Minnesota Health care News December 2012

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December 2012 • Volume 10 Number 12

Addiction and seniors Marvin Seppala, MD

Winter safety Scott Benson, MD

Bereavement James Heymans, MSW

You call it “reminding mom to take her pills.�

We call it caregiving.

You or someone you know may be a caregiver.

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CONTENTS

4 7 8

DECEMBER 2012 • Volume 10 Number 12

16

NEWS

PUBLIC HEALTH Winter driving

MINNESOTA HEALTH CARE ROUNDTABLE

By Matt Hehl

PEOPLE

PERSPECTIVE Sonja Savre, MPH, RD Hennepin County Healthy Eating Minnesota project

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18 20

Healthy Holiday Eating

DIGESTIVE HEALTH Gluten sensitivity and celiac disease

By Joseph A. Murray, MD

24

10 QUESTIONS

CALENDAR

INSURANCE Appealing a denied claim

By Noe Baker

Jane Pederson.

MD, MS Stratis Health

12

TAKE CARE Winter safety

14

INFECTIOUS DISEASE Flu vaccine

26

PODIATRY Foot care

28

BEHAVIORAL HEALTH Addiction and the golden years

By Scott Benson, MD

By Donald Bucklin, MD

By Gerard Busch, DPM

By Marvin D. Seppala, MD

30

PALLIATIVE CARE Bereavement

By James Heymans, MSW, LICSW

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com

T H I R T Y- N I N T H

SESSION

Background and focus: The next step in health care reform involves the patient becoming more actively engaged with staying healthy.

New physician reimbursement models reward improved population health but bring new dynamics into the exam room.

Incorporating patient attitude and lifestyle Creating measures that work choices into health care delivery is Thursday, April 25, 2013 necessary, but how 1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers should it be done?

Creating conceptual and empirical clarity around this question may be best addressed by the term Patient Activation Measure (PAM).

Patient engagement

Objectives: We will examine the development of PAM, what it means and how it works. We will explore patient engagement methods that have been successful and the role of health insurance companies and employers in this process. We will explore how PAM may be used across the continuum of care and whose job it will be to implement and track these measures.

We will discuss the challenges that are inherent within the concept of PAM and how it may realize its best potential.

EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR MaryAnn Macedo mmacedo@mppub.com

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Address City, State, Zip

Advisory Board: Minnesota Medical Association (MMA), Minnesota Hospital Association (MHA), Minnesota Medical Group Management Association (MMGMA), Buyers Health Care Action Group (BHCAG), Minnesota Business Partnership (MBP), Minnesota Healthcare Network (MHN), Advocates for Marketplace Options for Mainstreet (AMOM), Minnesota HomeCare Association (MHCA), Minnesota Physician-Patient Alliance (MPPA), Physicians Service Network (PSN), Minnesota Center for Rural Health, and Minnesota Council of Health Plans.

Minnesota Health Care News is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $36.00. Individual copies are $4.00.

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DECEMBER 2012 MINNESOTA HEALTH CARE NEWS

3

NEWS

UCare Launches SilverSneakers Program Minneapolis-based UCare has entered into a three-year partnership with Nashville, Tenn.-based Healthways to offer a fitness program for older adults.

UCare officials say the SilverSneakers Fitness Program is a top exercise program for older adults, based on more than 16 years of research.

“We are pleased to offer approximately 125,000 UCare members the opportunity to improve their health and fitness by participating in the SilverSneakers program,” says Ghita Worcester, senior vice president at UCare. “SilverSneakers’ expertise, convenient locations, and positive approach to fitness are welcome additions to our preventive health care activities.”

The exercise program will be available to members of UCare for Seniors Medicare plan, UCare’s Minnesota Senior Health Options, and UCare Connect, officials say.

MDH Announces New Round of HIV Grants The Minnesota Department of Health (MDH) has announced $1.7 million in HIV grants, aimed at preventing the spread of HIV in adults and young people of all races and sexual orientations.

The two-year grants will go to 20 agencies around the state.

The funds come from the federal Centers for Disease Control and Prevention (CDC) and MDH. “The grants represent our continued commitment to target our limited resources to those communities that need it most,” says Peter Carr, director of the STD and HIV Section at MDH. “The awards were based on the new funding and program directives set forth by CDC and reach the target populations identified by the state's planning group, Community Cooperative Council on HIV/AIDS Prevention.”

Officials say the grants will help nonprofit community-based organizations, clinics, and agencies provide programs to reach

Jim

– UCare member Duluth, MN

underserved communities with higher HIV infection rates. The grants will help fund HIV testing and prevention programs.

Multicare Offers New Model for Primary Care A Fridley-based health care clinic is offering a new model of health delivery, providing consumers and employers with primary care services for a monthly fee.

