But the kids’ excitement for their new rides is tempered by a recurring question from worried parents: Are they safe?

That can be a difficult question to answer. The federal government’s e-bike regulations are sparse, and efforts to expand them have stalled, leaving states and even counties to fill the void with patchwork rules of their own. Meanwhile, the seemingly endless variety of e-bikes for sale vary in design, speed, and quality.

In that environment, retailers like Fletcher aim to educate consumers so they can make informed decisions.

“We’re super careful about what comes in the shop because there are hazards,” he said.

Federal rules requiring in e-bikes and other devices such as e-scooters are in limbo after the Consumer Product Safety Commission, the independent federal regulatory agency meant to protect people against death and injury from bicycles and other consumer products, in August.

The commission then sent the rules for review by the Office of Information and Regulatory Affairs inside the Office of Management and Budget, responding to President Donald Trump’s February demanding that independent agencies like the CPSC be more aligned with White House priorities. In May, Trump fired three members of the commission who had been appointed by his predecessor, former President Joe Biden.

Meanwhile, by the commission to address injuries from mechanical failings have languished. Shira Rawlinson, the CPSC’s communications director, said it plans to update the status of both proposed rules.

That leaves e-bikes subject to existing standards written for traditional bicycles and which the commission has said, based on a preliminary assessment, aren’t adequate to reduce the risk of e-bike injuries. , , and recently passed laws regulating e-bikes to fill the gap.

The laws address issues such as battery fire risks and rider safety and seek to distinguish lower-speed e-bikes from faster e-motos, or electric motorcycles, which can reach top speeds of 35 miles an hour or faster. No federal law dictates the age at which someone may operate an e-bike, but more than half of states have age restrictions for who can operate , which reach a top speed of 28 miles an hour with pedal assist, while two California counties recently set a minimum age to operate Class 2 bikes, with their 20 mph top assisted speed.

“The biggest issue is e-bikes that switch from a power-assisted bike to essentially a motorized scooter,” said Democratic state Rep. Lesley Smith, who co-sponsored Colorado’s bill.

Colorado’s e-bike law requires safety certification of lithium-ion batteries, which can explode when manufactured or used improperly. They caused 39 deaths and 181 injuries in people using micromobility devices such as e-bikes from 2019 to 2023, according to the CPSC.

Most dealers, importers, and distributors have agreed to use batteries that meet safety standards, but there will always be manufacturers who cut corners on safety to save money, said Ed Benjamin, chairman of the Light Electric Vehicle Association, whose hundreds of members supply light electric vehicles such as e-bikes, or their parts.

“There are some out there who don’t care what is the right thing to do. They just want to make the cheapest bike possible,” Benjamin said.

Amy Thompson, the Safe Routes to School program coordinator for the Boulder Valley School District, said education officials are scrambling to install more bike racks at several schools to meet the increase in e-bike usage.

Students use them to quickly get to school or activities and carry their sports equipment or instruments with ease, Thompson said. She said she’s seen some alarming behavior, such as students’ riding three to a bike, riding without helmets, or attempting power wheelies popularized by social media.

Thompson said kids are disabling the speed limiter on e-bikes to operate at higher speeds. “It’s super easy for kids to go on YouTube and find a video that will coach you how to override or disable the governor on a bicycle,” she said.

Thompson to monitor their children’s e-bikes in September and described the between e-bikes and e-motos last fall.

Those blurred lines bedevil an adopted, in part or full, by nearly all states, in which e-bike motors generally must operate at 750 watts or lower. Class 1 e-bikes use pedal assist that must not exceed 20 mph; Class 2 e-bikes include a throttle that also must not exceed 20 mph; and Class 3 e-bikes use pedal assist that must not exceed 28 mph.

Some e-bikes easily switch between Class 2 and 3, sometimes unbeknownst to parents, said Smith, the Colorado lawmaker. A California parent sued an e-bike manufacturer last year, saying it falsely advertised as Class 2 an e-bike that could switch to Class 3.

The dangers of Class 2 e-bikes prompted California’s Marin County to under 16 from operating them and require that anyone riding one wear a helmet. Youths ages 10 to 15 who crash their e-bikes require an ambulance at of other age groups involved in e-bike crashes, according to county health officials. A growing number of serious injuries on e-bikes, particularly among adolescents, is an emerging public safety problem, the American College of Surgeons .

Talia Smith, Marin County’s legislative director, championed that permits Marin County to impose age restrictions. After hearing from a dozen other counties experiencing similar problems, though, she said state legislators should move to a statewide law from piecemeal, county-by-county ordinances. San Diego County from operating Class 1 or 2 bikes.

Vehicles claiming to be both e-bikes and e-motos fall into the cracks between two regulatory agencies, the CPSC and the National Highway Traffic Safety Administration, said Matt Moore, general and policy counsel for PeopleForBikes, a trade association for bicycles, including e-bikes.

PeopleForBikes wants the traffic safety administration to stop shipments of or take other legal action against e-motos that are labeled as e-bikes and do not comply with federal standards, Moore said.

If the federal government won’t act, states should clarify their laws to define e-motos as off-road dirt bikes or motor vehicles that require licenses, he said. In October, California , which it requires to display an identification plate issued by the Department of Motor Vehicles for use off-highway.

In Boulder, Thompson said, the school district considers communication and education cornerstones of safety. Children and teens should learn and practice traffic rules, whether they’re powering two wheels with their own legs or a throttle, she said.

“E-bikes are fun, environmentally friendly, and relatively cheap transportation. So how can we make them safer and more viable for families?” Thompson said.

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While the 76-year-old Milwaukee resident waited to hear back, Miller did something patients increasingly do when they can’t reach their health care team. She put her test results into Claude and asked the AI assistant to evaluate the data.

“Claude helped give me a clear understanding of the abnormalities,” Miller said. The generative AI model didn’t report anything alarming, so she wasn’t anxious while waiting to hear back from her doctor, she said.

Patients have unprecedented access to their medical records, often through online patient portals such as MyChart, because federal law requires health organizations to immediately release electronic health information, such as notes on doctor visits and test results. published in 2023 found that 96% of patients surveyed want immediate access to their records, even if their provider hasn’t reviewed them.

And many patients are using large language models, or LLMs, like OpenAI’s ChatGPT, Anthropic’s Claude, and Google’s Gemini, to interpret their records. That help comes with some risk, though. Physicians and patient advocates warn that AI chatbots can produce wrong answers and that sensitive medical information might not remain private.

Yet, most adults are cautious about AI and health. Fifty-six percent of those who use or interact with AI are not confident that information provided by AI chatbots is accurate, according to . Â鶹ŮÓÅ is a health information nonprofit that includes Â鶹ŮÓÅ Health News.

“LLMs are theoretically very powerful and they can give great advice, but they can also give truly terrible advice depending on how they’re prompted,” said Adam Rodman, an internist at Beth Israel Deaconess Medical Center in Massachusetts and the chair of a steering group on generative AI at Harvard Medical School.

Justin Honce, a neuroradiologist at UCHealth in Colorado, said it can be very difficult for patients who are not medically trained to know whether AI chatbots make mistakes.

“Ultimately, it’s just the need for caution overall with LLMs. With the latest models, these concerns are continuing to get less and less of an issue but have not been entirely resolved,” Honce said.

Rodman has seen a surge in AI use among his patients in the past six months. In one case, a patient took a screenshot of his hospital lab results on MyChart then uploaded them to ChatGPT to prepare questions ahead of his appointment. Rodman said he welcomes patients’ showing him how they use AI, and that their research creates an opportunity for discussion.

Roughly 1 in 7 adults over 50 use AI to receive health information, according to a recent poll from the , while 1 in 4 adults under age 30 do so, according to the Â鶹ŮÓÅ poll.

Using the internet to advocate for better care for oneself isn’t new. Patients have traditionally used websites such as WebMD, PubMed, or Google to search for the latest research and have sought advice from other patients on social media platforms like Facebook or Reddit. But AI chatbots’ ability to generate personalized recommendations or second opinions in seconds is novel.

, communications and patient initiatives director at OpenNotes, an academic lab at Beth Israel Deaconess that advocates for transparency in health care, had wondered how good AI is at interpretation, specifically for patients.

In a published this year, Salmi and colleagues analyzed the accuracy of ChatGPT, Claude, and Gemini responses to patients’ questions about a clinical note. All three AI models performed well, but how patients framed their questions mattered, Salmi said. For example, telling the AI chatbot to take on the persona of a clinician and asking it one question at a time improved the accuracy of its responses.

Privacy is a concern, Salmi said, so it’s critical to remove personal information like your name or Social Security number from prompts. Data goes directly to tech companies that have developed AI models, Rodman said, adding that he is not aware of any that comply with federal privacy law or consider patient safety. Sam Altman, CEO of OpenAI, warned on a about putting personal information into ChatGPT.

“Many people who are new to using large language models might not know about hallucinations,” Salmi said, referring to a response that may appear sensible but is inaccurate. For example, OpenAI’s Whisper, an AI-assisted transcription tool used in hospitals, introduced an imaginary medical treatment into a transcript, according to a

Using generative AI demands a new type of digital health literacy that includes asking questions in a particular way, verifying responses with other AI models, talking to your health care team, and protecting your privacy online, said Salmi and Dave deBronkart, a cancer survivor and patient advocate who devoted to patients’ use of AI.

Patients aren’t the only ones using AI to explain test results. has launched an AI assistant that helps its physicians draft interpretations of clinical tests and lab results to send to patients. Colorado researchers studied the accuracy of ChatGPT-generated summaries of 30 radiology reports, along with four patients’ satisfaction with them. Of the 118 valid responses from patients, 108 indicated the ChatGPT summaries clarified details about the original report.

But ChatGPT sometimes overemphasized or underemphasized findings, and a small but significant number of responses indicated patients were more confused after reading the summaries, said Honce, who participated in .

Meanwhile, after four weeks and a couple of follow-up messages from Miller in MyChart, Miller’s doctor ordered a repeat of her blood work and an additional test that Miller suggested. The results came back normal. Miller was relieved and said she was better informed because of her AI inquiries.

“It’s a very important tool in that regard,” Miller said. “It helps me organize my questions and do my research and level the playing field.”

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, , and are among the states that have recently required safeguarding brain data collected by devices outside of medical settings. That includes headphones, earbuds, and other wearable consumer products that aim to improve sleep, focus, and aging by measuring electrical activity and sending the data to an app on users’ phones.

by the Neurorights Foundation, an advocacy group that aims to protect people from the misuse of neurotechnology, found that 29 of 30 companies with neurotechnology products that can be purchased online have access to brain data and “provide no meaningful limitations to this access.” Almost all of them can share data with third parties.

In June, the American Medical Association of neural data. In April, several Democratic members of the U.S. Senate Committee on Commerce, Science, and Transportation to investigate whether companies are exploiting consumers’ brain data. Juliana Gruenwald Henderson, a deputy director of the FTC’s Office of Public Affairs, said the agency had received the letter but had no additional comment.

Although current devices gather relatively basic information like sleep states, advocates for brain data protection caution that future technologies, including artificial intelligence, could extract more personal and sensitive information about people’s medical conditions or innermost thoughts.

“If you collect the data today, what can you read from it five years from now because the technology is advancing so quickly?” said Democratic state Sen. Cathy Kipp, who sponsored Colorado’s 2024 neural data protection bill when she was in the state House of Representatives.

As both excitement and trepidation about AI build, at least 28 states and the U.S. Virgin Islands some type of AI regulation separate from the privacy bills protecting neural data. President Donald Trump’s “” included a 10-year halt on states passing laws to regulate AI, but the Senate stripped that provision out of the budget reconciliation bill before voting to approve it on July 1.

The spirit of laws in Colorado, California, and Montana is to protect the neural data itself, not to regulate any algorithm or AI that might use it, said Sean Pauzauskie, medical director for the .

But neurotechnology and AI go hand in hand, Pauzauskie said. “A lot of what these devices promise is based on pattern recognition. AI is really driving the usability and significance of the patterns in the brain data.”

a professor of neurosurgery at the University of Colorado School of Medicine, said that AI’s ability to identify patterns is a game changer in her field. “But contribution of a person’s neural data on an AI training set should be voluntary. It should be an opt-in, not a given.”

Chile in 2021 became the first country to adopt a constitutional amendment for neurorights, which prioritize human rights in the development of neurotechnology and collection of neural data, and UNESCO has said that neurotechnology and artificial intelligence could together pose a threat to human identity and autonomy.

Neurotechnology can sound like science fiction. Researchers used a and an AI model to decode the brain’s electric signals from thoughts into speech. And two years ago, a study described how neuroscientists reconstructed the Pink Floyd song “” by analyzing the brain signals of 29 epilepsy patients who listened to the song with electrodes implanted in their brains.

The aim is to use neurotechnology to help those with paralysis or speech disabilities, as well as treat or diagnose traumatic brain injuries and brain disorders such as Alzheimer’s or Parkinson’s. Elon Musk’s Neuralink and , funded by Bill Gates and Jeff Bezos, are among the companies with clinical trials underway for devices implanted in the brain.

Pauzauskie, a hospital neurologist, started worrying four years ago about the blurring of the line between clinical and consumer use of neural data. He noted that the devices used by his epilepsy patients were also available for purchase online, but without protections afforded by the Health Insurance Portability and Accountability Act in medical settings.

Pauzauskie approached Kipp two years ago at a constituent meetup in his hometown of Fort Collins to propose a law to protect brain data in Colorado. “The first words out of her mouth that I’ll never forget were, ‘Who would be against people owning their own brain data?’” he said.

Brain data protection is one of the rare issues that unite lawmakers across the political aisle. The bills in California, Montana, and Colorado passed unanimously or nearly unanimously. Montana’s law will go into effect in October.

