College part of national efforts to advance precision medicine

The College of Community Health Sciences is participating in a nationwide network of academic and health-care institutions charged with implementing the National Institutes of Health’s All of Us Research Program, an effort to advance research into precision medicine.

The overall project seeks to enroll one million individuals living in the US and gather their health information and other data over time, with the ultimate goal of accelerating research and improving health. Researchers will use the data for studies on a variety of health conditions to learn more about the impact of individual differences in lifestyle, environment and biological makeup.

By taking into account individual differences in lifestyle, environment and biology, researchers hope to find ways to deliver precision medicine.

The College, through its University Medical Center, is an awardee of a part of the program known as the Southern All of Us Network (see list of awardees below). Combined, the awardees will receive $13.8 million from NIH.

“This is the project that will change the way we practice medicine in the future,” says Dr. John C. Higginbotham, associate dean for Research and Health Policy for CCHS and associate vice president for Research for The University of Alabama.

CCHS has been asked to enroll 400 individuals into the All of Us Research Program in the first year, says Higginbotham, who is coordinating the College’s efforts along with Dr. Tom Weida, the College’s associate dean for Clinical Affairs.

“We will be collecting data and following these folks for 10 years,” Weida says. “This is on the forefront of precision medicine and this is where medicine is going. We’re staying on the forefront of how we deliver care and the type of care we deliver.”

According to the NIH, precision medicine is “an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment and lifestyle.” This approach allows doctors and researchers to predict more accurately which treatment and prevention strategies for a particular disease will work in which groups of people, in contrast to a one-size-fits-all approach with treatment and prevention strategies developed for the average person with less consideration for individual differences.

According to the NIH, All of Us participants will extend the geographic coverage of the program and strengthen its reach within underserved communities, including lower-income, Hispanic and Latino, African-American, rural and American Indian communities.

“We want this program to reflect the rich diversity of our country,” says Eric Dishman, director of the All of Us Research Program at NIH. “Expanding our national network of health care provider organizations enhances our ability to reach communities traditionally underrepresented in medical research. Working with participants across the country, we hope to contribute to medical breakthroughs that may lead to more tailored disease prevention and treatment solutions in the future.”

Adds Higginbotham: “This program will be a catalyst for innovative research and policies.”

Awardees include:

Southern All of Us Network: University of Alabama at Birmingham; Cooper Green Mercy Hospital, Birmingham, Alabama; Huntsville Hospital, Alabama; Louisiana State University Health Sciences Center, New Orleans; Tulane Medical Center, New Orleans; Tuskegee University, Alabama; UAB Hospital, Birmingham, Alabama; UAB School of Medicine’s Montgomery Internal Medicine and Selma Family Medicine programs, Birmingham, Alabama; University of Mississippi Medical Center, Jackson; University of South Alabama Health System, Mobile; and The University of Alabama College of Community Health Sciences/University Medical Center, Tuscaloosa, Alabama.

SouthEast Enrollment Center: University of Miami Miller School of Medicine, Florida; Emory University, Atlanta; Morehouse School of Medicine, Atlanta; and the OneFlorida Clinical Research Consortium led by the University of Florida in Gainesville.

All of Us Wisconsin: Marshfield Clinic Research Institute; BloodCenter of Wisconsin, Milwaukee; Medical College of Wisconsin, Milwaukee; and the University of Wisconsin-Madison.


Note: The All of Us Research Program plans to continue building the network of health care provider organizations over time to engage a large participant community that reflects the geographic, ethnic, racial and socioeconomic diversity of the country. The network will include regional medical center, community health centers and medical centers operated by the US Department of Veterans Affairs.

The challenges of rural health care

The College of Community Health Sciences hosted a panel discussion focused on rural health care challenges in Alabama during its October Board of Visitors meeting to share perspectives, brainstorm ideas and build collaborations.