Multicare Associates, which has clinics in Blaine, Fridley, and Roseville, is contracting with individuals and employers to provide primary care, in many cases with a high-deductible health plan for specialty care. According to Multicare CEO Matt Brandt, the new model provides the kind of care that can hold down medical costs. “The idea behind this is that we want to encourage [primary care] and make it easy to access, because that’s what keeps you healthy and productive in the long term,” Brandt says.

With the new model, individuals or employers contract with Multicare and pay a monthly fee for primary care services, which include preventive care, disease management, wellness, and urgent care. Specialty and hospital care is not included.

The idea grew out of Multicare’s occupational health services, which provide preemployment physicals and wellness screenings to employers in the area. In working with employers such as the International Union of Operating Engineers, Multicare officials realized there was a demand for primary care services for employer groups, and saw an opportunity to provide those services without the additional bureaucracy and cost of working with an insurance company.

“For self-insured employers, it makes a lot of sense,” Brandt says. “They can pay us a monthly fee and then they don’t have to pay by claim; they bypass the insurance system, which saves them some money. And it gives

D

iscover UCare for Seniors , the simple, affordable health plan that provides great benefits at a great price — just what you’d expect from health care that starts with you.

SM

Visit: UCareplans.org to access rates, plan details, and more.

Call: (toll free) 1-877-523-1518 (TTY) 1-800-688-2534, 8 a.m. to 8 p.m. daily.

UCare Minnesota and UCare Wisconsin, Inc. are health plans with Medicare contracts. © 2011, UCare H2459 H4270_081211_4 CMS File & Use (08172011) 4

MINNESOTA HEALTH CARE NEWS DECEMBER 2012

your employees easy access to primary care services and encourages them to come here first before they utilize high-cost services such as the ER.” The new model was marketed initially to employers, Brandt notes, but Multicare will also promote the service to individuals and families in the near future.

His company also hopes to work with other independent physician groups in expanding the model to a wider geographic area.

State Groups Announce Healthy Babies Campaign State health groups are working together on a public campaign to discourage births from being scheduled before 39 weeks of pregnancy.

Early births can’t be avoided in many cases, but the March Of Dimes, one of the sponsors of the Healthy Babies Are Worth the Wait campaign, is urging expectant parents and their physicians not to induce labor before 39 weeks.

Thirty-seven weeks of pregnancy is considered full term, but health officials say health outcomes are better for babies delivered at or after 39 weeks, with exceptions for medical need.

March of Dimes officials say new research has shown that a baby’s brain nearly doubles in weight during the last few weeks of pregnancy and that important lung and other organ development occur at this time. They add that although the overall risk of death is small, it is double for infants born at 37 weeks of pregnancy when compared with babies born at 40 weeks, for all races and ethnicities.

“With one in 10 babies being born premature in Minnesota, we need to do more to make sure that more babies are being born healthy, excess health care costs are being reduced, and families are being spared the heartache of having a baby born too soon,” says Glenn Andis, March of Dimes chapter board chair.

Campaign cosponsor the Minnesota Hospital Association has begun public education efforts with a pregnancy and birth safety program, which includes a focus on preventing elective deliveries prior to 39 weeks, patient education, and training for providers and nurses on key topics.

“The health of our babies is a critical measure of the health of our community,” says Ed Ehlinger, MD, Minnesota Department of Health commissioner. “Minnesota is a leader in creating conditions that allow people to be healthy and we can do better for babies.”

Lead Poisoning Levels Drop Dramatically, Officials Say Officials with the Minnesota Department of Health (MDH) have reported that efforts to prevent lead poisoning in children have reduced the number of children with elevated levels of lead in their blood by 87 percent since 1995.

The dramatic reduction in lead poisoning in children is a result of sustained efforts on the state and community level, officials say. Since 1995, the number of children in Minnesota tested each year for lead poisoning has tripled, from 35,000 in 1998 to almost 100,000 in 2010. At the same time, the number of children with elevated blood levels of lead decreased by 87 percent, from 4,339 in 1995 to 584 in 2011.

The numbers were released as MDH celebrated Lead Poisoning Prevention Week at the end of October. But officials say they believe that even more should be done.

MDH says that recent research suggests that no level of lead exposure can be considered safe. Public health officials are now working with families to eliminate lead exposure based on a more conservative standard set by the federal Centers for Disease Control and Prevention. With the more conservative measurement,

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News to page 6 DECEMBER 2012 MINNESOTA HEALTH CARE NEWS

5

News from page 5 and considering the numerous sources of lead in the environment, officials say thousands of children could still be at risk.

“Many of the families we work with thought childhood lead poisoning was a thing of the past, until it affected their own children,” says Megan Curran, director of community programs for the St. Paul office of CLEARCorps USA. “But three-fourths of the homes in Minnesota were built before 1978, when the use of lead paint was banned in residential housing. Children living in these homes may still be at risk.”

Officials say children can be exposed to lead from a variety of sources. Lead can get into drinking water from lead plumbing or supply pipes. It can make its way into the home from the workplace. It may be present in soil.