Neural data protection laws in Colorado and California amend each state’s general consumer privacy act, while Montana’s law adds to its existing genetic information privacy act. Colorado and Montana require initial express consent to collect or use neural data and separate consent or the ability to opt out before disclosing that data to a third party. A business must provide a way for consumers to delete their data when operating in all three states.

“I want a very hard line in the sand that says, you own this completely,” said Montana state Republican Sen. Daniel Zolnikov, who sponsored his state’s neural data bill and other privacy laws. “You have to give consent. You have the right to have it deleted. You have complete rights over this information.”

For Zolnikov, Montana’s bill is a blueprint for a national neural data protection law, and Pauzauskie said support of regulatory efforts by groups like the AMA pave the way for further federal and state efforts.

Welle agreed that federal regulations are needed in addition to these new state laws. “I absolutely hope that we can come up with something on a national level that can enshrine people’s neural rights into law, because I think this is going to be more important than we can even imagine at this time.”

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The dawn of state-regulated psychedelic mushrooms has arrived in Colorado, nearly two years since Oregon began offering them. The mushrooms are a Schedule I drug and illegal under federal law except for clinical research. But more than a dozen cities nationwide have deprioritized or decriminalized them in the past five years, and many eyes are turned toward Oregon’s and Colorado’s state-regulated programs.

“In Oregon and Colorado, we’re going to learn a lot about administration of psychedelics outside of clinical, religious, and underground settings because they’re the first to try this in the U.S.,” said William R. Smith, an assistant professor of psychiatry at the University of North Carolina School of Medicine.

Psychedelic mushrooms and their psychoactive compound psilocybin have the potential to treat people with depression and anxiety, including those unresponsive to other medications or therapy. , part of the National Institutes of Health, says the risk of mental health problems caused by ingesting mushrooms in a supervised clinical setting is low, but may be higher outside of a clinical setting. Robert F. Kennedy Jr. said in a social media post last year, before his nomination as U.S. health secretary, that his “mind is open to the idea of psychedelics for treatment.”

Medical experts say is needed, particularly in people with a diagnosis or family history of psychotic or bipolar disorder. Adverse effects of psilocybin, including headache and nausea, typically resolve within . However, extended difficulties from using psychedelics can last weeks, months, or years; anxiety and fear, existential struggle, social disconnection, and feeling detached from oneself and one’s surroundings are . After the decriminalization and legalization in Oregon and Colorado, psychedelic mushroom exposures reported to ticked up in these states and nationally.

In February, about 40 people organized by the psychedelic advocacy group the gathered in Boulder to talk about the coming changes in Colorado. They included Mandy Grace, who received her state license to administer psychedelic mushrooms, and Amanda Clark, a licensed mental health counselor from Denver, who both praised the therapeutic power of mushrooms.

“You get discouraged in your practice because the current therapies are not enough for people,” Clark said.

Colorado voters approved in 2022 to legalize natural psychedelics, after Oregon voters in 2020 approved legalizing psilocybin for therapeutic use. Colorado’s program is modeled after, but not the same as, Oregon’s, under which 21,246 psilocybin products have been sold as of March, a total that could include secondary doses, according to the Oregon Health Authority.

As of mid-March, Colorado for at least 15 healing center licenses, nine cultivation licenses, four manufacturer licenses, and one testing facility license for growing and preparing the mushrooms, under by the governor-appointed Natural Medicine Advisory Board.

Psychedelic treatments in Oregon are expensive, and are likely to be so in Colorado, too, said Tasia Poinsatte, Colorado director of the nonprofit Healing Advocacy Fund, which supports state-regulated programs for psychedelic therapy. In Oregon, psychedelic mushroom sessions are typically $1,000 to $3,000, are not covered by insurance, and must be paid for up front.

The mushrooms themselves are not expensive, Poinsatte said, but a facilitator’s time and support services are costly, and there are state fees. In Colorado, for doses over 2 milligrams, facilitators will screen participants at least 24 hours in advance, then supervise the session in which the participant consumes and experiences mushrooms, lasting several hours, plus a later meeting to integrate the experience.

Facilitators, who may not have experience with mental health emergencies, need training in screening, informed consent, and postsession monitoring, Smith said. “Because these models are new, we need to gather data from Colorado and Oregon to ensure safety.”

Facilitators generally pay a $420 training fee, which allows them to pursue the necessary consultation hours, and roughly $900 a year for a license, and healing centers pay $3,000 to $6,000 for initial licenses in Colorado. But the up-front cost for facilitators is significant: The required 150 hours in a state-accredited program and 80 hours of hands-on training can cost $10,000 or more, and Clark said she wouldn’t pursue a facilitator license due to the prohibitive time and cost.

To increase affordability for patients in Colorado, Poinsatte said, healing centers plan to offer sliding-scale pay options, and discounts for veterans, Medicaid enrollees, and those with low incomes. Group sessions are another option to lower costs.

Colorado law does not allow retail sales of psilocybin, unlike cannabis, which can be sold both recreationally and medically in the state. But it allows adults 21 and older to grow, use, and share psychedelic mushrooms for personal use.

Despite the retail ban, adjacent businesses have mushroomed. Inside the warehouse and laboratory of Activated Brands in Arvada, brown bags of sterilized grains such as corn, millet, and sorghum and plastic bags of soil substrate are for sale, along with genetic materials and ready-to-grow kits.

Co-founder Sean Winfield sells these supplies for growing psychedelic or functional mushrooms such as lion’s mane to people hoping to grow their own at home. Soon, Activated Brands will host cultivation and education classes for the public, Winfield said.

Winfield and co-founder Shawn Cox recently hosted a psychedelic potluck at which experts studying and cultivating psychedelic mushrooms discussed genetics, extraction, and specialized equipment.

Psychedelic mushrooms have a long history in Indigenous cultures, and provisions for their use in spiritual, cultural, or religious ceremonies are included in Colorado law, along with recognition of the to federally recognized tribes and Indigenous people if natural medicine is overly commercialized or exploited.

Several studies over the past five years have shown the long-term benefits of psilocybin for , and the Food and Drug Administration designated it a . Late-stage trials, often a precursor to application for FDA approval, are underway.

Smith said psilocybin is a promising tool for treating mental health disorders but has not yet been shown to be better than other advanced treatments. Joshua Woolley, an associate professor of psychiatry and behavioral sciences at the University of California-San Francisco, said he has seen the benefits of psilocybin as an investigator in clinical trials.

“People can change hard-set habits. They can become unstuck. They can see things in new ways,” he said of treating patients with a combination of psilocybin and psychotherapy.

Colorado, unlike Oregon, allows integration of psilocybin into existing mental health and medical practices with a clinical facilitator license, and through micro-healing centers that are more limited in the amounts of mushrooms they can store.

Still, Woolley said, between the federal ban and new state laws for psychedelics, this is uncharted territory. Most drugs used to treat mental health disorders are regulated by the FDA, something that Colorado is “taking into its own hands” by setting up its own program to regulate manufacturing and administration of psilocybin.

The U.S. Attorney’s Office for the District of Colorado declined to comment on its policy toward state-regulated psychedelic programs or personal use provisions, but Poinsatte hopes the same federal hands-off approach to marijuana will be taken for psilocybin in Oregon and Colorado.

Winfield said he looks forward to the upcoming rollout and potential addition of other plant psychedelics, such as mescaline. “We’re talking about clandestine industries coming into the light,” he said.

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Karter rested for a week and a half at home in Centennial, Colorado, then returned to school when her concussion symptoms were tolerable — initially for just half-days and with accommodations allowing her to do schoolwork on paper instead of a screen and take extra time to get to and from classes. Karter went to the nurse’s office when she had a headache, Duey said. She began physical therapy to rehab her neck and regain her balance after the accident left her unsteady on her feet.

After children get concussions, a top concern for them and their parents or caregivers is when they can go back to sports, said , Karter’s doctor and a co-director of the Concussion Program at Children’s Hospital Colorado in Aurora. Returning to school as quickly as possible, with appropriate support, and getting light exercise that doesn’t pose a head injury risk are important first steps in concussion recovery, and in line with the latest research.

“It’s really important to get children and teens back to their usual daily activities as soon as possible, and as soon as they can tolerate them,” Wilson said.

In August, the Colorado Department of Education dispelling common myths about concussions, such as a loss of consciousness being necessary for a concussion diagnosis. The revised guidelines reflect evidence-based best practices on how returning to school and exercise can improve recovery. Educating families and schools about the new guidelines is critical, according to medical experts, particularly during autumn’s uptick in concussions from sports such as football and soccer.

More than nationwide had been diagnosed at some point with a concussion or brain injury, according to the 2022 National Health Interview Survey. in the past decade that adolescents recover more quickly from concussions and decrease the risk for prolonged symptoms by exercising lightly, for example on a stationary bike or with a brisk walk, two days after a concussion. That time frame may also be the sweet spot for , as long as the kids can tolerate any remaining concussion symptoms.

“Even though the brain is not a muscle, it acts like one and has a use-it-or-lose-it phenomenon,” said , a pediatrician and sports medicine and brain injury specialist at Children’s Hospital of Philadelphia.

Instead of waiting at home to fully recover, Master said, students should return to school with extra support from teachers and breaks in their schedule to relieve symptoms such as headaches or fatigue, with a goal of gradually doing more.

Every state has return-to-play laws for student-athletes that include policies such as removal from sports, medical clearance to return, and education about concussions. While some states, such as Virginia and Illinois, have “return-to-learn” policies, Colorado is not among them. It and have community-based concussion management protocols.

That is what Colorado updated this summer. REAP — which stands for Remove/Reduce; Educate; Adjust/Accommodate; and Pace — is a protocol for families, health care providers, and schools to help students recover during the first four weeks after a concussion. For example, school personnel can use an email-based system to alert teachers that a student sustained a concussion, then send weekly updates with details about how to manage symptoms, like difficulty concentrating.

“We have new protocols to support these kiddos,” said Toni Grishman, senior brain injury consultant at the Colorado Department of Education. “They might still have symptoms of concussion, but we can support them.”

Symptoms of concussion resolve in most patients in the first month. However, patients with ongoing symptoms, called persistent post-concussive symptoms, can benefit from a multidisciplinary care team that may include physicians, physical therapists, psychologists, and additional school support, Wilson said.

, director of the Colorado Concussion Research Laboratory at the University of Colorado Anschutz Medical Campus, is studying how children and their families cope with the physical, cognitive, social, and emotional impacts of concussions. In some studies, adolescents wear sensors to measure exercise intensity and volume, as well as common symptoms of concussion, like sleep and balance problems. In others, children and their parents answer questions about their perceptions and expectations of the recovery process.

“What you bring to an injury is oftentimes exacerbated by the injury,” Howell said, citing anxiety, depression, or just going through a difficult time socially. Recovery can be influenced by peer and family relationships.

Duey said the most difficult part of Karter’s recovery was her not being able to participate in cheer for nine weeks, including her team’s final competition in Florida. Karter, now 12, watched practice and supported her teammates in the spring, but missing out tore her up inside, Duey said.

“There were a lot of tears,” Duey said.

While recognizing a concussion and acting quickly can help anyone, in practice, more than half of students in Colorado may slip through the cracks with undiagnosed concussions, according to Grishman’s estimates.

The reasons for missed diagnoses are many, Grishman said, including lack of education, barriers to medical care, parental reluctance to inform schools about a concussion for fear their child will be excluded from activities, or not taking symptoms seriously in a student with a history of behavioral issues.

Getting schools to follow concussion guidelines, in general, is a challenge, Grishman said, adding that some districts still do not. She said it was hard to track the number of schools that followed Colorado education department guidelines last year but hopes improved data collection will provide more specifics this year. During the past school year, Grishman and her colleagues trained 280 school personnel in concussion management across 50 school districts in Colorado.

Whenever possible, athletic trainers should be on the sidelines to support student-athletes, Master said, and athletes should be aware of concussion symptoms in themselves and their teammates and seek care right away.

But concussions are not limited to the school athletic field or sports like football or soccer. Adventure sports like parkour, slacklining, motocross, rodeo, skiing, and snowboarding also pose concussion risks, Wilson and Grishman said. “Cheerleading is actually one that has a lot of concussions associated with it,” Howell added.

Duey said Karter occasionally has headaches, but her balance returned with help from physical therapy and she no longer experiences symptoms of her concussion. She is back to flying with her cheerleading squad and preparing to compete.

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It was the first time Xcel Energy preemptively switched off electricity in Colorado as a wildfire prevention tool, according to a company official. The practice, also known as public safety power shut-offs, has and is as a way to keep downed and damaged power lines from sparking blazes and fueling the West’s more frequent and intense wildfires.

In Boulder, Frasier staff and residents heard about the planned outage from news reports. A Frasier official called the utility to confirm and was initially told the home’s power would not be affected. The utility then called back to say the home’s power would be cut, after all, said Tomas Mendez, Frasier’s vice president of operations. The home had just 75 minutes before Xcel Energy shut off the lights on April 6.

Staff rushed to prepare the 20-acre campus home to nearly 500 residents. Generators kept running the oxygen machines, most refrigerators and freezers, hallway lights, and Wi-Fi for phones and computers. But the heating system and some lights stayed off as the overnight temperature dipped into the 30s.

Power was restored to Frasier after 28 hours. During the shut-off, staff tended to nursing home and assisted living residents, many with dementia, Mendez said.

“These are the folks that depend on us for everything: meals, care, and medications,” he said.

Not knowing when power would be restored, even 24 hours into the crisis, was stressful and expensive, including the next-day cost of refilling fuel for two generators, Mendez said.

“We’re lucky we didn’t have any injuries or anything major, but it is likely these could happen when there are power outages — expected or unexpected. And that puts everyone at risk,” Mendez said.