Panel members included: James Cowan, administrator of Choctaw General Hospital in Butler; W.O. Buddy Kirk, a retired district judge from Pickens County; Don Lilly, senior vice president of UAB Health System in Birmingham; Nisa Miranda, director of The University of Alabama Center for Economic Development; Wallace Strickland, CEO of Rush Health System in Meridian, Miss.; and R.B. Walker, director of Government Relations for UA.

The panel discussion was moderated by Pat Duggins, news director at Alabama Public Radio.

The Board of Visitors is made up of volunteers, including alumni, donors, community physicians and other friends of CCHS who help the College develop relationships and partnerships with Alabama communities and with organizations at the state and national levels.

“Alabama is more rural than most of the US and the concern for sustaining rural communities and their health and economies is great. So are the challenges,” said Dr. Richard Streiffer, dean of CCHS, as he provided a framework for the panel discussion. “Rural communities have populations that are older, sicker and poorer. They have difficulty attracting and retaining young people and families because of a lack of jobs, inadequate education and few services and amenities. Rural communities struggle to attract and retain physicians and other health-care professionals, and to support hospitals and health-care services.”

In Alabama, 55 of its 67 counties are considered rural. There’s a critical shortage of doctors and other health-care professionals in rural counties, and eight counties have no hospital at all. Over the last eight years, seven rural hospitals have closed in the state, placing Alabama near the top of the list for rural hospital closures nationwide.

A key recurring theme during the panel discuss was the need for the state to include health care and rural hospitals in economic development efforts. “A hospital is an industry unto itself and should be recognized as that,” Strickland said. Lilly added: “Hospitals are good economic development for the state. When an industry comes, the state rolls out the red carpet.”

Walker noted that larger employers in rural areas are generally school systems and hospitals. Cowan pointed out that a single physician in a rural community can potentially create 23 additional jobs and $1 million in economic benefit for the local community. “It’s economic development worthy of the state’s attention,” he said.

“It’s hard to recruit industry if you don’t have health care or a hospital,” Walker added. “The state needs to look at health care as part of the economy. That’s the way to make it important to the Legislature.”

Miranda said it might be difficult for officials to know how to bring hospitals, including rural hospitals, into the economic development equation because of the complex way that health care is financed, and because hospitals are often recognized not as an industry but as a public service. She also said industrial recruitment is easier “because that structure is in place.”

Strickland said better planning is needed to match health-care resources with health-care needs. “No health planning exists in this country, whether it’s a rural area or an urban area. Right now, we’re scatter shooting.” Lilly said there is likely duplication of services from one rural area to the next “so it’s not sustainable because there’s not the volume. It’s like rural hospitals exist on an island.”

Panel members stressed the importance of considering creative solutions.

Walker said more programs are needed like one currently being launched by the College and Tuscaloosa Fire and Rescue Services that treats low-emergency conditions at the scene, reducing costly emergency room transports. Cowen suggested telemedicine could bring needed health care to areas.

Strickland explained that Rush Health System has, when building rural hospitals, placed admissions and cafeteria sections in space separate from traditional hospital space. The reason – $110 per square foot in construction costs as compared to $300-plus per square foot typically required for in-patient space.

In addition, Strickland said Choctaw General Hospital in Butler, which is owned by Rush Health System, has “swing beds” that can switch from acute care status to skilled care status, something that Medicare provides coverage for and that particularly serves the needs of smaller hospitals and communities.

Lilly said some rural hospitals might need to provide emergency care only “so they can get the reimbursement they need to stay open.”

Cowan said it’s important for rural hospitals to be an active part of a community. He said Choctaw General Hospital provides space for town hall meetings, and the cafeteria also operates as a place for the public to eat. “You have to engage with the community and keep it fresh and new. You can’t just build it and they keep coming back. You have to work at it.”

Kirk agreed, adding that it is important to get local citizens involved well before a rural hospital faces possible closure. “That speaks volumes to the Legislature and elected officials.”