In some communities, it has been found in snack foods or home remedies.

Officials say parents can take a number of steps to help reduce the risk of lead exposure for their children. Families should get their homes tested, and those looking to purchase an older home should ask for a lead inspection before buying. Families should also have their children tested, especially those under six years of age.

Minnesotans can also obtain lead poisoning information from local health departments or from the Minnesota Department of Health.

State to Receive $9 Million Settlement For Medicaid Fraud The Office of Inspector General at the Department of Human Services (DHS) has announced that Minnesota will receive $9 million as part of a national settlement with Abbott Laboratories.

The creation of the DHS Office of Inspector General was one of several steps Gov. Mark Dayton’s administration has taken

to make the state’s health care system more efficient. When the office was established in 2011, DHS officials said the reorganization would improve DHS’ fraud prevention and recovery efforts and more effectively structure staff who investigate and audit DHS programs.

The office, led by Inspector General Jerry Kerber, is involved in several multijurisdictional task forces across federal, state, and local government, officials say.

The total amount recovered by the office this year is $30 million.

In the latest case, Abbott Laboratories pleaded guilty to illegally marketing the drug Depakote for uses that were not approved by the U.S. Food and Drug Administration (FDA) as safe and effective. This resulted in false claims to Medicaid and other taxpayer-funded health care programs. Depakote is approved for use in treating seizures and mania associated with bipolar disorder and to prevent migraines. How-

ever, Abbott marketed the drug for use in the control of agitation and aggression in older patients experiencing dementia.

“Fraud hurts all of us,” says Kerber. “Minnesotans deserve to know that their public health care dollars are going for care to our fellow Minnesotans, not lining the pockets of irresponsible pharmaceutical companies.”

Costs for the Medicaid program are shared by federal and state governments. DHS officials note that half of all Medicaid fraud recoveries by the Office of Inspector General are returned to the state’s General Fund, and half goes to the federal government.

Supporting Our Patients.

Supporting Our Partners.

Supporting You. In 2008, Tanzanian missionaries brought little Zawadi Rajabu to the U.S. to seek treatment for her two severely clubbed feet. A physician referred Zawadi to Dr. Mark T. Dahl of St. Croix Orthopaedics. Using the Ilizarov Method, Dr. Dahl surgically changed the course of Zawadi’s feet and her life.

Dr. David Palmer and Russ McGill, OPA-C, recently traveled to Tanzania on another of their frequent medical missionary trips. They dedicated an entire day to checking in on their partner’s patient.

To their delight, they were greeted by 6-year-old Zawadi her face aglow, her healed feet dancing toward them.

David Palmer, M.D. & Zawadi’s brother Russ McGill, OPA-C & Zawadi

Appointments:

Online or Call 651-439-8807 Providing P roviding care care at at multiple mu ultiple moder modern n clinics in Minnesota Minne esota and Wisconsin Wisconsin

6

MINNESOTA HEALTH CARE NEWS DECEMBER 2012

PEOPLE Three Minnesota health care leaders have been named to Beckerʼs Hospital Reviewʼs “120 Women Hospital and Health System Leaders to Know”: Cathy Barr, MBA, RN, senior vice president of community services for HealthEast Care System and president of Bethesda Hospital in St. Paul; Sara Criger, senior vice president of Allina Health and president of Mercy Hospital in Coon Rapids; Cathy Barr, MBA, RN

and Carolyn Wilson, RN, president and CEO of the

University of Minnesota Medical Center, Fairview, and Amplatz Childrenʼs Hospital in Minneapolis. The list, compiled by the Chicagobased health-care publishing company, included women health leaders from around the country.

“These 120 women demonstrate outstanding leadership within the hospital and health care industry and were chosen based on a wide range of management and leadership skills, including oversight of hospital or health system operations, financial turnarounds, and quality,” the company Sara Criger

said in a statement.

Dermatologist Susan Rudolph, MD, has joined the medical staffs of Skin Specialists Ltd., which has offices in Minneapolis and Wayzata, and Zel Skin & Laser Specialists in Edina. She completed her residency in dermatology at Marshfield Clinic–St. Joseph’s Hospital, Marshfield, Wis. Chris Yang, MD, has joined Children’s Hospital and Children’s Respiratory and Critical Care Specialists, PA as a pediatric intensivist.

Previously she was an assistant professor of pediatric anesthesiology and critical care medicine at Johns Hopkins University School of Medicine, Baltimore, where she also was director for

KNOW the 10 SIGNS

medical student and resident education in the Chris Yang, MD

Pediatric Intensive Care Unit and co-medical

director of Hopkins Outreach for Pediatric Education. Yang earned

EARLY DETECTION MATTERS

her medical degree from Drexel University College of Medicine in Philadelphia.