As preemptive power cuts become more widespread, nursing homes are being forced to evaluate their preparedness. But it shouldn’t be up to the facilities alone, according to industry officials and academics: Better communication between utilities and nursing homes, and including the facilities in regional disaster preparedness plans, is critical to keep residents safe.

“We need to prioritize these folks so that when the power does go out, they get to the front of the line to restore their power accordingly,” said David Dosa, chief of geriatrics and professor of medicine at UMass Chan Medical School in Worcester, Massachusetts, of nursing home residents.

Restoring power to hospitals and nursing homes was a priority throughout the windstorm, wrote Xcel Energy spokesperson Tyler Bryant in an email. But, he acknowledged, public safety power shut-offs can improve, and the utility will work with community partners and the Colorado Public Utilities Commission to help health facilities prepare for extended power outages in the future.

When the forecast called for wind gusts of up to 100 mph on April 6, Xcel Energy implemented a public safety power shut-off. Nearly 275,000 customers were without power from the windstorm.

Officials had adapted after the Marshall Fire killed two people and destroyed or damaged more than 1,000 homes in Boulder and the neighboring communities of Louisville and Superior two and a half years ago. Two fires converged to form that blaze, and electricity from an Xcel Energy power line that detached from its pole in hurricane-force winds “” of one of them.

“A preemptive shutdown is scary because you don’t really have an end in mind. They don’t tell you the duration,” said Jenny Albertson, director of quality and regulatory affairs for the Colorado Health Care Association and Center for Assisted Living.

More than half of nursing homes in the West are within 3.1 miles of an area with elevated wildfire risk, according to a . Yet, nursing homes with the greatest risk of fire danger in the Mountain West and Pacific Northwest had poorer compliance with federal emergency preparedness standards than their lower-risk counterparts.

Under federal guidelines, nursing homes must have disaster response plans that include or building evacuation. Those plans don’t necessarily include contingencies for public safety power shut-offs, in the past five years but are still relatively new. And nursing homes in the West are rushing to catch up.

In California, a more stringent law to bring emergency power in nursing homes up to code is expected by the California Association of Health Facilities to . But the state has not allocated any funding for these facilities to comply, said Corey Egel, the association’s director of public affairs. The association is asking state officials to delay implementation of the law for five years, to Jan. 1, 2029.

Most nursing homes operate on a razor’s edge in terms of federal reimbursement, Dosa said, and it’s incredibly expensive to retrofit an old building to keep up with new regulations.

Frasier’s three buildings for its 300 residents in independent living apartments each have their own generators, in addition to two generators for assisted living and skilled nursing, but none is hooked up to emergency air conditioning or heat because those systems require too much energy.

Keeping residents warm during a minus-10-degree night or cool during two 90-degree days in Boulder “are the kinds of things we need to think about as we consider a future with preemptive power outages,” Mendez said.

Federal audits of emergency preparedness at nursing homes in and found facilities lacking. In Colorado, eight of 20 nursing homes had deficiencies related to emergency supplies and power, according to the report. These included three nursing homes without plans for alternate energy sources like generators and four nursing homes without documentation showing generators had been properly tested, maintained, and inspected.

For Debra Saliba, director of UCLA’s Anna and Harry Borun Center for Gerontological Research, making sure nursing homes are part of emergency response plans could help them respond effectively to any kind of power outage. Her after a magnitude 6.7 earthquake that shook the Los Angeles area in 1994 motivated LA County to integrate nursing homes into community disaster plans and drills.

Too often, nursing homes are forgotten during emergencies because they are not seen by government agencies or utilities as health care facilities, like hospitals or dialysis centers, Saliba added.

Albertson said she is working with hospitals and community emergency response coalitions in Colorado on disaster preparedness plans that include nursing homes. But understanding Xcel Energy’s prioritization plan for power restoration would also help her prepare, she said.

Bryant said Xcel Energy’s prioritization plan for health facilities specifies not whether their electricity will be turned off during a public safety power shut-off — but how quickly it will be restored.

Julie Soltis, Frasier’s director of communications, said the home had plenty of blankets, flashlights, and batteries during the outage. But Frasier plans to invest in headlamps for caregivers, and during a town hall meeting, independent living residents were encouraged to purchase their own backup power for mobile phones and other electronics, she said.

Soltis hopes her facility is spared during the next public safety power shut-off or at least given more time to respond.

“With weather and climate change, this is definitely not the last time this will happen,” she said.

This article was produced by Â鶹ŮÓÅ Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at — the independent source for health policy research, polling, and journalism. 

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“We’re seeing more oral disease than the general population. There is a bigger need,” Braun said of the patients she treats at Bernard F. Gipson Eastside Family Health Center, which is part of Denver Health, the largest safety-net hospital in Colorado, serving low-income, uninsured, and underinsured residents.

Braun is part of a trend across the United States to integrate oral health into medical checkups for children, pregnant women, and others who cannot afford or do not have easy access to dentists. With federal and private funding, these programs have expanded in the past 10 years, but they face socioeconomic barriers, workforce shortages, and the challenge of dealing with the needs of new immigrants.

With a five-year, $6 million federal grant, Braun and her colleagues have helped train 250 primary care providers in oral health in Colorado, Montana, Wyoming, and Arizona. Similar projects are wrapping up in Illinois, Michigan, Virginia, and New York, funded by the federal Health Resources and Services Administration’s Maternal and Child Health Bureau. Beyond assessment, education, and preventive care, primary care providers refer patients to on- or off-site dentists, or work with embedded dental hygienists as part of their practice.

“Federally qualified health centers have a long history of co-locating dental services within their systems,” Braun said. “We’re taking that next step where care is not just co-located, meaning, say, we’re upstairs and dental is downstairs, but we’re integrated so that it becomes part of the same visit for the patient.”

Having doctors, nurses, and physician assistants who assess oral health, make referrals, and apply fluoride at community health centers is critical for the many children who lack access to dental care, said Tara Callaghan, director of operations for the Montana Primary Care Association, which represents 14 federally qualified health centers and five Urban Indian organizations.

“Providing these services during medical visits increases the frequency of fluoride application,” Callaghan said, and “improves parents’ knowledge of caring for their child’s teeth.” But obstacles remain.

Because of Montana’s large geographic area and small population, recruiting dental professionals is difficult, Callaghan said. Fifty of the state’s 56 counties are designated dental shortage areas and some counties don’t have a single dentist who takes Medicaid, she added. Montana ranks near the bottom for residents having access to , which can prevent cavities and strengthen teeth.

Pediatric dental specialists, in particular, are scarce in rural areas, with families sometimes driving hours to neighboring counties for care, she said.

Embedding dental hygienists with medical doctors is one way to reach patients in a single medical visit.

Valerie Cuzella, a registered dental hygienist, works closely with Braun and others at Denver Health, which serves nearly half of the city’s children and has embedded hygienists in five of its clinics that see children.

State regulations vary on which services hygienists can provide without supervision from a dentist. In Colorado, Cuzella can, among other things, independently perform X-rays and apply silver diamine fluoride, a tool to harden teeth and slow decay. She does all this in a cozy corner office.

Braun and Cuzella work so closely that they often finish each other’s sentences. Throughout the day they text each other, taking advantage of brief lulls when Cuzella can pop into an exam room to check for gum disease or demonstrate good brushing habits. Braun herself takes similar opportunities to assess oral health during her exams, and both focus on educating parents.

Medical and dental care have traditionally been siloed. “Schools are getting better at interprofessional collaboration and education, but by and large we train separately, we practice separately,” said Katy Battani, a registered dental hygienist and assistant professor at Georgetown University.

Battani is trying to bridge the divide by helping community health centers in nine states — including California, Texas, and Maryland — integrate dental care into prenatal visits for pregnant women. Pregnancy creates opportunities to improve oral health because some women and see providers at least once a month, Battani said.

In Denver, housing instability, language barriers, lack of transportation, and the “astronomical cost” of dentistry without insurance make dental care inaccessible for many children, the migrant community, and seniors, said Sung Cho, a dentist who oversees the dental program at STRIDE Community Health Center, serving the Denver metro area.

STRIDE tries to overcome these barriers by offering interpretation services and a sliding pay scale for those without insurance. That includes people like Celinda Ochoa, 35, of Wheat Ridge, who waited at STRIDE Community Health Center while her 15-year-old son, Alexander, had his teeth cleaned. He was flagged for dental care during a past medical checkup and now he and his three siblings regularly see a dentist and hygienist at STRIDE.

One of Ochoa’s children has Medicaid dental coverage, but her three others are uninsured, and they couldn’t otherwise afford dental care, said Ochoa. STRIDE offers an exam, X-rays, and cleaning for $60 for the uninsured.

In the past year, Cho has seen an influx of migrants and refugees who have never seen a dentist before and need extensive care. Medical exams for refugees at STRIDE increased to 1,700 in 2023 from 1,300 in 2022, said Ryn Moravec, STRIDE’s director of development. She estimates the program has seen 800 to 1,000 new immigrants in 2024.

Even with growing needs, Cho said the Medicaid “unwinding” — the process underway to for the government program that provides health coverage for people with low incomes and disabilities — has created financial uncertainty. He said he worries about meeting the upfront costs of new staff and of replacing aging dental equipment.

At STRIDE’s Wheat Ridge clinic, two hygienists float between dental and pediatrics as part of the medical-dental integration. Yet Cho said he needs more hygienists at other locations to keep up with demand. The pandemic created bottlenecks of need that are only now being slowly cleared, particularly because few dentists take Medicaid. If they do accept it, they often limit the number of Medicaid patients they’ll take, said Moravec. Ideally, STRIDE could hire two hygienists and three dental assistants, Moravec said.

In 2022, Colorado enacted a law to alleviate workforce shortages by allowing — midlevel providers who do preventive and restorative care — to practice. But Colorado does not have any schools to train or accredit them.

Before age 3, children are scheduled to see a pediatrician for 12 well visits, a, particularly for at-risk children. As part of Braun’s program in the Rocky Mountain region, providers have applied more than 17,000 fluoride varnishes and increased the percentage of children 3 and younger who received preventive oral health care to 78% from 33% in its first 2½ years.

Callaghan, at the Montana Primary Care Association, witnesses that on the ground at community health centers in Montana. “It’s about leveraging the fact that kids see their medical provider for a well-child visit much more often and before they see their dental provider — if they have one.”

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But this transaction was different from typical exchanges that occur every day at thousands of pharmacies across the United States. The cost to Phoenix, 50, who lives in the nearby community of Falcon and has no health insurance, was nothing.

runs Colorado’s only current drug donation program. Most of the medications it dispenses come from nursing homes across the state.

“We take any and all of it,” said founding pharmacist Frieda Martin, who used those donations to fill 1,900 prescriptions for 200 low-income and uninsured adults last year. Participants pay a $15 annual registration fee for free medications and care at the adjoining clinic.

Drug donation programs like this one in Colorado and one in California take unopened, unexpired medications from health care facilities, private residents, pharmacies, or prisons that pile up when patients are discharged, change drugs, or die, and re-dispense them to uninsured and low-income patients. About 8% of adults in the U.S. who took prescription drugs in 2021, about 9 million people, did not take them as prescribed because of cost, and uninsured adults were more likely to skip medications than those with insurance, according to the .

The programs vary in size but are often run by charitable pharmacies, nonprofits, or governments, and keep drugs out of landfills or incinerators, where an estimated $11 billion in unused medications are disposed of each year.

Forty-four states already have laws allowing drug donations, according to the . Many programs, like Colorado’s, are small or underutilized. Now, Colorado and other states are seeking to expand their approach.

“Drug donation programs are effective. There is a huge need for them. And there are opportunities for states to help their residents by enacting new laws,” said George Wang, a co-founder of SIRUM, which stands for Supporting Initiatives to Redistribute Unused Medicine, a of drug donors and distributors in the U.S.

Colorado Senate Majority Leader Robert Rodriguez, a Democrat, said he plans to introduce a bill next year to create a drug donation program to help the who can’t fill their prescriptions because of cost.

Similarly, signed last year allows expansion of the state’s first and only drug donation program, in Santa Clara County, to San Mateo and San Francisco counties. Kathy Le, the supervising pharmacist at Better Health, said it is in “the early stages” of working with other county-run pharmacies in California to develop similar programs.

The , based in Cheyenne, uses mail distribution to reach residents, including those in remote parts of the state who may not have local pharmacies, said Sarah Gilliard, a pharmacist and its program manager. The program mails a total of approximately 16,000 free prescriptions annually to 2,000 Wyoming residents who are low-income, uninsured, or underinsured.

“Access is definitely a big consideration when it comes to the design of our program,” she said.

Many of the Wyoming program’s participants are 65 and older, on Medicare, with fixed incomes and unaffordable copays, but Gilliard said there has been a recent increase in participants between the ages of 20 and 40. Wyoming is one of 10 states that have not expanded Medicaid to cover more low-income residents, which could be a factor in that uptick, Gilliard said.

Donations come from all 50 states, with the majority from people who find the program online or through word of mouth. Sometimes donors tuck handwritten notes inside the packages about the high cost of medication or memories of a relative who died.

Gilliard saves each one and tacks them to the pharmacy wall.

Wyoming’s program, with its central state-run pharmacy that receives, processes, and mails prescriptions to residents, could be a model for Colorado, said Gina Moore, a pharmacist and senior associate dean at the University of Colorado’s Skaggs School of Pharmacy and Pharmaceutical Sciences in Aurora. Moore co-authored a for the state government last December about the feasibility of a drug donation program.

The report noted the success of programs with external funding, which, in Wyoming’s case, comes directly from taxpayer dollars. Using Wyoming’s budget, it projected a Colorado drug donation program would cost an estimated $431,000 in the first year, with a pharmacist and pharmacy technician serving roughly 1,500 patients.