UMC-Demopolis hosts open house

In August, University Medical Center added a permanent location in Demopolis, Alabama, adjacent to the Bryan W. Whitfield Memorial Hospital, within the hospital’s outpatient facility. The establishment of UMC-Demopolis is a way that the College of Community Health Sciences, which also operates UMC locations in Tuscaloosa and Northport, can help that community directly and support the local hospital, while also developing a model that combines a full spectrum rural practice with medical education – all linked to the larger infrastructure of University Medical Center and CCHS.

To celebrate the progress that has been made at the new location, the College hosted an open house October 19 within the UMC-Demopolis clinic. Leadership from CCHS and UMC were in attendance, along with the hospital’s CEO, Arthur Evans, Board Chairman Rob Fleming, and Board Member Don Lilly, who is also Senior Vice Pre

sident of Network Development and Affiliate Operations at UAB.

“It’s important to be here for our entire community. Demopolis has gotten in new business and major employers have made monetary commitments toward our development. We just need a hospital. That’s why there are so many people here. Everyone here is committed to this town.” — Hunter Compton, local civil lawyer

The clinic was packed at the open house with Demopolis citizens, including families with young children, as well as members of the City Council, the Rotary Club and city school representatives. Also attending was state Rep. AJ McCampbell, whose district includes Demopolis.

UMC to join IMPLICIT family medicine network

Dr. Heidi Knoll, from Mountain Area Health Education Center in North Carolina, visited the College October 17 to present the IMPLICIT Interconception Care program. IMPLICIT stands for Interventions to Minimize Preterm and Low birthweight Infants through Continuous Improvement Techniques.

The infant mortality rate in Alabama is 7.8 deaths per 1,000 births, compared to the US rate of 5.8 deaths per 1,000 births.

“This [program] would work to improve those rates,” Knoll said. “This [program] is going to help babies be born into healthier families.”

University Medical Center, which the College operates, received a grant from the March of Dimes to start the IMPLICIT Network in Alabama. IMPLICIT is a family medicine network that looks at modified risk and works to improve the health of pregnant women before pregnancy.

The modified risks identified by IMPLICIT are smoking, depression, family planning and multivitamin use. The goal is to talk to women of childbearing age at primary care physician visits. If the woman is already a mother, then she will be screened at well-child visits, from zero  to 24 months, and if any factors are identified, the mother is connected with either a primary care physician or other resources. If the woman plans on getting pregnant, she will be screened at primary care visits and introduced to preconception health visits to ensure a healthier pregnancy.

There are currently 25 sites nationwide in the IMPLICIT Network, but  only a few locations in the South; UMC is the only location in Alabama. Other Southern locations include the University of Mississippi Medical Center in Jackson Mississippi, and locations in North Carolina, including MAHEC.

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Celiac Disease

During a presentation for the Mini Medical School Program, a lecture series the College of Community Health Sciences provides in collaboration with UA’s Osher Lifelong Learning Institute, Dr. Ed Geno spoke about the identification and treatment of celiac disease.

“What I’m going to do is take you on a journey of gluten through the body,” said Geno.

Throughout the lecture, Geno described the various actions and reactions the human body goes through if a person has celiac disease or is gluten intolerant. The symptoms of celiac disease are common and can often be interpreted as other diseases, making it difficult to diagnose. Symptoms include: malabsorption, diarrhea, bloating, and vitamin deficiency.

“You tend to see this disease in families,” said Geno. “It can occur in kids, and it can occur later in life as well.”

Because celiac disease can affect a wide-range of people and shows symptoms common to other diseases, it can be difficult to diagnose. If a parent, sibling or child has celiac disease, it is wise to get screened.

About 1 percent of the North American population has celiac disease and most people who suffer from gluten intolerance are not born with the disease, rather they develop it over time. Once developed, the only treatment is to maintain a gluten-free diet. Symptoms of celiac disease may resolve while being gluten-free, but the disease is lifelong.