The Minnesota Department of Human Services (DHS) recently announced two leadership moves. Carol Backstrom was named the state Medicaid director for DHS, and Karen Jones was named director of the agencyʼs substance abuse treatment program. Backstrom has worked as a regulator at both the state and federal level, most recently as a senior policy advisor at the Centers for Medicare & Medicaid Services. Previously she served as assistant to the commissioner for health reform at the Minnesota Department of Health, overseeing implementation of state health reform laws passed by Minnesota law-

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makers in 2008. Backstrom will lead an agency that already has been a pioneer in working with the federal government on the Affordable Care Act. Minnesota recently became the first state to win federal approval for a health-care delivery demonstration project, which will seek to improve care for Medicaid enrollees while saving taxpayer dollars. Jones was named statewide director of Community Addiction Recovery Enterprise, the substance abuse treatment program at DHS, after serving as the programʼs interim director. She will direct the programʼs administrative and clinical services for clients requiring chemical dependency treatment.

24/7 Information Helpline 800.272.3900 alz.org/mnnd DECEMBER 2012 MINNESOTA HEALTH CARE NEWS

7

PERSPECTIVE

Hennepin County Healthy Eating Minnesota Multiple programs make fresh produce more available

M Sonja Savre, MPH, RD Hennepin County

Sonja Savre, MPH, RD, is a program supervisor for Hennepin County.

Hennepin County Healthy Eating Minnesota (HC HEM) is funded by Blue Cross and Blue Shield of Minnesota’s Prevention Minnesota initiative to tackle root causes of preventable heart disease and cancer.

HC HEM partners include Bloomington Public Health, Emergency Foodshelf Network, Gardening Matters, The Minnesota Project, Minneapolis Department of Health and Family Support, Minnesota Grown, and Minnesota FoodShare.

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om was right: A diet high in fruits and borhood food shelves. In 2012, the number of parvegetables reduces the risk for many ticipating gardens more than doubled. chronic diseases and plays an impor- In addition to providing produce, these gardens tant role in weight management. Unfortunately, provide access to nature, physical activity, and according to the 2009 State Indicator Report on social connections. Plus, the CAPI garden fosters Fruits and Vegetables, the most recent such report intergenerational learning and preservation of culfrom the Centers for Disease Control and tural traditions via its youth plot, where youth can Prevention, only 27 percent of Minnesota adults imitate elders tending larger plots. eat the recommended two servings of fruit Shopping for produce. Once the growing season per day, only 26 percent eat three vegetable serv- is over, there’s still a need for affordable produce. ings per day, and only 12 percent eat the recom- Fare For All (FFA), a program of the Emergency mended five total servings Foodshelf Network, helps of fruits and vegetables meet this need. FFA buys each day.

A diet high in fruits and produce and other foods in Enter the Hennepin County and passes the savvegetables reduces the risk bulk, Healthy Eating Minnesota ings on to its customers by (HC HEM) project, which for many chronic diseases. delivering the food to localooks for ways to get more tions throughout the metro fruits and vegetables into where people can buy it. the hands—and mouths—of county residents. HC HEM identified four high-need neighborhoods HC HEM has identified several ways to make pro- to receive new FFA sites. Since the cost savings duce more available. with FFA come from buying in bulk, the more peoCommunity gardens. Ten mini-grants to initiate or ple that participate, the more cost-efficient the expand community gardens were awarded in program. FFA sites are open to the public and any2011–12 to community organizations, benefiting one can benefit from the reduced cost, which is neighborhoods in Brooklyn Park, Brooklyn Center, nearly 40 percent less than typical grocery store Crystal, New Hope, St. Louis Park, and Mound. prices.

Five gardens initiated in 2011 allowed 200 new Small corner markets are often the source of progardeners to grow their own produce. Besides duce and groceries for those without reliable growing food for themselves, they donated 1,700 transportation. Yet these markets struggle to propounds of fresh produce to local food shelves. vide quality produce at affordable prices due to In 2012, five new gardens added 15,000 square high transportation costs. To help, a pilot project feet of gardening space, with each garden com- has been started to: mitting 20 percent of its produce to food shelves. • Provide market “makeovers” to improve the

By August, more than 1,400 pounds of produce display and promotion of produce to increase had been donated. sales, thus decreasing the per-unit cost.

The Garden Gleaning Project is a collaborative • Test a delivery system for small corner markets. effort spearheaded by The Minnesota Project to The delivery system piggybacks on the connect those who have excess food with those Emergency Foodshelf Network’s larger foodwho need food. Its volunteers move fresh produce delivery operations, helping small markets to from community and individual gardens to neighobtain the small quantities of produce they sell borhood food shelves, making a special effort to without the usual high transportation costs. get the right food to the right people. For example, If the current pilot project saves money for small CAPI, formerly the Centre for Asian and Pacific markets, it will expand to additional small markets Islanders, which assists East African immigrants throughout the Twin Cities. as well as Asians, helps sponsor a Brooklyn Center garden where many Hmong gardeners Resources grow culturally suitable food. Some of that pro- Garden Gleaning Project:To donate produce or volduce is donated to the CAPI food shelf in unteer, contact (651) 789-3321, gardengleaning Minneapolis, the state’s only Asian-specific food @gmail.com, www.mnproject.org shelf and the only one in the Twin Cities managed Fare For All: Locations/hours: (763) 450-3880,

by Hmong speakers. Culturally suitable vegeta- (800) 582-4291, www.emergencyfoodshelf.org/ bles are available at this food shelf, which serves OurFamilyOfPrograms/ffa/ an average of 2,000 low-income individuals CAPI food shelf: Sabathani Community Center, (approximately 350 families) monthly.