In Colorado Springs, Martin and her husband, Jeff Martin, who is the executive director of Open Bible Medical Clinic and Pharmacy, believe a charitable, volunteer-run model like theirs would be feasible for Colorado, and they wonder how their long-running pharmacy will fit in with potential state-run efforts. In the task force report, Moore and her colleagues write that the state-run model and the Martins’ program could coexist.

Since Colorado to allow drug donation in 2005, it has been amended several times in attempts to help it grow. But the state has not invested money or infrastructure to make a drug donation program take off.

Drug donations mailed to Open Bible dwindled during the pandemic and are only now slowly rebounding. The pharmacy ships roughly half of all donated medications to clinics across Colorado that serve uninsured and low-income patients in other cities such as Denver, Loveland, and Longmont.

Elsewhere in the U.S., SIRUM ensures that donors have packaging to ship donated medications, and it provides software to make inventorying and dispensing easier. Recently, it built a live online inventory of medications for , a nonprofit pharmacy that mails 90-day prescriptions for about $6 to residents of Illinois and Georgia.

SIRUM helps facilitate donations for California’s Better Health Pharmacy, which has dispensed medications to 15,000 Santa Clara County residents since opening in 2015, Le said. Many are uninsured, underinsured, and speak Spanish or Vietnamese. Ten volunteers, often students, help log donations, and Better Health Pharmacy fills roughly 40,000 prescriptions a year with annual operating costs of just over $1 million, according to Le and Santa Clara County public health officials.

Besides prescriptions, Better Health Pharmacy provides free covid antigen tests and flu vaccinations to address its community’s needs. “We try to come up with creative solutions to expand the scope of our services,” Le said.

This commitment to addressing gaps in health care access and reducing impact on the environment means the “timing is right” for expansion of drug donation programs in California and beyond, said Monika Roy, assistant health officer and communicable disease controller at Santa Clara County’s Public Health Department.

“During the pandemic, inequities in access to care were magnified,” Roy said. “When we have solutions like these, it’s a step forward to address both equity and climate change in the same model.”

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“It’s much lighter work. It’s nurturing. It’s slow,” said Streim, a licensed massage therapist.

Massage therapy for someone near the end of life looks and feels different from a spa treatment. Some people stay clothed or lie in bed. Others sit up in their wheelchairs. Streim avoids touching bedsores and fresh surgery wounds and describes her work as “meditating and moving at the same time.” She recalled massaging the shoulders, hands, and feet of one client as he sat in his favorite recliner and watched baseball on TV in the final weeks of his life.

“When you’re dying and somebody touches you without expectation of anything in return, you just get to be,” said Streim.

Massage therapists like Streim, who specializes in working with people who are dying or have an advanced form of cancer or other illness, are rare. Fewer than 1% of therapists specialize in hospice or palliative care massage, according to research by the , although many more may periodically offer massage for hospice patients.

Streim has a private practice in Lafayette, and her clients pay her out-of-pocket, as Medicare and private insurance typically don’t cover massage therapy. She also volunteers as a hospice massage therapist four hours a month.

It’s common for hospice organizations to use volunteer therapists for treatments, though some massage therapists, with physicians backing them, are pushing for paid positions as part of medical teams working alongside nurses and social workers. In the hospice unit at Palo Alto VA Medical Center, in Palo Alto, California, for example, massage therapists have been integral members of the multidisciplinary team for decades, said , a professor of medicine at Stanford University and the founding director of its palliative care education and training program.

The covid-19 pandemic made the recruitment of specialists for this intimate work, both paid and volunteer, more difficult, as the pool of massage therapists shrank amid school closures and exits from the profession. There are up to 10% fewer massage therapists today than before the pandemic, according to Les Sweeney, president of .

“It’s still hard for us to hire and recruit therapists,” said operations director at Healwell, a nonprofit that trains and employs massage therapists to work in hospitals in the Washington, D.C., area.

For three weeks in April 2020, licensed massage therapist , who works at Faith Presbyterian Hospice in Dallas, could not massage patients due to the state’s lockdown orders. Then, the state granted an allowance for massage therapists like her, working in medical settings under supervision, to resume giving massages. But it took several months for many therapists to return to work, and some didn’t return at all, Spence said.

“The pandemic was not kind to massage therapists,” Spence said. “And so we have lost a lot of people like me who are of an age and experience level that would really be called to and suitable” for oncology, hospice, and palliative massage.

“We need to get more therapists trained,” she said. She described receiving several calls each month from people who have found her name online. It has become harder since covid to find a therapist to refer them to, Spence said.

At TRU Community Care, which operates in several locations in Colorado, Volunteer Services Supervisor Wendy Webster said massages are a top request from patients and their families, but they’re limited in how many sessions they can offer, with only two volunteer massage therapists. (A third volunteer did not return after the pandemic.)

Finding new massage therapist volunteers is challenging, said Webster, in part because they can earn money in other settings and “they’re coming to us for free.” Thirty years ago, TRU Community Care’s nonprofit status was the norm, but now the majority of hospices are for-profit, with .

Despite that shift, hospices still rely heavily on volunteers. Medicare pays for at least six months of hospice for a patient on the condition that providers use volunteers for at least worked by paid staff and contractors. Sometimes, those volunteer hours are filled by massage therapists.

“All hospices, not-for-profit or for profit alike, should aim to include medically-trained massage therapists as part of best holistic care,” , a professor of medicine at Georgetown University who directs palliative care at MedStar Washington Hospital Center in Washington, D.C., wrote in an email. Employing these specialists is beneficial and does not diminish the important service of volunteers, particularly in end-of-life care, he added.

More studies on the impact of specialized massage could enact changes in the field, said , founder and executive director of Healwell, which, since 2009, has trained 500 therapists in hospital-based and oncology massage, as well as in how to work collaboratively with doctors and nurses.

In a of 387 patients in palliative care at MedStar, including some nearing the end of their lives, Groninger, Cates, Jordan, and other co-authors found that massage therapy improved quality of life.

Despite new research on the benefits of massage, Cates said, many hospices bring on volunteers who don’t have advanced training, because hospices may not know that specialized training — such as the kind Healwell offers — exists.

Streim, who paid for her own classes in oncology and lymphatic massage, said that investment in education qualified her for a six-year career as an oncology massage therapist at Good Samaritan Medical Center’s Center for Integrative Medicine in Lafayette and later her private practice. She teaches classes in adapting massage for the elderly and those with illnesses at Boulder Massage Therapy Institute. In her 39 years as a therapist, Streim has done it all: volunteer, staff, entrepreneur, teacher.

Like Streim, Spence has continually redefined her role. She began in private practice before becoming an employee of a large hospice agency in which she traveled across nine counties in Texas, giving thousands of massages to people dying in their homes, assisted living communities, and skilled nursing homes. Today, at Faith Presbyterian Hospice, she is one of three licensed massage therapists on staff and fully integrated as an employee of the organization, which has more than 100 patients.

“Those of us who do this work have made big investments in our profession and I’m glad to see that we can be paid for it,” she said.

Spence collects data on how patients rate their pain on a scale of 1 to 10 before and after a massage. Most fall asleep during the massage, which she takes as an indication their pain has lessened or they became more relaxed. Of those who stay awake, almost all say their pain subsided significantly or went away completely.

That kind of positive engagement with providers is more urgent than ever since the pandemic, Groninger said. Spence agreed: “The pandemic taught us all, in a very painful way, what it’s like to be deprived of human touch and human connections.”

Sometimes the nursing staff at Faith Presbyterian will roll a bed out onto the patio so a patient can hear the sounds of nature and the fountain gurgling during Spence’s massage. There is more teasing and laughter than she would have imagined. For patients unable to speak, Spence watches their reactions carefully: a deep exhalation or the face and body softening. Sometimes it’s tears running down their cheeks.

“It’s profound, helping someone find safe breaths along this very difficult dying journey,” she said.

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“They’re somebody’s mom, somebody’s grandma, somebody’s great-grandmother,” Shelton said. “I want to take care of them like I would take care of my family.”

Shelton trained to be a personal care aide through an apprenticeship program designed to meet the increasing need for health care workers in rural western Colorado. Here, far from Denver’s bustling urban corridor, worker shortages mount as baby boomers retire, young people move away from these older communities, and demand for health care in homes and facilities rises.

Rural areas often have than urban areas do. And the most rural regions have relatively fewer direct care workers, like personal care aides, to help people with disabilities than less-rural regions do, according to a recent study in the journal .

Besides increasing the number of direct care workers, the Colorado apprenticeship program offers opportunities for improving earning power to residents who live at or below the poverty line, who lost their jobs during the covid-19 pandemic, or who are unemployed or underemployed. They train to become personal care aides, who help patients with daily tasks such as bathing or housekeeping, or certified nursing assistants, who can provide some direct health care, like checking blood pressure.

Apprentices take training classes at Western Colorado Area Health Education Center in Grand Junction, and the center pays for students who live in more rural areas to attend classes at Technical College of the Rockies in Delta County. The apprentices receive on-the-job training with one of 58 local employers — an assisted living facility, for example — and they are required to work there for one year. Each apprentice has an employer mentor. Staff members at Western Colorado AHEC also provide mentorship, plus the center has a life coach on hand.

“We really just want students to get into health care, get jobs, and retain those jobs,” said Georgia Hoaglund, executive director of Western Colorado AHEC, which has 210 active apprentices and was bolstered by a $2 million grant from the U.S. Labor Department in 2021.

Some apprentices are recent high school graduates. Others are single mothers or veterans. They often have educational or economic barriers to employment. Hoaglund and her staff of 10 buy the apprentices scrubs so they can start new jobs with the right uniforms; otherwise, they might not be able to afford them. Staff members pay for apprentices’ gas if they can’t afford to fill up their tanks to drive to work. They talk to apprentices on the phone monthly, sometimes weekly.

Even though the apprenticeship program gives these workers a solid start, the jobs can be stressful, and burnout and low pay are the norm. Career advancement is another obstacle, said Hoaglund, because of the logistics or cost of higher education. Hoaglund, who calls her staff family and some of the apprentices her kids, dreams of offering more advanced training — in nursing, for example — with scholarship money.

Apprenticeships are perhaps better known as a workforce training tool among electricians, plumbers, carpenters, and other tradespeople. But they are also viewed as a way of building a needed pipeline of direct care health workers, said Robyn Stone, senior vice president for research at LeadingAge, an association of nonprofit providers of aging services.

“Traditionally, health care employers have hired people after they finish a training program,” said Susan Chapman, a registered nurse and a professor in the school of nursing at the University of California-San Francisco. “Now, we’re asking the employer to take part in that training and pay the person while they’re training.”

The pandemic exacerbated shortages of direct care workers, which could encourage employers to invest in apprenticeships programs, both Chapman and Stone said. Federal investment could help, too, and a Biden administration initiative to improve the quality of nursing homes includes $35 million in grants to address workforce shortages in rural areas.

Shelton had never worked in health care before moving to Fruita, a small town that is about 12 miles northwest of Grand Junction and is surrounded by red sandstone towers. She left Fresno, California, a year ago to take care of an uncle who has multiple sclerosis. She and her 16-year-old daughter live in a trailer home on her uncle’s property, where Blackie, her rescue Labrador retriever, roams with the chickens and cats.

Blackie also sometimes accompanies Shelton to BeeHive to visit with the residents. Shelton said that it is more than a job to her and that she is grateful to the apprenticeship program for helping her get there. “It opened a door for me,” Shelton said.

Shelton works three 12-hour shifts a week, in addition to taking care of her uncle and daughter. Yet, she said, she struggles to have enough money for gas, bills, and food and has taken out small loans to make ends meet.

She is not alone. Personal care aides are often underpaid and undervalued, said Chapman, who has found significantly higher poverty rates among these workers than among the general population.

Direct care workers nationwide, on average, make $13.56 an hour, , and these low wages make recruiting and retaining workers difficult, leading to further shortages and instability.

In an effort to keep workers in the state, for personal care aides and certified nursing assistants to $15 an hour this year with money from the American Rescue Plan Act. And the Colorado Department of Health Care Policy and Financing’s 2023-24 budget request includes a bump to $15.75. Similar efforts to raise wages are underway in 18 other states, including New York, Florida, and Texas, according to a recent .

Another way to keep apprentices in jobs, and encourage career and salary growth, is to provide opportunities for specialized training in dementia care, medication management, or behavioral health. “What apprenticeships offer are career mobility and advancement,” Stone said.

To practice in Colorado, new certified nursing assistants complete in-class training, do clinical rotations, and pass a certification exam made up of a written test and a skills test. Hoaglund said the testing requirements can be stressful for students. Shelton, 43, has passed the written exam but must retake the skills test to become licensed as a certified nursing assistant.

Hoaglund’s program started in 2019, but it really took off with the 2021 federal grant. Since then, 16 people have completed the program and have received pay increases or promotions. Twice as many people have left without finishing. The largest hospital in Grand Junction, Intermountain Healthcare-St. Mary’s Medical Center, recruits workers from the program.

Hoaglund said each person who enters the health care field is a win.

Brandon Henry, 23, was a student at Colorado Mesa University in Grand Junction and working at PetSmart before he joined the apprenticeship program in 2019. After enrolling, he trained and worked as a certified nursing assistant through the worst of the pandemic. As an apprentice, he said, he learned the importance of having grace while caring for patients.

He went back for more training at Western Colorado AHEC to earn a license that allows him to dispense medicine in accredited facilities, such as assisted living centers. He now works at Intermountain Healthcare-St. Mary’s Medical Center, where he took training classes in wound care and physical therapy hosted at the hospital. This winter, he’ll graduate from Colorado Mesa with a Bachelor of Science in nursing.