Being gluten-free requires cutting any foods that contain wheat, rye, barley and malt. This includes bread, pastas, beer, and even some over-the-counter medications.

While many people can see health benefits of going gluten-free, it is very important to replace the nutrients lost by avoiding wheat in your diet. There are alternative sources for carbohydrates, fiber, iron, and folic acid that are gluten-free. Many of these sources are alternative grain products (such as rice, corn, or potato based products), green leafy vegetables, and meat, fish, and poultry.

Pickens County Heart Walk

The annual Pickens County Heart Walk took place in Gordo, Alabama, on Saturday, Oct. 28. The walk was organized by members of the Pickens County community and sponsored by the American Heart Association. The walk started and ended at Gordo City Hall and despite the cold and rain, attendance was good.

As part of the partnership between the College of Community Health Sciences and the American Heart Association, the Pickens County Partnership had a presence at the Pickens County Heart Walk. The Pickens County Partnership offered handouts containing general information about the partnership as well as information about the Pickens County Medical Center Cardiac Rehab Clinic.

After the walk, the College offered participants apple cinnamon chips, a seasonal and heart healthy snack.

The College hosts the Brussels Sprouts Challenge each year at the West Alabama Heart Walk in Tuscaloosa.

Increasing the primary care physician workforce in Alabama, region

More than a dozen prospective medical students interested in becoming primary-care physicians will visit the College of Community Health Sciences in November.

The 16 students have expressed interest in a new track that is part of the University of Alabama School of Medicine’s four-year medical degree program. The Primary Care Track is being offered at the College, which is a regional campus of the School of Medicine.

The students will attend an admissions day at the College on Nov. 3. The first admissions day was held in October and 15 students attended. Brook Hubner, the College’s director of Medical Student Affairs, says the monthly admissions days through January are already filled.

“Students who apply and who are accepted to the track will want to go into primary care,” says Dr. Richard Streiffer, dean of CCHS. Students accepted will begin medical school in 2018.

The Primary Care Track is designed to provide students a strong foundation in clinical medicine focused on preparation for residency training in primary care and other community-based specialty fields, through longitudinal experiences with patients, lasting relationships with mentoring physicians, and special programming on population health and physician leadership skills.

The primary care-oriented training will also be an excellent experience for students who envision a community-based career in a variety of non-primary care specialties, College officials said.

Students in the Primary Care Track will spend their first two years completing the prerequisite basic science curriculum in Birmingham, and their third year in a model of clinical education called a longitudinal integrated clerkship, or LIC, based in Tuscaloosa or other communities around the state. They will work alongside faculty for a majority of the year to follow and care for patients longitudinally, learning across the core disciplines of medicine and in all settings, including outpatient clinics, hospitals, nursing homes and patients’ home. This is a departure from the traditional model – a series of discipline-specific and hospital-dominant four- to eight-week clerkships, where students typically experience few encounters with the same patient and only single episodes of illness.

The goal of the Primary Care Track is to continue addressing the critical need for more primary care physicians in Alabama and the region. In 2012 in Alabama, the state had 3,512 active primary care physicians for a ratio of approximately 73 per 100,000 people, ranking it 45th in the nation, according to a study by the Association of American Medical Colleges. The provider shortage is even worse in rural areas – 55 of Alabama’s 67 counties are considered rural, and eight counties have no hospital at all.

Integrating mental health care in primary care

Dr. Anna Ratzliff, associate director for Education for the AIMS Center

Behavioral health issues such as depression and anxiety are debilitating conditions and, unfortunately, common. But the integration of behavioral health and primary care services is proving successful in improving patient outcomes.

The College is exploring such an integrated model of care for University Medical Center, which it operates. In September, the College hosted a group from the University of Washington AIMS Center, short for Advancing Integrated Mental Health Solutions, that presented its Collaborative Care model to College faculty and resident physicians who care for patients at UMC.