310 E. 38th St., Minneapolis 55409, (612) 721-0122, In its first year (2011), the Garden Gleaning Project www.capiusa.org/AsianFoodShelf.aspx delivered 7,345 pounds of fresh produce to neigh-

MINNESOTA HEALTH CARE NEWS DECEMBER 2012

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10 QUESTIONS

Promoting healthy aging Jane Pederson, MD, MS Dr. Jane Pederson is a geriatrician and the director of medical affairs for Bloomington-based Stratis Health, an independent, nonprofit organization that develops and implements initiatives and projects to improve health care.

What can a person do to promote healthy aging? Some of it is just luck. If your parents were alive and active into their 90s, that is good for you. Otherwise, it is the same advice we always hear. Exercise and activity are important because they help people maintain strength and agility that in turn helps maintain bone strength and promotes good balance, which helps to prevent falls and other accidents. Maintaining a healthy weight helps to avoid additional wear and tear on joints. Socialization and maintaining meaningful relationships is very important for mental health as well as for maintaining a sense of purpose. Of course, don’t smoke, drink in moderation, don’t use illicit drugs, and wear seatbelts and use other appropriate safety devices such as bicycle helmets.

What does a geriatrician do?

A geriatrician is a physician who specializes in the care of older people. Geriatricians are considered primary care physicians and typically were initially trained in internal medicine or family medicine.

Now, to become a board-certified geriatrician requires additional training beyond becoming an internist or family medicine physician. Geriatricians practice in any health care setting, but many practice in nursing homes, assisted living facilities, or work in various types of home care. Their focus is on managing the whole person and working to match the health care provided to the values and preferences of the patient.

Outside of traumatic events, what helps people the most to make healthy lifestyle changes as they age? Usually, something occurs that causes us to make a change, especially a lifestyle change. While that may not be a traumatic event, it is likely something that nonetheless makes us feel that the challenge of making the change is worth the benefit. This could be a health care scare like developing diabetes, realizing you can’t do something that for years you had taken for granted, or maybe a new relationship.

Please tell us about the history of your specialty.

The term “geriatrics” was coined in the early 1900s and the American Geriatrics Society was founded in 1942 to encourage and promote the study of geriatrics.

When is it appropriate for someone to switch health care providers from a general practitioner to a geriatrician? This is really a personal preference. Many times, it occurs when someone is moving from home or an independent living situation to a long-term care setting. Because geriatricians specialize in diagnosing, treating, and managing the conditions that tend to be more common as people age, switching from a general practitioner to a geriatrician can be helpful to patients and families. Geriatricians may be able to link patients and families with community services or to suggest interventions that can help people remain independent as they age.

10

MINNESOTA HEALTH CARE NEWS DECEMBER 2012

Photo credit: Bruce Silcox

How do you respond to the saying, “Age is just a number?” My dad is 92 years old and made the comment the other day that he has to resign himself to the fact that he is getting old. While his body is 92, he still sees himself as a young man.

So I think for all of us, age is a number, and just because that number gets bigger does not mean we feel like a different person.

Doctors must take

health conditions and delivering care that Dementia is a major concern in is in accordance with patient wishes. aging. How are diagnosis and the time to learn what is treatment improving? There is a lot of important to the patient Please tell us what you think the work going on in Minnesota to encourage and then provide care that future holds for geriatrics. With early recognition of dementia. Some may baby boomers and longer life spans, gerisay this doesn’t make sense because why meets that patient’s goals. atrics and gerontology (the study of aging) would we want to identify something early will continue to exist. However, the entire that we can’t cure? However, early identifihealth-care delivery system is changing and it cation can be very helpful to the person with is likely the role of geriatricians and all physicians will evolve. I dementia and to his or her family. Some agents can be used to slow think there will be more incentive for physicians to work with the progression of the disease. Often, people with early dementia teams or health care providers to deliver care. That’s what geriatrirealize there is something wrong and are afraid to ask. Learning cians are already doing. For many years we have worked in teams what is happening can help them prepare and make appropriate composed of a physician and a nurse practitioner or physician assisadjustments to their life. It can also help families better understand tant and have worked closely with professionals in pharmacy, therawhat support will be needed in the future. py, and nursing to provide care.