“At the hospital, I’ve found more opportunities for pay raises and job growth,” Henry said.

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But the kids’ excitement for their new rides is tempered by a recurring question from worried parents: Are they safe?

That can be a difficult question to answer. The federal government’s e-bike regulations are sparse, and efforts to expand them have stalled, leaving states and even counties to fill the void with patchwork rules of their own. Meanwhile, the seemingly endless variety of e-bikes for sale vary in design, speed, and quality.

In that environment, retailers like Fletcher aim to educate consumers so they can make informed decisions.

“We’re super careful about what comes in the shop because there are hazards,” he said.

Federal rules requiring in e-bikes and other devices such as e-scooters are in limbo after the Consumer Product Safety Commission, the independent federal regulatory agency meant to protect people against death and injury from bicycles and other consumer products, in August.

The commission then sent the rules for review by the Office of Information and Regulatory Affairs inside the Office of Management and Budget, responding to President Donald Trump’s February demanding that independent agencies like the CPSC be more aligned with White House priorities. In May, Trump fired three members of the commission who had been appointed by his predecessor, former President Joe Biden.

Meanwhile, by the commission to address injuries from mechanical failings have languished. Shira Rawlinson, the CPSC’s communications director, said it plans to update the status of both proposed rules.

That leaves e-bikes subject to existing standards written for traditional bicycles and which the commission has said, based on a preliminary assessment, aren’t adequate to reduce the risk of e-bike injuries. , , and recently passed laws regulating e-bikes to fill the gap.

The laws address issues such as battery fire risks and rider safety and seek to distinguish lower-speed e-bikes from faster e-motos, or electric motorcycles, which can reach top speeds of 35 miles an hour or faster. No federal law dictates the age at which someone may operate an e-bike, but more than half of states have age restrictions for who can operate , which reach a top speed of 28 miles an hour with pedal assist, while two California counties recently set a minimum age to operate Class 2 bikes, with their 20 mph top assisted speed.

“The biggest issue is e-bikes that switch from a power-assisted bike to essentially a motorized scooter,” said Democratic state Rep. Lesley Smith, who co-sponsored Colorado’s bill.

Colorado’s e-bike law requires safety certification of lithium-ion batteries, which can explode when manufactured or used improperly. They caused 39 deaths and 181 injuries in people using micromobility devices such as e-bikes from 2019 to 2023, according to the CPSC.

Most dealers, importers, and distributors have agreed to use batteries that meet safety standards, but there will always be manufacturers who cut corners on safety to save money, said Ed Benjamin, chairman of the Light Electric Vehicle Association, whose hundreds of members supply light electric vehicles such as e-bikes, or their parts.

“There are some out there who don’t care what is the right thing to do. They just want to make the cheapest bike possible,” Benjamin said.

Amy Thompson, the Safe Routes to School program coordinator for the Boulder Valley School District, said education officials are scrambling to install more bike racks at several schools to meet the increase in e-bike usage.

Students use them to quickly get to school or activities and carry their sports equipment or instruments with ease, Thompson said. She said she’s seen some alarming behavior, such as students’ riding three to a bike, riding without helmets, or attempting power wheelies popularized by social media.

Thompson said kids are disabling the speed limiter on e-bikes to operate at higher speeds. “It’s super easy for kids to go on YouTube and find a video that will coach you how to override or disable the governor on a bicycle,” she said.

Thompson to monitor their children’s e-bikes in September and described the between e-bikes and e-motos last fall.

Those blurred lines bedevil an adopted, in part or full, by nearly all states, in which e-bike motors generally must operate at 750 watts or lower. Class 1 e-bikes use pedal assist that must not exceed 20 mph; Class 2 e-bikes include a throttle that also must not exceed 20 mph; and Class 3 e-bikes use pedal assist that must not exceed 28 mph.

Some e-bikes easily switch between Class 2 and 3, sometimes unbeknownst to parents, said Smith, the Colorado lawmaker. A California parent sued an e-bike manufacturer last year, saying it falsely advertised as Class 2 an e-bike that could switch to Class 3.

The dangers of Class 2 e-bikes prompted California’s Marin County to under 16 from operating them and require that anyone riding one wear a helmet. Youths ages 10 to 15 who crash their e-bikes require an ambulance at of other age groups involved in e-bike crashes, according to county health officials. A growing number of serious injuries on e-bikes, particularly among adolescents, is an emerging public safety problem, the American College of Surgeons .

Talia Smith, Marin County’s legislative director, championed that permits Marin County to impose age restrictions. After hearing from a dozen other counties experiencing similar problems, though, she said state legislators should move to a statewide law from piecemeal, county-by-county ordinances. San Diego County from operating Class 1 or 2 bikes.

Vehicles claiming to be both e-bikes and e-motos fall into the cracks between two regulatory agencies, the CPSC and the National Highway Traffic Safety Administration, said Matt Moore, general and policy counsel for PeopleForBikes, a trade association for bicycles, including e-bikes.

PeopleForBikes wants the traffic safety administration to stop shipments of or take other legal action against e-motos that are labeled as e-bikes and do not comply with federal standards, Moore said.

If the federal government won’t act, states should clarify their laws to define e-motos as off-road dirt bikes or motor vehicles that require licenses, he said. In October, California , which it requires to display an identification plate issued by the Department of Motor Vehicles for use off-highway.

In Boulder, Thompson said, the school district considers communication and education cornerstones of safety. Children and teens should learn and practice traffic rules, whether they’re powering two wheels with their own legs or a throttle, she said.

“E-bikes are fun, environmentally friendly, and relatively cheap transportation. So how can we make them safer and more viable for families?” Thompson said.

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While the 76-year-old Milwaukee resident waited to hear back, Miller did something patients increasingly do when they can’t reach their health care team. She put her test results into Claude and asked the AI assistant to evaluate the data.

“Claude helped give me a clear understanding of the abnormalities,” Miller said. The generative AI model didn’t report anything alarming, so she wasn’t anxious while waiting to hear back from her doctor, she said.

Patients have unprecedented access to their medical records, often through online patient portals such as MyChart, because federal law requires health organizations to immediately release electronic health information, such as notes on doctor visits and test results. published in 2023 found that 96% of patients surveyed want immediate access to their records, even if their provider hasn’t reviewed them.

And many patients are using large language models, or LLMs, like OpenAI’s ChatGPT, Anthropic’s Claude, and Google’s Gemini, to interpret their records. That help comes with some risk, though. Physicians and patient advocates warn that AI chatbots can produce wrong answers and that sensitive medical information might not remain private.

Yet, most adults are cautious about AI and health. Fifty-six percent of those who use or interact with AI are not confident that information provided by AI chatbots is accurate, according to . Â鶹ŮÓÅ is a health information nonprofit that includes Â鶹ŮÓÅ Health News.

“LLMs are theoretically very powerful and they can give great advice, but they can also give truly terrible advice depending on how they’re prompted,” said Adam Rodman, an internist at Beth Israel Deaconess Medical Center in Massachusetts and the chair of a steering group on generative AI at Harvard Medical School.

Justin Honce, a neuroradiologist at UCHealth in Colorado, said it can be very difficult for patients who are not medically trained to know whether AI chatbots make mistakes.

“Ultimately, it’s just the need for caution overall with LLMs. With the latest models, these concerns are continuing to get less and less of an issue but have not been entirely resolved,” Honce said.

Rodman has seen a surge in AI use among his patients in the past six months. In one case, a patient took a screenshot of his hospital lab results on MyChart then uploaded them to ChatGPT to prepare questions ahead of his appointment. Rodman said he welcomes patients’ showing him how they use AI, and that their research creates an opportunity for discussion.

Roughly 1 in 7 adults over 50 use AI to receive health information, according to a recent poll from the , while 1 in 4 adults under age 30 do so, according to the Â鶹ŮÓÅ poll.

Using the internet to advocate for better care for oneself isn’t new. Patients have traditionally used websites such as WebMD, PubMed, or Google to search for the latest research and have sought advice from other patients on social media platforms like Facebook or Reddit. But AI chatbots’ ability to generate personalized recommendations or second opinions in seconds is novel.

, communications and patient initiatives director at OpenNotes, an academic lab at Beth Israel Deaconess that advocates for transparency in health care, had wondered how good AI is at interpretation, specifically for patients.

In a published this year, Salmi and colleagues analyzed the accuracy of ChatGPT, Claude, and Gemini responses to patients’ questions about a clinical note. All three AI models performed well, but how patients framed their questions mattered, Salmi said. For example, telling the AI chatbot to take on the persona of a clinician and asking it one question at a time improved the accuracy of its responses.

Privacy is a concern, Salmi said, so it’s critical to remove personal information like your name or Social Security number from prompts. Data goes directly to tech companies that have developed AI models, Rodman said, adding that he is not aware of any that comply with federal privacy law or consider patient safety. Sam Altman, CEO of OpenAI, warned on a about putting personal information into ChatGPT.

“Many people who are new to using large language models might not know about hallucinations,” Salmi said, referring to a response that may appear sensible but is inaccurate. For example, OpenAI’s Whisper, an AI-assisted transcription tool used in hospitals, introduced an imaginary medical treatment into a transcript, according to a

Using generative AI demands a new type of digital health literacy that includes asking questions in a particular way, verifying responses with other AI models, talking to your health care team, and protecting your privacy online, said Salmi and Dave deBronkart, a cancer survivor and patient advocate who devoted to patients’ use of AI.

Patients aren’t the only ones using AI to explain test results. has launched an AI assistant that helps its physicians draft interpretations of clinical tests and lab results to send to patients. Colorado researchers studied the accuracy of ChatGPT-generated summaries of 30 radiology reports, along with four patients’ satisfaction with them. Of the 118 valid responses from patients, 108 indicated the ChatGPT summaries clarified details about the original report.

But ChatGPT sometimes overemphasized or underemphasized findings, and a small but significant number of responses indicated patients were more confused after reading the summaries, said Honce, who participated in .

Meanwhile, after four weeks and a couple of follow-up messages from Miller in MyChart, Miller’s doctor ordered a repeat of her blood work and an additional test that Miller suggested. The results came back normal. Miller was relieved and said she was better informed because of her AI inquiries.

“It’s a very important tool in that regard,” Miller said. “It helps me organize my questions and do my research and level the playing field.”

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, , and are among the states that have recently required safeguarding brain data collected by devices outside of medical settings. That includes headphones, earbuds, and other wearable consumer products that aim to improve sleep, focus, and aging by measuring electrical activity and sending the data to an app on users’ phones.

by the Neurorights Foundation, an advocacy group that aims to protect people from the misuse of neurotechnology, found that 29 of 30 companies with neurotechnology products that can be purchased online have access to brain data and “provide no meaningful limitations to this access.” Almost all of them can share data with third parties.

In June, the American Medical Association of neural data. In April, several Democratic members of the U.S. Senate Committee on Commerce, Science, and Transportation to investigate whether companies are exploiting consumers’ brain data. Juliana Gruenwald Henderson, a deputy director of the FTC’s Office of Public Affairs, said the agency had received the letter but had no additional comment.

Although current devices gather relatively basic information like sleep states, advocates for brain data protection caution that future technologies, including artificial intelligence, could extract more personal and sensitive information about people’s medical conditions or innermost thoughts.

“If you collect the data today, what can you read from it five years from now because the technology is advancing so quickly?” said Democratic state Sen. Cathy Kipp, who sponsored Colorado’s 2024 neural data protection bill when she was in the state House of Representatives.

As both excitement and trepidation about AI build, at least 28 states and the U.S. Virgin Islands some type of AI regulation separate from the privacy bills protecting neural data. President Donald Trump’s “” included a 10-year halt on states passing laws to regulate AI, but the Senate stripped that provision out of the budget reconciliation bill before voting to approve it on July 1.

The spirit of laws in Colorado, California, and Montana is to protect the neural data itself, not to regulate any algorithm or AI that might use it, said Sean Pauzauskie, medical director for the .

But neurotechnology and AI go hand in hand, Pauzauskie said. “A lot of what these devices promise is based on pattern recognition. AI is really driving the usability and significance of the patterns in the brain data.”

a professor of neurosurgery at the University of Colorado School of Medicine, said that AI’s ability to identify patterns is a game changer in her field. “But contribution of a person’s neural data on an AI training set should be voluntary. It should be an opt-in, not a given.”

Chile in 2021 became the first country to adopt a constitutional amendment for neurorights, which prioritize human rights in the development of neurotechnology and collection of neural data, and UNESCO has said that neurotechnology and artificial intelligence could together pose a threat to human identity and autonomy.

Neurotechnology can sound like science fiction. Researchers used a and an AI model to decode the brain’s electric signals from thoughts into speech. And two years ago, a study described how neuroscientists reconstructed the Pink Floyd song “” by analyzing the brain signals of 29 epilepsy patients who listened to the song with electrodes implanted in their brains.

The aim is to use neurotechnology to help those with paralysis or speech disabilities, as well as treat or diagnose traumatic brain injuries and brain disorders such as Alzheimer’s or Parkinson’s. Elon Musk’s Neuralink and , funded by Bill Gates and Jeff Bezos, are among the companies with clinical trials underway for devices implanted in the brain.

Pauzauskie, a hospital neurologist, started worrying four years ago about the blurring of the line between clinical and consumer use of neural data. He noted that the devices used by his epilepsy patients were also available for purchase online, but without protections afforded by the Health Insurance Portability and Accountability Act in medical settings.

Pauzauskie approached Kipp two years ago at a constituent meetup in his hometown of Fort Collins to propose a law to protect brain data in Colorado. “The first words out of her mouth that I’ll never forget were, ‘Who would be against people owning their own brain data?’” he said.

Brain data protection is one of the rare issues that unite lawmakers across the political aisle. The bills in California, Montana, and Colorado passed unanimously or nearly unanimously. Montana’s law will go into effect in October.