“This is a way to improve access to mental health care,” said Dr. Tom Weida, UMC’s chief medical officer. “This is a great opportunity for folks who have mental health needs to get the care they need.”

Collaborative Care treats common mental health conditions such as depression and anxiety that require systematic follow-up due to their persistent nature. Components of the AIMS model include: primary care providers and embedded behavioral health professionals; a behavioral care manager; a patient registry that allows providers to track patients and their response to treatment over time; the provision of medications and/or psychosocial treatments; and psychiatric consultation.

“Collaborative care gives mental health care support to primary care physicians,” Dr. Anna Ratzliff, associate director for Education for the AIMS Center, said during the presentation at the College. “When you deliver collaborative care, it doubles the effectiveness of treatment. Collaborative care results in improved outcomes – less depression, less physical pain, better functioning and higher quality of life.”

Ratzliff, also an associate professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington, said key to the AIMS Collaborative Care model is the oversight provided by a behavioral care manager, as well as the use of a patient registry and tracking. She said some health-care facilities “drop a mental health provider into a primary care setting, but without coordination, it might not be effective.”

She also said the population health approach of the model – the patient registry and tracking – is important “because it makes sure patients don’t fall through the cracks and it’s a way to go out and actively engage them in care. Providers can also see who is improving and who isn’t, and tracking also helps patients see the progress they’re making, which is important when they feel stuck.”

According to the AIMS Center, offering mental health care in primary care is convenient for patients, builds on existing provider-patient relationships and can help improve care for patients who have both medical and mental issues.

“Collaborative care saves medical care costs and helps patients lead high-quality lives,” Ratzliff said.

College welcomes new Behavioral Health Fellow

The College of Community Health Sciences welcomes Dr. Danielle Andrews to the Behavioral Health Fellowship.

The Behavioral Health fellowship along with Obstetrics, Sports Medicine, Emergency Medicine, Geriatric Medicine, Hospital Medicine, and Rural Public Psychiatry comprise the seven fellowships offered by the College. Each fellowship is a year-long program designed to offer additional, specialized training to physicians.

The Behavioral Health Fellowship for family medicine physicians, one of few in the country, trains family medicine physicians, particularly those planning to practice in rural communities, to better care for patients with psychiatric concerns.

The goal of the fellowship is to provide administrative training and public psychiatric experience for psychiatrists interested in practicing or serving in a community setting.

Andrews received a bachelor’s degree in Biology from Clark Atlanta University. She earned a master’s degree in Public Health at Boston University School of Public Health, concentrating in Social and Behavioral Sciences.  She completed her medical degree at Boston University School of Medicine and family medicine training at Phoebe Family Medicine Residency in Albany, Georgia.

Boxmeyer selected for Leadership U

Dr. Caroline Boxmeyer, the College’s assistant dean for medical education, was selected to participate in Leadership U, a University of Alabama program that prepares faculty and staff in leadership positions to take on increasing levels of responsibility within their organizations.

Boxmeyer is also a professor in the College’s Department of Psychiatry and Behavioral Medicine and a practicing psychologist at University Medical Center, which the College operates.

Leadership U is offered by the Office for Academic Affairs and serves all areas on campus. In addition to Boxmeyer, this year’s other participants come from Advancement, Financial Affairs, Intercollegiate Athletics, Student Life and Strategic Communications.

The current program began in September and will run through August 2018. The class recently participated in a two-day professional development workshop designed to assess their personal strengths leaders and to help them hone interpersonal skills. They will meet with University leaders throughout the academic year to learn more about the University, its goals and mission and the leadership styles of UA’s top administration.

Faculty participants also are part of the Southeastern Conference’s Academic Development Leadership Program, and they will visit LSU and Auburn for three-day workshops this year.

For participants, the Leadership U curriculum seeks to: broaden their perspectives on how the vision and mission of UA is realized; enhance capacity for collaboration and relationship building; strengthen practical skills essential to effective leadership; and increase their sensitivity to the influence of culture in the academic setting.