What other important developments in geriatrics have What are the biggest issues facing our society as we occurred during the last decade? In geriatrics, we have change the way we handle elder-related issues? I am become better informed in a number of ways. We now have good not sure my answer is a lot different for geriatrics than for any information on medication use in older persons that helps geriatriother age group, but we are going to have to decide how to balance cians identify medications that are no longer felt to be beneficial or the ever-growing use of technologies and procedures with patient that may have a negative effect. Vitamin D has been an interesting preference and values. In geriatrics, that means doctors must take issue. Deficiency of vitamin D has been found to be fairly common, the time to learn what is important to the patient and then provide and treating with vitamin D supplements has been shown to reduce care that meets that patient’s goals. Currently, our health care sysfalls and improve function. We are becoming better at recognizing tem does not always support taking the time for these types of condelirium in patients who are hospitalized or have an illness. This is versations—we are too focused on “doing something.” very important for patient outcomes. And finally, there is a better understanding of the role of palliative care in addressing chronic

A One Stop Shop for Minnesota Seniors

Call to get helpp with: with s Planning for long-term care s Remaining independent in your community s Arranging for in-home services s Getting help from state agencies s Becoming involved in your community

s &INDING A VOLUNTEER OPPORTUNITY s &IGHTING FRAUD s Understanding Medicare &IND MORE RESOURCES AT

DECEMBER 2012 MINNESOTA HEALTH CARE NEWS

11

TA K E C A R E

Winter safety Winter brings peaceful snowfalls and twinkling lights. But it also can bring aching muscles, electrical shocks, and other hazards. Here’s how to stay safe this winter.

Shoveling snow An estimated 11,500 people are treated in U.S. emergency departments every year for snow shoveling injuries, reports the American Journal of Emergency Medicine. Not surprisingly, the most common complaint involves muscular pain, especially of the back. Often, these injuries can be treated with rest, ice, and pain relievers, but they can lead to lifelong muscle weakness.

Let’s be honest. Most of us are not in the best of shape.

Yet even those who are can experience back, shoulder, and arm injuries because muscles and connective tissue are less elastic and more prone to injury when cold. To reduce the risk of those injuries:

Enjoy the season injury-free

By Scott Benson, MD

• Before shoveling, warm up with a few stretching movements focused on your back, shoulders, and arms. Light aerobic activity, like walking in place for 15 minutes, also helps to get your body ready.

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651-232-6830 651-23 32-66830 12

MINNESOTA HEALTH CARE NEWS DECEMBER 2012

Health Clinics

www.nwhealth.edu/patients www .nnwhealth.edu/patients

• Avoid shoveling after a heavy meal or drinking alcohol. Both can make you underestimate the extra strain cold weather places on your body.

• To prevent hypothermia, dress in layers and wear a hat; much of the body’s heat escapes through your head.

• A lightweight shovel with a small blade reduces the weight of each shovel full. The handle should be long enough that you don’t need to stoop to shovel.

• Push, rather than lift, snow. If you must lift, hold the shovel close to your body.

• Never twist your body or shovel snow over your shoulder. Keep your back straight.

• Shovel small amounts at a time; rest when tired.

shocks. According to the CPSC, during November and December 2010, more than 13,000 individuals were treated in emergency departments as a result of injuries involving holiday decorations.

To avoid injury: • Hang outdoor decorations before the snow falls. This eliminates the need to crawl on a slippery roof.

• Make sure any ladder is securely placed on a steady, non-icy surface.

More than 13,000 individuals were treated in emergency departments as a result of injuries involving holiday decorations.

• If you feel chest or back pain, stop immediately and get help. If you see someone who might be suffering from a heart attack, call 911.

While cardiac-related incidents only accounted for 6.7 percent of the 11,500 cases in the study mentioned above, they were responsible for all of the 1,647 deaths reported in the study. The American Heart Association suggests a check-up prior to the first anticipated snowfall, especially if you don’t exercise on a regular basis, have an existing medical condition, or are middle-aged or older.

Operating a snow blower Snow blowers make snow removal easier but carry their own risks.

According to the U.S. Consumer Product Safety Commission (CPSC), 3,000 people end up in emergency departments every year as a result of snow blower accidents, many with hand injuries such as damaged joints, broken bones, severe cuts, and even amputations. Others experience back strain from operating the machine or get hit with projectiles blown from it. To stay safe: • Read the snow blower manual and safety precautions before you begin.

• Never disable safety mechanisms.

• Check the area for rocks, branches, or anything else that could get caught in the machine or be thrown out while you are working.

• Aim snow away from people.

• Keep hands and feet away from moving parts. If the machine gets clogged, turn it off, unplug it, and use a stick to clear the obstruction. Never use your hands! Once the clog is removed, the blades often jump, even when the machine is off.

• Don’t operate the snow blower in a garage or other enclosed area.

This can result in carbon monoxide buildup, which can lead to illness or death.

• Never run the snow blower when you are angry or intoxicated.

• Turn the machine off and unplug it before you move it.