Neural data protection laws in Colorado and California amend each state’s general consumer privacy act, while Montana’s law adds to its existing genetic information privacy act. Colorado and Montana require initial express consent to collect or use neural data and separate consent or the ability to opt out before disclosing that data to a third party. A business must provide a way for consumers to delete their data when operating in all three states.

“I want a very hard line in the sand that says, you own this completely,” said Montana state Republican Sen. Daniel Zolnikov, who sponsored his state’s neural data bill and other privacy laws. “You have to give consent. You have the right to have it deleted. You have complete rights over this information.”

For Zolnikov, Montana’s bill is a blueprint for a national neural data protection law, and Pauzauskie said support of regulatory efforts by groups like the AMA pave the way for further federal and state efforts.

Welle agreed that federal regulations are needed in addition to these new state laws. “I absolutely hope that we can come up with something on a national level that can enshrine people’s neural rights into law, because I think this is going to be more important than we can even imagine at this time.”

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The dawn of state-regulated psychedelic mushrooms has arrived in Colorado, nearly two years since Oregon began offering them. The mushrooms are a Schedule I drug and illegal under federal law except for clinical research. But more than a dozen cities nationwide have deprioritized or decriminalized them in the past five years, and many eyes are turned toward Oregon’s and Colorado’s state-regulated programs.

“In Oregon and Colorado, we’re going to learn a lot about administration of psychedelics outside of clinical, religious, and underground settings because they’re the first to try this in the U.S.,” said William R. Smith, an assistant professor of psychiatry at the University of North Carolina School of Medicine.

Psychedelic mushrooms and their psychoactive compound psilocybin have the potential to treat people with depression and anxiety, including those unresponsive to other medications or therapy. , part of the National Institutes of Health, says the risk of mental health problems caused by ingesting mushrooms in a supervised clinical setting is low, but may be higher outside of a clinical setting. Robert F. Kennedy Jr. said in a social media post last year, before his nomination as U.S. health secretary, that his “mind is open to the idea of psychedelics for treatment.”

Medical experts say is needed, particularly in people with a diagnosis or family history of psychotic or bipolar disorder. Adverse effects of psilocybin, including headache and nausea, typically resolve within . However, extended difficulties from using psychedelics can last weeks, months, or years; anxiety and fear, existential struggle, social disconnection, and feeling detached from oneself and one’s surroundings are . After the decriminalization and legalization in Oregon and Colorado, psychedelic mushroom exposures reported to ticked up in these states and nationally.

In February, about 40 people organized by the psychedelic advocacy group the gathered in Boulder to talk about the coming changes in Colorado. They included Mandy Grace, who received her state license to administer psychedelic mushrooms, and Amanda Clark, a licensed mental health counselor from Denver, who both praised the therapeutic power of mushrooms.

“You get discouraged in your practice because the current therapies are not enough for people,” Clark said.

Colorado voters approved in 2022 to legalize natural psychedelics, after Oregon voters in 2020 approved legalizing psilocybin for therapeutic use. Colorado’s program is modeled after, but not the same as, Oregon’s, under which 21,246 psilocybin products have been sold as of March, a total that could include secondary doses, according to the Oregon Health Authority.

As of mid-March, Colorado for at least 15 healing center licenses, nine cultivation licenses, four manufacturer licenses, and one testing facility license for growing and preparing the mushrooms, under by the governor-appointed Natural Medicine Advisory Board.

Psychedelic treatments in Oregon are expensive, and are likely to be so in Colorado, too, said Tasia Poinsatte, Colorado director of the nonprofit Healing Advocacy Fund, which supports state-regulated programs for psychedelic therapy. In Oregon, psychedelic mushroom sessions are typically $1,000 to $3,000, are not covered by insurance, and must be paid for up front.

The mushrooms themselves are not expensive, Poinsatte said, but a facilitator’s time and support services are costly, and there are state fees. In Colorado, for doses over 2 milligrams, facilitators will screen participants at least 24 hours in advance, then supervise the session in which the participant consumes and experiences mushrooms, lasting several hours, plus a later meeting to integrate the experience.

Facilitators, who may not have experience with mental health emergencies, need training in screening, informed consent, and postsession monitoring, Smith said. “Because these models are new, we need to gather data from Colorado and Oregon to ensure safety.”

Facilitators generally pay a $420 training fee, which allows them to pursue the necessary consultation hours, and roughly $900 a year for a license, and healing centers pay $3,000 to $6,000 for initial licenses in Colorado. But the up-front cost for facilitators is significant: The required 150 hours in a state-accredited program and 80 hours of hands-on training can cost $10,000 or more, and Clark said she wouldn’t pursue a facilitator license due to the prohibitive time and cost.

To increase affordability for patients in Colorado, Poinsatte said, healing centers plan to offer sliding-scale pay options, and discounts for veterans, Medicaid enrollees, and those with low incomes. Group sessions are another option to lower costs.

Colorado law does not allow retail sales of psilocybin, unlike cannabis, which can be sold both recreationally and medically in the state. But it allows adults 21 and older to grow, use, and share psychedelic mushrooms for personal use.

Despite the retail ban, adjacent businesses have mushroomed. Inside the warehouse and laboratory of Activated Brands in Arvada, brown bags of sterilized grains such as corn, millet, and sorghum and plastic bags of soil substrate are for sale, along with genetic materials and ready-to-grow kits.

Co-founder Sean Winfield sells these supplies for growing psychedelic or functional mushrooms such as lion’s mane to people hoping to grow their own at home. Soon, Activated Brands will host cultivation and education classes for the public, Winfield said.

Winfield and co-founder Shawn Cox recently hosted a psychedelic potluck at which experts studying and cultivating psychedelic mushrooms discussed genetics, extraction, and specialized equipment.

Psychedelic mushrooms have a long history in Indigenous cultures, and provisions for their use in spiritual, cultural, or religious ceremonies are included in Colorado law, along with recognition of the to federally recognized tribes and Indigenous people if natural medicine is overly commercialized or exploited.

Several studies over the past five years have shown the long-term benefits of psilocybin for , and the Food and Drug Administration designated it a . Late-stage trials, often a precursor to application for FDA approval, are underway.

Smith said psilocybin is a promising tool for treating mental health disorders but has not yet been shown to be better than other advanced treatments. Joshua Woolley, an associate professor of psychiatry and behavioral sciences at the University of California-San Francisco, said he has seen the benefits of psilocybin as an investigator in clinical trials.

“People can change hard-set habits. They can become unstuck. They can see things in new ways,” he said of treating patients with a combination of psilocybin and psychotherapy.

Colorado, unlike Oregon, allows integration of psilocybin into existing mental health and medical practices with a clinical facilitator license, and through micro-healing centers that are more limited in the amounts of mushrooms they can store.

Still, Woolley said, between the federal ban and new state laws for psychedelics, this is uncharted territory. Most drugs used to treat mental health disorders are regulated by the FDA, something that Colorado is “taking into its own hands” by setting up its own program to regulate manufacturing and administration of psilocybin.

The U.S. Attorney’s Office for the District of Colorado declined to comment on its policy toward state-regulated psychedelic programs or personal use provisions, but Poinsatte hopes the same federal hands-off approach to marijuana will be taken for psilocybin in Oregon and Colorado.

Winfield said he looks forward to the upcoming rollout and potential addition of other plant psychedelics, such as mescaline. “We’re talking about clandestine industries coming into the light,” he said.

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Karter rested for a week and a half at home in Centennial, Colorado, then returned to school when her concussion symptoms were tolerable — initially for just half-days and with accommodations allowing her to do schoolwork on paper instead of a screen and take extra time to get to and from classes. Karter went to the nurse’s office when she had a headache, Duey said. She began physical therapy to rehab her neck and regain her balance after the accident left her unsteady on her feet.

After children get concussions, a top concern for them and their parents or caregivers is when they can go back to sports, said , Karter’s doctor and a co-director of the Concussion Program at Children’s Hospital Colorado in Aurora. Returning to school as quickly as possible, with appropriate support, and getting light exercise that doesn’t pose a head injury risk are important first steps in concussion recovery, and in line with the latest research.

“It’s really important to get children and teens back to their usual daily activities as soon as possible, and as soon as they can tolerate them,” Wilson said.

In August, the Colorado Department of Education dispelling common myths about concussions, such as a loss of consciousness being necessary for a concussion diagnosis. The revised guidelines reflect evidence-based best practices on how returning to school and exercise can improve recovery. Educating families and schools about the new guidelines is critical, according to medical experts, particularly during autumn’s uptick in concussions from sports such as football and soccer.

More than nationwide had been diagnosed at some point with a concussion or brain injury, according to the 2022 National Health Interview Survey. in the past decade that adolescents recover more quickly from concussions and decrease the risk for prolonged symptoms by exercising lightly, for example on a stationary bike or with a brisk walk, two days after a concussion. That time frame may also be the sweet spot for , as long as the kids can tolerate any remaining concussion symptoms.

“Even though the brain is not a muscle, it acts like one and has a use-it-or-lose-it phenomenon,” said , a pediatrician and sports medicine and brain injury specialist at Children’s Hospital of Philadelphia.

Instead of waiting at home to fully recover, Master said, students should return to school with extra support from teachers and breaks in their schedule to relieve symptoms such as headaches or fatigue, with a goal of gradually doing more.

Every state has return-to-play laws for student-athletes that include policies such as removal from sports, medical clearance to return, and education about concussions. While some states, such as Virginia and Illinois, have “return-to-learn” policies, Colorado is not among them. It and have community-based concussion management protocols.

That is what Colorado updated this summer. REAP — which stands for Remove/Reduce; Educate; Adjust/Accommodate; and Pace — is a protocol for families, health care providers, and schools to help students recover during the first four weeks after a concussion. For example, school personnel can use an email-based system to alert teachers that a student sustained a concussion, then send weekly updates with details about how to manage symptoms, like difficulty concentrating.

“We have new protocols to support these kiddos,” said Toni Grishman, senior brain injury consultant at the Colorado Department of Education. “They might still have symptoms of concussion, but we can support them.”

Symptoms of concussion resolve in most patients in the first month. However, patients with ongoing symptoms, called persistent post-concussive symptoms, can benefit from a multidisciplinary care team that may include physicians, physical therapists, psychologists, and additional school support, Wilson said.

, director of the Colorado Concussion Research Laboratory at the University of Colorado Anschutz Medical Campus, is studying how children and their families cope with the physical, cognitive, social, and emotional impacts of concussions. In some studies, adolescents wear sensors to measure exercise intensity and volume, as well as common symptoms of concussion, like sleep and balance problems. In others, children and their parents answer questions about their perceptions and expectations of the recovery process.

“What you bring to an injury is oftentimes exacerbated by the injury,” Howell said, citing anxiety, depression, or just going through a difficult time socially. Recovery can be influenced by peer and family relationships.

Duey said the most difficult part of Karter’s recovery was her not being able to participate in cheer for nine weeks, including her team’s final competition in Florida. Karter, now 12, watched practice and supported her teammates in the spring, but missing out tore her up inside, Duey said.

“There were a lot of tears,” Duey said.

While recognizing a concussion and acting quickly can help anyone, in practice, more than half of students in Colorado may slip through the cracks with undiagnosed concussions, according to Grishman’s estimates.

The reasons for missed diagnoses are many, Grishman said, including lack of education, barriers to medical care, parental reluctance to inform schools about a concussion for fear their child will be excluded from activities, or not taking symptoms seriously in a student with a history of behavioral issues.

Getting schools to follow concussion guidelines, in general, is a challenge, Grishman said, adding that some districts still do not. She said it was hard to track the number of schools that followed Colorado education department guidelines last year but hopes improved data collection will provide more specifics this year. During the past school year, Grishman and her colleagues trained 280 school personnel in concussion management across 50 school districts in Colorado.

Whenever possible, athletic trainers should be on the sidelines to support student-athletes, Master said, and athletes should be aware of concussion symptoms in themselves and their teammates and seek care right away.

But concussions are not limited to the school athletic field or sports like football or soccer. Adventure sports like parkour, slacklining, motocross, rodeo, skiing, and snowboarding also pose concussion risks, Wilson and Grishman said. “Cheerleading is actually one that has a lot of concussions associated with it,” Howell added.

Duey said Karter occasionally has headaches, but her balance returned with help from physical therapy and she no longer experiences symptoms of her concussion. She is back to flying with her cheerleading squad and preparing to compete.

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It was the first time Xcel Energy preemptively switched off electricity in Colorado as a wildfire prevention tool, according to a company official. The practice, also known as public safety power shut-offs, has and is as a way to keep downed and damaged power lines from sparking blazes and fueling the West’s more frequent and intense wildfires.

In Boulder, Frasier staff and residents heard about the planned outage from news reports. A Frasier official called the utility to confirm and was initially told the home’s power would not be affected. The utility then called back to say the home’s power would be cut, after all, said Tomas Mendez, Frasier’s vice president of operations. The home had just 75 minutes before Xcel Energy shut off the lights on April 6.

Staff rushed to prepare the 20-acre campus home to nearly 500 residents. Generators kept running the oxygen machines, most refrigerators and freezers, hallway lights, and Wi-Fi for phones and computers. But the heating system and some lights stayed off as the overnight temperature dipped into the 30s.

Power was restored to Frasier after 28 hours. During the shut-off, staff tended to nursing home and assisted living residents, many with dementia, Mendez said.

“These are the folks that depend on us for everything: meals, care, and medications,” he said.

Not knowing when power would be restored, even 24 hours into the crisis, was stressful and expensive, including the next-day cost of refilling fuel for two generators, Mendez said.

“We’re lucky we didn’t have any injuries or anything major, but it is likely these could happen when there are power outages — expected or unexpected. And that puts everyone at risk,” Mendez said.

