been used in cases in Australia, the United Kingdom, Canada, and other countries, according to the group.

“This is a really important opportunity for ACEP to make things right,” she said of the upcoming vote.

ACEP officials declined KFF Health News requests for an interview.

Starting in the mid-1990s, the leading proponents of excited delirium produced research with funding from Taser International, a maker of stun guns used by police, which later changed its name to Axon. The research purported to show that the technique of prone restraint, in which suspects are lying face down on the ground with the police officer's weight on top of them, and Taser shocks couldn't kill someone. That research formed the basis of the white paper, providing an alternative cause of death that defense attorneys could argue in court. Many emergency physicians say the ACEP document never lived up to the group's standard for clinical guidelines.

Axon officials did not respond to a call or email seeking comment on the white paper or the upcoming ACEP vote. In 2017, Taser officials used the American College of Emergency Physicians' position on excited delirium as evidence that it is a “universally recognized condition,” according to Reuters.

A recent review published in the journal Forensic Science, Medicine, and Pathology concluded no scientific evidence exists for the diagnosis, and that the authors of the 2009 white paper engaged in circular reasoning and faulty logic.

“Excited delirium is a proxy for prone-related restraint when there is a death,” said Michael Freeman, an associate professor of forensic medicine at Maastricht University in the Netherlands, who co-authored the review. “You don't find that people get ‘excited delirium' if they haven't also been restrained.”

Between 2009 and 2019, Florida medical examiners attributed 85 deaths to excited delirium, and at least 62% involved the use of force by law enforcement, according to a January 2020 report in Florida Today. Black and Hispanic people accounted for 56% of 166 deaths in police custody attributed to excited delirium from 2010 to 2020, according to a December 2021 Virginia Law Review article.

This year, ACEP issued a formal statement saying the group no longer recognizes the term “excited delirium” and new guidance to doctors on how to treat individuals presenting with delirium and agitation in what it now calls “hyperactive delirium syndrome.” But the group stopped short of retracting the 2009 white paper. For the past 14 years, ACEP took no steps to withdraw the document or to discourage defense attorneys from using it in court.

Even now, lawyers say, they must continually debunk the theory.

“Excited delirium has continued to come up in every single restraint asphyxia case that my partner and I have handled,” said Julia Sherwin, a California civil rights attorney. “Instead of acknowledging that the person died from the police tactics, they want to point to this alternate theory of deaths.”

Now, plaintiffs' attorneys say, if ACEP passes the resolution it would be the most meaningful step yet toward keeping the theory out of the courtroom. The resolution calls on ACEP to “clarify its position in writing that the 2009 white paper is inaccurate and outdated,” and to withdraw approval for it.

Despite the theory's lack of scientific underpinning, backers of the ACEP resolution expect heated debate before the vote scheduled for the weekend of Oct. 7-8. Emergency physicians often encounter patients with agitation and delirium, they say, and are sympathetic to other first responders who share the challenge of managing such patients. While they have tools like sedation to help them in the emergency room, law enforcement officials must often subdue potentially dangerous individuals without such help.

Most people won't die as a result of police tactics such as prone restraint or Taser use, but a small fraction do.

“It's a crappy, crappy situation, when you have someone who's out of control, who can't make decisions for himself, and is potentially a threat somewhere,” said Jared Strote, an emergency medicine professor at the University of Washington. “It's not like they have a sticker on their head that says, ‘Hey, I'm at high risk. If you hold me down, then I could go into sudden cardiac arrest.'”

Nonetheless, sentiment is growing among emergency physicians that the 2009 ACEP white paper has resulted in real harm and injustices, and it's time to set it aside.

“We'll be able to close the chapter on it and move forward to recognize explicitly that this was in error,” said Brooks Walsh, an emergency physician from Bridgeport, Connecticut, and a key player in bringing the resolution up for a vote. “We definitely have an ethical responsibility to address mistakes or evolutions in medical thinking.”

Chris Vanderveen, KUSA-TV's director of special projects, contributed to this report.

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By: Markian Hawryluk and Renuka Rayasam
Title: Police Blame Some Deaths on ‘Excited Delirium.' ER Docs Consider Pulling the Plug on the Term.
Sourced From: kffhealthnews.org/news/article/police-blame-some-deaths-on-excited-delirium-er-docs-consider-pulling-the-plug-on-the-term/
Published Date: Mon, 02 Oct 2023 09:00:00 +0000