• Don’t wear anything that could get caught in the snow blower, such as long scarves or loose clothing.

• Wear boots with traction to avoid slipping.

• Be careful when refilling the machine with gasoline. Gasoline is highly flammable, and its vapors are explosive.

• Keep children and pets away from the work area. Never let a child operate a snow blower.

• Wear boots that have traction to reduce the chance of slipping.

• Always work with someone, never alone.

• Only use lights that have been tested for safety by a recognized authority and certified for outdoor use. Check each set of lights every year for broken or cracked sockets, frayed or bare wires, or loose connections. Discard damaged sets.

• Do not exceed the maximum number of lights for each extension cord, and make sure the extension cord is certified for outdoor use.

• Never use electric lights on a metallic tree. This can cause shocks.

• Keep all lights away from power lines or utility poles. Fasten lights securely to trees, the house, or other stable supports.

Winter safety to page 34

Leg Pain Study Do your legs hurt when you walk?

Does it go away when you rest?

Or, have you been diagnosed with PAD? You may have claudication, caused by lack of blood supply to the leg muscles The University of Minnesota is seeking volunteers to take part in an exercise-training program, funded by the National Institutes of Health

To see if you qualify, contact the EXERT Research Team at

612-624-7614 or email EXERT@umn.edu or visit EXERTstudy.org

Holiday decorating Falling off a roof or ladder can cause major injury or death.

Working with improper or damaged light cords can cause electrical

EXERTstudy.org DECEMBER 2012 MINNESOTA HEALTH CARE NEWS

13

INFECTIOUS DISEASE

Flu vaccine Approximately 40,000 people die of influenza (the flu) each year in this country. Virtually all of these deaths could be prevented by an annual flu shot.

Where does vaccine come from?

The World Heath Organization (WHO), which is the public health arm of the United Nations, is responsible for updating flu vaccine each year.

The first ingredient needed to make flu vaccine is influenza virus. Because flu viruses arise in animals and then infect people who live where there is close contact between animals and humans, WHO searches for these viruses in rural areas of Southeast Asia, where humans and animals frequently live in close proximity. The H1N1 “swine flu” virus of 2009–2010, for example, arose in swine (pigs) before infecting humans.

Why you need it

By Donald Bucklin, MD

Manufacturing vaccine WHO collects swabs of nasal mucus from a cross-section of sick people in Southeast Asia to find the new and dominant viruses each flu season. Then, WHO combines the three worst viruses into a manmade virus. This man-made virus has an inert core and an exterior shell resembling the three flu viruses. That’s important, because the human body produces antibodies—proteins that attack viruses—to the exterior of viruses. The man-made virus’ inert core makes it incapable of infecting anyone.

To mass-produce vaccine, this noninfectious man-made virus is injected into chicken eggs, where it multiplies. Copies of this virus are also mass-produced in metal incubators for people who are allergic to eggs and might have an allergic reaction to egg-grown vaccine.

The original man-made virus and its copies are chemically treated and broken into pieces for additional assurance that it won’t infect anyone.

The finished vaccine Flu vaccine can’t infect anyone because there is no living virus in it.

(Remember, in addition to having an inert core, it is chemically treated and broken.)

When you get a flu shot, the exterior shell of the vaccine stimulates your body to make antibodies that recognize the viruses’ exterior. That way, if you encounter this viral surface again—like when someone with the flu sneezes on you—your antibodies attach to the flu virus in the sneeze droplets and destroy the virus. Within about nine days after vaccination, someone who has been vaccinated has made enough antibodies to destroy the flu virus.

It takes six months from finding a new virus to mass-producing vaccine. Each year’s current viruses are found when it’s spring in Minnesota, so vaccine is available by autumn: perfect timing for Minnesota’s flu season.

14

MINNESOTA HEALTH CARE NEWS DECEMBER 2012

Dispelling flu myths

Flu vaccine can’t infect anyone.

1 Flu shots are useless after November. It’s never too late to get vaccinated. Flu season in Minnesota typically lasts from October through April.

2 Preservative in injectable flu vaccine is dangerous. There is no scientific evidence that this preservative, Thimerosal, is harmful except to someone allergic to it. However, for people wishing to avoid preservatives, injectable vaccine is available in preservative-free form. Another alternative is FluMist nasal spray vaccine, which contains no preservative.

3 I can’t afford a flu shot. Flu vaccination is covered by some insurance plans, including vaccination obtained in a pharmacy instead of a doctor’s office. A large research study published in the medical journal The Lancet in 2003 found that every person vaccinated against the flu saved an average of $47 in health care expenses each year they got vaccinated. Doctor visits and work absences were significantly reduced among the vaccinated.

Vaccinated children miss fewer days of school.

10 Only old people die from the flu. Most years, 90 percent of flu deaths occur among people 65 years old and older, but deaths from 2009–2010’s H1N1 swine flu were almost all among people under 30 years of age.