As preemptive power cuts become more widespread, nursing homes are being forced to evaluate their preparedness. But it shouldn’t be up to the facilities alone, according to industry officials and academics: Better communication between utilities and nursing homes, and including the facilities in regional disaster preparedness plans, is critical to keep residents safe.

“We need to prioritize these folks so that when the power does go out, they get to the front of the line to restore their power accordingly,” said David Dosa, chief of geriatrics and professor of medicine at UMass Chan Medical School in Worcester, Massachusetts, of nursing home residents.

Restoring power to hospitals and nursing homes was a priority throughout the windstorm, wrote Xcel Energy spokesperson Tyler Bryant in an email. But, he acknowledged, public safety power shut-offs can improve, and the utility will work with community partners and the Colorado Public Utilities Commission to help health facilities prepare for extended power outages in the future.

When the forecast called for wind gusts of up to 100 mph on April 6, Xcel Energy implemented a public safety power shut-off. Nearly 275,000 customers were without power from the windstorm.

Officials had adapted after the Marshall Fire killed two people and destroyed or damaged more than 1,000 homes in Boulder and the neighboring communities of Louisville and Superior two and a half years ago. Two fires converged to form that blaze, and electricity from an Xcel Energy power line that detached from its pole in hurricane-force winds “” of one of them.

“A preemptive shutdown is scary because you don’t really have an end in mind. They don’t tell you the duration,” said Jenny Albertson, director of quality and regulatory affairs for the Colorado Health Care Association and Center for Assisted Living.

More than half of nursing homes in the West are within 3.1 miles of an area with elevated wildfire risk, according to a . Yet, nursing homes with the greatest risk of fire danger in the Mountain West and Pacific Northwest had poorer compliance with federal emergency preparedness standards than their lower-risk counterparts.

Under federal guidelines, nursing homes must have disaster response plans that include or building evacuation. Those plans don’t necessarily include contingencies for public safety power shut-offs, in the past five years but are still relatively new. And nursing homes in the West are rushing to catch up.

In California, a more stringent law to bring emergency power in nursing homes up to code is expected by the California Association of Health Facilities to . But the state has not allocated any funding for these facilities to comply, said Corey Egel, the association’s director of public affairs. The association is asking state officials to delay implementation of the law for five years, to Jan. 1, 2029.

Most nursing homes operate on a razor’s edge in terms of federal reimbursement, Dosa said, and it’s incredibly expensive to retrofit an old building to keep up with new regulations.

Frasier’s three buildings for its 300 residents in independent living apartments each have their own generators, in addition to two generators for assisted living and skilled nursing, but none is hooked up to emergency air conditioning or heat because those systems require too much energy.

Keeping residents warm during a minus-10-degree night or cool during two 90-degree days in Boulder “are the kinds of things we need to think about as we consider a future with preemptive power outages,” Mendez said.

Federal audits of emergency preparedness at nursing homes in and found facilities lacking. In Colorado, eight of 20 nursing homes had deficiencies related to emergency supplies and power, according to the report. These included three nursing homes without plans for alternate energy sources like generators and four nursing homes without documentation showing generators had been properly tested, maintained, and inspected.

For Debra Saliba, director of UCLA’s Anna and Harry Borun Center for Gerontological Research, making sure nursing homes are part of emergency response plans could help them respond effectively to any kind of power outage. Her after a magnitude 6.7 earthquake that shook the Los Angeles area in 1994 motivated LA County to integrate nursing homes into community disaster plans and drills.

Too often, nursing homes are forgotten during emergencies because they are not seen by government agencies or utilities as health care facilities, like hospitals or dialysis centers, Saliba added.

Albertson said she is working with hospitals and community emergency response coalitions in Colorado on disaster preparedness plans that include nursing homes. But understanding Xcel Energy’s prioritization plan for power restoration would also help her prepare, she said.

Bryant said Xcel Energy’s prioritization plan for health facilities specifies not whether their electricity will be turned off during a public safety power shut-off — but how quickly it will be restored.

Julie Soltis, Frasier’s director of communications, said the home had plenty of blankets, flashlights, and batteries during the outage. But Frasier plans to invest in headlamps for caregivers, and during a town hall meeting, independent living residents were encouraged to purchase their own backup power for mobile phones and other electronics, she said.

Soltis hopes her facility is spared during the next public safety power shut-off or at least given more time to respond.

“With weather and climate change, this is definitely not the last time this will happen,” she said.

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“We’re seeing more oral disease than the general population. There is a bigger need,” Braun said of the patients she treats at Bernard F. Gipson Eastside Family Health Center, which is part of Denver Health, the largest safety-net hospital in Colorado, serving low-income, uninsured, and underinsured residents.

Braun is part of a trend across the United States to integrate oral health into medical checkups for children, pregnant women, and others who cannot afford or do not have easy access to dentists. With federal and private funding, these programs have expanded in the past 10 years, but they face socioeconomic barriers, workforce shortages, and the challenge of dealing with the needs of new immigrants.

With a five-year, $6 million federal grant, Braun and her colleagues have helped train 250 primary care providers in oral health in Colorado, Montana, Wyoming, and Arizona. Similar projects are wrapping up in Illinois, Michigan, Virginia, and New York, funded by the federal Health Resources and Services Administration’s Maternal and Child Health Bureau. Beyond assessment, education, and preventive care, primary care providers refer patients to on- or off-site dentists, or work with embedded dental hygienists as part of their practice.

“Federally qualified health centers have a long history of co-locating dental services within their systems,” Braun said. “We’re taking that next step where care is not just co-located, meaning, say, we’re upstairs and dental is downstairs, but we’re integrated so that it becomes part of the same visit for the patient.”

Having doctors, nurses, and physician assistants who assess oral health, make referrals, and apply fluoride at community health centers is critical for the many children who lack access to dental care, said Tara Callaghan, director of operations for the Montana Primary Care Association, which represents 14 federally qualified health centers and five Urban Indian organizations.

“Providing these services during medical visits increases the frequency of fluoride application,” Callaghan said, and “improves parents’ knowledge of caring for their child’s teeth.” But obstacles remain.

Because of Montana’s large geographic area and small population, recruiting dental professionals is difficult, Callaghan said. Fifty of the state’s 56 counties are designated dental shortage areas and some counties don’t have a single dentist who takes Medicaid, she added. Montana ranks near the bottom for residents having access to , which can prevent cavities and strengthen teeth.

Pediatric dental specialists, in particular, are scarce in rural areas, with families sometimes driving hours to neighboring counties for care, she said.

Embedding dental hygienists with medical doctors is one way to reach patients in a single medical visit.

Valerie Cuzella, a registered dental hygienist, works closely with Braun and others at Denver Health, which serves nearly half of the city’s children and has embedded hygienists in five of its clinics that see children.

State regulations vary on which services hygienists can provide without supervision from a dentist. In Colorado, Cuzella can, among other things, independently perform X-rays and apply silver diamine fluoride, a tool to harden teeth and slow decay. She does all this in a cozy corner office.

Braun and Cuzella work so closely that they often finish each other’s sentences. Throughout the day they text each other, taking advantage of brief lulls when Cuzella can pop into an exam room to check for gum disease or demonstrate good brushing habits. Braun herself takes similar opportunities to assess oral health during her exams, and both focus on educating parents.

Medical and dental care have traditionally been siloed. “Schools are getting better at interprofessional collaboration and education, but by and large we train separately, we practice separately,” said Katy Battani, a registered dental hygienist and assistant professor at Georgetown University.

Battani is trying to bridge the divide by helping community health centers in nine states — including California, Texas, and Maryland — integrate dental care into prenatal visits for pregnant women. Pregnancy creates opportunities to improve oral health because some women and see providers at least once a month, Battani said.

In Denver, housing instability, language barriers, lack of transportation, and the “astronomical cost” of dentistry without insurance make dental care inaccessible for many children, the migrant community, and seniors, said Sung Cho, a dentist who oversees the dental program at STRIDE Community Health Center, serving the Denver metro area.

STRIDE tries to overcome these barriers by offering interpretation services and a sliding pay scale for those without insurance. That includes people like Celinda Ochoa, 35, of Wheat Ridge, who waited at STRIDE Community Health Center while her 15-year-old son, Alexander, had his teeth cleaned. He was flagged for dental care during a past medical checkup and now he and his three siblings regularly see a dentist and hygienist at STRIDE.

One of Ochoa’s children has Medicaid dental coverage, but her three others are uninsured, and they couldn’t otherwise afford dental care, said Ochoa. STRIDE offers an exam, X-rays, and cleaning for $60 for the uninsured.

In the past year, Cho has seen an influx of migrants and refugees who have never seen a dentist before and need extensive care. Medical exams for refugees at STRIDE increased to 1,700 in 2023 from 1,300 in 2022, said Ryn Moravec, STRIDE’s director of development. She estimates the program has seen 800 to 1,000 new immigrants in 2024.

Even with growing needs, Cho said the Medicaid “unwinding” — the process underway to for the government program that provides health coverage for people with low incomes and disabilities — has created financial uncertainty. He said he worries about meeting the upfront costs of new staff and of replacing aging dental equipment.

At STRIDE’s Wheat Ridge clinic, two hygienists float between dental and pediatrics as part of the medical-dental integration. Yet Cho said he needs more hygienists at other locations to keep up with demand. The pandemic created bottlenecks of need that are only now being slowly cleared, particularly because few dentists take Medicaid. If they do accept it, they often limit the number of Medicaid patients they’ll take, said Moravec. Ideally, STRIDE could hire two hygienists and three dental assistants, Moravec said.

In 2022, Colorado enacted a law to alleviate workforce shortages by allowing — midlevel providers who do preventive and restorative care — to practice. But Colorado does not have any schools to train or accredit them.

Before age 3, children are scheduled to see a pediatrician for 12 well visits, a, particularly for at-risk children. As part of Braun’s program in the Rocky Mountain region, providers have applied more than 17,000 fluoride varnishes and increased the percentage of children 3 and younger who received preventive oral health care to 78% from 33% in its first 2½ years.

Callaghan, at the Montana Primary Care Association, witnesses that on the ground at community health centers in Montana. “It’s about leveraging the fact that kids see their medical provider for a well-child visit much more often and before they see their dental provider — if they have one.”

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But this transaction was different from typical exchanges that occur every day at thousands of pharmacies across the United States. The cost to Phoenix, 50, who lives in the nearby community of Falcon and has no health insurance, was nothing.

runs Colorado’s only current drug donation program. Most of the medications it dispenses come from nursing homes across the state.

“We take any and all of it,” said founding pharmacist Frieda Martin, who used those donations to fill 1,900 prescriptions for 200 low-income and uninsured adults last year. Participants pay a $15 annual registration fee for free medications and care at the adjoining clinic.

Drug donation programs like this one in Colorado and one in California take unopened, unexpired medications from health care facilities, private residents, pharmacies, or prisons that pile up when patients are discharged, change drugs, or die, and re-dispense them to uninsured and low-income patients. About 8% of adults in the U.S. who took prescription drugs in 2021, about 9 million people, did not take them as prescribed because of cost, and uninsured adults were more likely to skip medications than those with insurance, according to the .

The programs vary in size but are often run by charitable pharmacies, nonprofits, or governments, and keep drugs out of landfills or incinerators, where an estimated $11 billion in unused medications are disposed of each year.

Forty-four states already have laws allowing drug donations, according to the . Many programs, like Colorado’s, are small or underutilized. Now, Colorado and other states are seeking to expand their approach.

“Drug donation programs are effective. There is a huge need for them. And there are opportunities for states to help their residents by enacting new laws,” said George Wang, a co-founder of SIRUM, which stands for Supporting Initiatives to Redistribute Unused Medicine, a of drug donors and distributors in the U.S.

Colorado Senate Majority Leader Robert Rodriguez, a Democrat, said he plans to introduce a bill next year to create a drug donation program to help the who can’t fill their prescriptions because of cost.

Similarly, signed last year allows expansion of the state’s first and only drug donation program, in Santa Clara County, to San Mateo and San Francisco counties. Kathy Le, the supervising pharmacist at Better Health, said it is in “the early stages” of working with other county-run pharmacies in California to develop similar programs.

The , based in Cheyenne, uses mail distribution to reach residents, including those in remote parts of the state who may not have local pharmacies, said Sarah Gilliard, a pharmacist and its program manager. The program mails a total of approximately 16,000 free prescriptions annually to 2,000 Wyoming residents who are low-income, uninsured, or underinsured.

“Access is definitely a big consideration when it comes to the design of our program,” she said.

Many of the Wyoming program’s participants are 65 and older, on Medicare, with fixed incomes and unaffordable copays, but Gilliard said there has been a recent increase in participants between the ages of 20 and 40. Wyoming is one of 10 states that have not expanded Medicaid to cover more low-income residents, which could be a factor in that uptick, Gilliard said.

Donations come from all 50 states, with the majority from people who find the program online or through word of mouth. Sometimes donors tuck handwritten notes inside the packages about the high cost of medication or memories of a relative who died.

Gilliard saves each one and tacks them to the pharmacy wall.

Wyoming’s program, with its central state-run pharmacy that receives, processes, and mails prescriptions to residents, could be a model for Colorado, said Gina Moore, a pharmacist and senior associate dean at the University of Colorado’s Skaggs School of Pharmacy and Pharmaceutical Sciences in Aurora. Moore co-authored a for the state government last December about the feasibility of a drug donation program.

The report noted the success of programs with external funding, which, in Wyoming’s case, comes directly from taxpayer dollars. Using Wyoming’s budget, it projected a Colorado drug donation program would cost an estimated $431,000 in the first year, with a pharmacist and pharmacy technician serving roughly 1,500 patients.

In Colorado Springs, Martin and her husband, Jeff Martin, who is the executive director of Open Bible Medical Clinic and Pharmacy, believe a charitable, volunteer-run model like theirs would be feasible for Colorado, and they wonder how their long-running pharmacy will fit in with potential state-run efforts. In the task force report, Moore and her colleagues write that the state-run model and the Martins’ program could coexist.

Since Colorado to allow drug donation in 2005, it has been amended several times in attempts to help it grow. But the state has not invested money or infrastructure to make a drug donation program take off.

Drug donations mailed to Open Bible dwindled during the pandemic and are only now slowly rebounding. The pharmacy ships roughly half of all donated medications to clinics across Colorado that serve uninsured and low-income patients in other cities such as Denver, Loveland, and Longmont.

Elsewhere in the U.S., SIRUM ensures that donors have packaging to ship donated medications, and it provides software to make inventorying and dispensing easier. Recently, it built a live online inventory of medications for , a nonprofit pharmacy that mails 90-day prescriptions for about $6 to residents of Illinois and Georgia.

SIRUM helps facilitate donations for California’s Better Health Pharmacy, which has dispensed medications to 15,000 Santa Clara County residents since opening in 2015, Le said. Many are uninsured, underinsured, and speak Spanish or Vietnamese. Ten volunteers, often students, help log donations, and Better Health Pharmacy fills roughly 40,000 prescriptions a year with annual operating costs of just over $1 million, according to Le and Santa Clara County public health officials.

Besides prescriptions, Better Health Pharmacy provides free covid antigen tests and flu vaccinations to address its community’s needs. “We try to come up with creative solutions to expand the scope of our services,” Le said.

This commitment to addressing gaps in health care access and reducing impact on the environment means the “timing is right” for expansion of drug donation programs in California and beyond, said Monika Roy, assistant health officer and communicable disease controller at Santa Clara County’s Public Health Department.

“During the pandemic, inequities in access to care were magnified,” Roy said. “When we have solutions like these, it’s a step forward to address both equity and climate change in the same model.”

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“It’s much lighter work. It’s nurturing. It’s slow,” said Streim, a licensed massage therapist.

Massage therapy for someone near the end of life looks and feels different from a spa treatment. Some people stay clothed or lie in bed. Others sit up in their wheelchairs. Streim avoids touching bedsores and fresh surgery wounds and describes her work as “meditating and moving at the same time.” She recalled massaging the shoulders, hands, and feet of one client as he sat in his favorite recliner and watched baseball on TV in the final weeks of his life.

“When you’re dying and somebody touches you without expectation of anything in return, you just get to be,” said Streim.

Massage therapists like Streim, who specializes in working with people who are dying or have an advanced form of cancer or other illness, are rare. Fewer than 1% of therapists specialize in hospice or palliative care massage, according to research by the , although many more may periodically offer massage for hospice patients.

Streim has a private practice in Lafayette, and her clients pay her out-of-pocket, as Medicare and private insurance typically don’t cover massage therapy. She also volunteers as a hospice massage therapist four hours a month.

It’s common for hospice organizations to use volunteer therapists for treatments, though some massage therapists, with physicians backing them, are pushing for paid positions as part of medical teams working alongside nurses and social workers. In the hospice unit at Palo Alto VA Medical Center, in Palo Alto, California, for example, massage therapists have been integral members of the multidisciplinary team for decades, said , a professor of medicine at Stanford University and the founding director of its palliative care education and training program.

The covid-19 pandemic made the recruitment of specialists for this intimate work, both paid and volunteer, more difficult, as the pool of massage therapists shrank amid school closures and exits from the profession. There are up to 10% fewer massage therapists today than before the pandemic, according to Les Sweeney, president of .

“It’s still hard for us to hire and recruit therapists,” said operations director at Healwell, a nonprofit that trains and employs massage therapists to work in hospitals in the Washington, D.C., area.

For three weeks in April 2020, licensed massage therapist , who works at Faith Presbyterian Hospice in Dallas, could not massage patients due to the state’s lockdown orders. Then, the state granted an allowance for massage therapists like her, working in medical settings under supervision, to resume giving massages. But it took several months for many therapists to return to work, and some didn’t return at all, Spence said.

“The pandemic was not kind to massage therapists,” Spence said. “And so we have lost a lot of people like me who are of an age and experience level that would really be called to and suitable” for oncology, hospice, and palliative massage.

“We need to get more therapists trained,” she said. She described receiving several calls each month from people who have found her name online. It has become harder since covid to find a therapist to refer them to, Spence said.

At TRU Community Care, which operates in several locations in Colorado, Volunteer Services Supervisor Wendy Webster said massages are a top request from patients and their families, but they’re limited in how many sessions they can offer, with only two volunteer massage therapists. (A third volunteer did not return after the pandemic.)

Finding new massage therapist volunteers is challenging, said Webster, in part because they can earn money in other settings and “they’re coming to us for free.” Thirty years ago, TRU Community Care’s nonprofit status was the norm, but now the majority of hospices are for-profit, with .

Despite that shift, hospices still rely heavily on volunteers. Medicare pays for at least six months of hospice for a patient on the condition that providers use volunteers for at least worked by paid staff and contractors. Sometimes, those volunteer hours are filled by massage therapists.

“All hospices, not-for-profit or for profit alike, should aim to include medically-trained massage therapists as part of best holistic care,” , a professor of medicine at Georgetown University who directs palliative care at MedStar Washington Hospital Center in Washington, D.C., wrote in an email. Employing these specialists is beneficial and does not diminish the important service of volunteers, particularly in end-of-life care, he added.

More studies on the impact of specialized massage could enact changes in the field, said , founder and executive director of Healwell, which, since 2009, has trained 500 therapists in hospital-based and oncology massage, as well as in how to work collaboratively with doctors and nurses.

In a of 387 patients in palliative care at MedStar, including some nearing the end of their lives, Groninger, Cates, Jordan, and other co-authors found that massage therapy improved quality of life.

Despite new research on the benefits of massage, Cates said, many hospices bring on volunteers who don’t have advanced training, because hospices may not know that specialized training — such as the kind Healwell offers — exists.

Streim, who paid for her own classes in oncology and lymphatic massage, said that investment in education qualified her for a six-year career as an oncology massage therapist at Good Samaritan Medical Center’s Center for Integrative Medicine in Lafayette and later her private practice. She teaches classes in adapting massage for the elderly and those with illnesses at Boulder Massage Therapy Institute. In her 39 years as a therapist, Streim has done it all: volunteer, staff, entrepreneur, teacher.

Like Streim, Spence has continually redefined her role. She began in private practice before becoming an employee of a large hospice agency in which she traveled across nine counties in Texas, giving thousands of massages to people dying in their homes, assisted living communities, and skilled nursing homes. Today, at Faith Presbyterian Hospice, she is one of three licensed massage therapists on staff and fully integrated as an employee of the organization, which has more than 100 patients.

“Those of us who do this work have made big investments in our profession and I’m glad to see that we can be paid for it,” she said.

Spence collects data on how patients rate their pain on a scale of 1 to 10 before and after a massage. Most fall asleep during the massage, which she takes as an indication their pain has lessened or they became more relaxed. Of those who stay awake, almost all say their pain subsided significantly or went away completely.

That kind of positive engagement with providers is more urgent than ever since the pandemic, Groninger said. Spence agreed: “The pandemic taught us all, in a very painful way, what it’s like to be deprived of human touch and human connections.”

Sometimes the nursing staff at Faith Presbyterian will roll a bed out onto the patio so a patient can hear the sounds of nature and the fountain gurgling during Spence’s massage. There is more teasing and laughter than she would have imagined. For patients unable to speak, Spence watches their reactions carefully: a deep exhalation or the face and body softening. Sometimes it’s tears running down their cheeks.

“It’s profound, helping someone find safe breaths along this very difficult dying journey,” she said.

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“They’re somebody’s mom, somebody’s grandma, somebody’s great-grandmother,” Shelton said. “I want to take care of them like I would take care of my family.”

Shelton trained to be a personal care aide through an apprenticeship program designed to meet the increasing need for health care workers in rural western Colorado. Here, far from Denver’s bustling urban corridor, worker shortages mount as baby boomers retire, young people move away from these older communities, and demand for health care in homes and facilities rises.

Rural areas often have than urban areas do. And the most rural regions have relatively fewer direct care workers, like personal care aides, to help people with disabilities than less-rural regions do, according to a recent study in the journal .

Besides increasing the number of direct care workers, the Colorado apprenticeship program offers opportunities for improving earning power to residents who live at or below the poverty line, who lost their jobs during the covid-19 pandemic, or who are unemployed or underemployed. They train to become personal care aides, who help patients with daily tasks such as bathing or housekeeping, or certified nursing assistants, who can provide some direct health care, like checking blood pressure.

Apprentices take training classes at Western Colorado Area Health Education Center in Grand Junction, and the center pays for students who live in more rural areas to attend classes at Technical College of the Rockies in Delta County. The apprentices receive on-the-job training with one of 58 local employers — an assisted living facility, for example — and they are required to work there for one year. Each apprentice has an employer mentor. Staff members at Western Colorado AHEC also provide mentorship, plus the center has a life coach on hand.

“We really just want students to get into health care, get jobs, and retain those jobs,” said Georgia Hoaglund, executive director of Western Colorado AHEC, which has 210 active apprentices and was bolstered by a $2 million grant from the U.S. Labor Department in 2021.

Some apprentices are recent high school graduates. Others are single mothers or veterans. They often have educational or economic barriers to employment. Hoaglund and her staff of 10 buy the apprentices scrubs so they can start new jobs with the right uniforms; otherwise, they might not be able to afford them. Staff members pay for apprentices’ gas if they can’t afford to fill up their tanks to drive to work. They talk to apprentices on the phone monthly, sometimes weekly.

Even though the apprenticeship program gives these workers a solid start, the jobs can be stressful, and burnout and low pay are the norm. Career advancement is another obstacle, said Hoaglund, because of the logistics or cost of higher education. Hoaglund, who calls her staff family and some of the apprentices her kids, dreams of offering more advanced training — in nursing, for example — with scholarship money.

Apprenticeships are perhaps better known as a workforce training tool among electricians, plumbers, carpenters, and other tradespeople. But they are also viewed as a way of building a needed pipeline of direct care health workers, said Robyn Stone, senior vice president for research at LeadingAge, an association of nonprofit providers of aging services.

“Traditionally, health care employers have hired people after they finish a training program,” said Susan Chapman, a registered nurse and a professor in the school of nursing at the University of California-San Francisco. “Now, we’re asking the employer to take part in that training and pay the person while they’re training.”

The pandemic exacerbated shortages of direct care workers, which could encourage employers to invest in apprenticeships programs, both Chapman and Stone said. Federal investment could help, too, and a Biden administration initiative to improve the quality of nursing homes includes $35 million in grants to address workforce shortages in rural areas.

Shelton had never worked in health care before moving to Fruita, a small town that is about 12 miles northwest of Grand Junction and is surrounded by red sandstone towers. She left Fresno, California, a year ago to take care of an uncle who has multiple sclerosis. She and her 16-year-old daughter live in a trailer home on her uncle’s property, where Blackie, her rescue Labrador retriever, roams with the chickens and cats.

Blackie also sometimes accompanies Shelton to BeeHive to visit with the residents. Shelton said that it is more than a job to her and that she is grateful to the apprenticeship program for helping her get there. “It opened a door for me,” Shelton said.

Shelton works three 12-hour shifts a week, in addition to taking care of her uncle and daughter. Yet, she said, she struggles to have enough money for gas, bills, and food and has taken out small loans to make ends meet.

She is not alone. Personal care aides are often underpaid and undervalued, said Chapman, who has found significantly higher poverty rates among these workers than among the general population.

Direct care workers nationwide, on average, make $13.56 an hour, , and these low wages make recruiting and retaining workers difficult, leading to further shortages and instability.

In an effort to keep workers in the state, for personal care aides and certified nursing assistants to $15 an hour this year with money from the American Rescue Plan Act. And the Colorado Department of Health Care Policy and Financing’s 2023-24 budget request includes a bump to $15.75. Similar efforts to raise wages are underway in 18 other states, including New York, Florida, and Texas, according to a recent .

Another way to keep apprentices in jobs, and encourage career and salary growth, is to provide opportunities for specialized training in dementia care, medication management, or behavioral health. “What apprenticeships offer are career mobility and advancement,” Stone said.

To practice in Colorado, new certified nursing assistants complete in-class training, do clinical rotations, and pass a certification exam made up of a written test and a skills test. Hoaglund said the testing requirements can be stressful for students. Shelton, 43, has passed the written exam but must retake the skills test to become licensed as a certified nursing assistant.

Hoaglund’s program started in 2019, but it really took off with the 2021 federal grant. Since then, 16 people have completed the program and have received pay increases or promotions. Twice as many people have left without finishing. The largest hospital in Grand Junction, Intermountain Healthcare-St. Mary’s Medical Center, recruits workers from the program.

Hoaglund said each person who enters the health care field is a win.

Brandon Henry, 23, was a student at Colorado Mesa University in Grand Junction and working at PetSmart before he joined the apprenticeship program in 2019. After enrolling, he trained and worked as a certified nursing assistant through the worst of the pandemic. As an apprentice, he said, he learned the importance of having grace while caring for patients.

He went back for more training at Western Colorado AHEC to earn a license that allows him to dispense medicine in accredited facilities, such as assisted living centers. He now works at Intermountain Healthcare-St. Mary’s Medical Center, where he took training classes in wound care and physical therapy hosted at the hospital. This winter, he’ll graduate from Colorado Mesa with a Bachelor of Science in nursing.

“At the hospital, I’ve found more opportunities for pay raises and job growth,” Henry said.

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