Not only that, but the more people who are unvaccinated, the more likely we are to create a flu pandemic. A pandemic is an epidemic of grand proportions; the influenza pandemic of 1918–1919 killed between 20 million and 40 million people. It’s each person’s contribution to public well-being to get vaccinated to avoid transmitting the flu this winter.

Maximize protection When you get your flu shot this year—and do it soon to maximize your protection—appreciate the power of a small amount of vaccine and a minimal investment of your time.

Donald Bucklin, MD, is a regional medical director for U.S. HealthWorks, a nationwide provider of occupational medical health care with clinics in Chaska, Minneapolis, and Robbinsdale. He has practiced clinical occupational medicine for more than 25 years.

4 Vaccination can give me the flu. That cannot happen. Flu

5 Vaccination won’t prevent me from getting the flu.

A normally healthy person will have developed immunity against the flu virus nine days after vaccination. Rarely, a flu virus is identified that was not part of the original man-made virus, and you’ll need to be vaccinated against it by getting a second vaccination.

6 I won’t get the flu. This assumption is dangerous. How often this winter will you be in stuck in the same room/elevator/vehicle with someone who is coughing, sneezing, and otherwise infecting you?

7 Flu shots hurt. In my clinic, we use needles that are the thickness of a human hair. There is very little pain from a flu shot. Besides, any fleeting discomfort felt by the recipient pales in comparison with the days of misery inflicted by a case of the flu. Plus, to avoid needles, you can choose nasal spray vaccine, which works just as well as a shot. Everyone older than six months of age should be vaccinated, including pregnant women. Infants younger than six months have their mothers’ immunity.

8 I’m still immune from last year’s shot. This is wrong for two reasons. First, flu vaccine produces strong immunity that lasts for six months before it fades away. Second, the structure of flu viruses changes from year to year, which is why the vaccine is redesigned every year to be specific for the current year’s viruses. You need the current year’s vaccine for protection against the current year’s flu.

It’s never too late to get vaccinated.

Telephone Equipment Distribution (TED) Program

vaccine is made from dead, broken-up virus. It is not infectious.

Do you have trouble using the telephone due to hearing loss, speech or physical disability?

If so…the TED Program provides assistive telephone equipment at NO COST to those who qualify.

Please contact us, or have your patients call directly, for more information.

1-800-657-3663 www.tedprogram.org Duluth • Mankato • Metro Moorhead • St. Cloud

9 I’m healthy, so getting the flu is no big deal. Influenza incapacitates even the strong and healthy with 104° fevers, profound discomfort, and lost work time. Plus, an unvaccinated person can infect others who may die of the flu, including infants, people with serious breathing problems, and the very old.

The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services DECEMBER 2012 MINNESOTA HEALTH CARE NEWS

15

PUBLIC HEALTH

Winter driving Expert advice from AAA Minneapolis

By Matt Hehl

W

inter driving in Minnesota can be stressful, since both drivers and vehicles are exposed to adverse and challenging conditions.

Safe driving under these conditions requires preparation and proper driving technique.

Preparing the vehicle Minnesota’s winter climate greatly increases stress and strain on your vehicle, and minor deficiencies can often develop into major problems.

Make sure to check the following components both before and throughout the winter months.

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MINNESOTA HEALTH CARE NEWS DECEMBER 2012

• Battery The heart of your vehicle’s electrical system is the battery. Cold-weather starts require a battery that is fully charged. Have your battery checked and replaced, if needed. Have your alternator or generator, voltage regulator, and drive belts checked, too.

• Lights During winter a vehicle’s lights play a critical role in allowing others to see the vehicle. Make sure to keep all lights and lenses clean and functioning properly. Grime on headlight lenses reduces their effectiveness by as much as 90 percent.

- Bag of abrasive material (sand, salt, cat litter) or traction mats - Snow shovel - Blankets - Extra warm clothing (gloves, hats, scarves) - Flashlight with extra batteries - Window washer solvent - Ice scraper with brush - Cloth or roll of paper towels - Jumper cables - Warning devices (flares or triangles) - Basic toolkit (screwdrivers, pliers, adjustable wrench) Preparing the driver

To minimize dangers associated with winter driving, both the vehicle and the driver must be prepared in advance. For the driver, this • Tires The amount of traction that exists between the tires and means approaching winter driving in the right frame of mind. Always roadway surface determines how well the vehicle accelerates, drive at a speed that matches the prevailing visibility, traffic, and road turns, and stops. Make sure that your tires are properly inflated conditions. Keep these tips in mind when preparing for winter travel: and in good condition.

All-season tires work well in light-to-moderate • Wear clothing that provides warmth, comfort, and snow conditions, provided they have adequate tread freedom of movement. Once a vehicle’s interior has depth. You may have used the “penny test” to help warmed up, a zip-fastened, lined jacket and pair of measure tread depth, but AAA believes it’s time to thin leather gloves are ideal. (Note: Never warm up a ditch the penny and replace it with the quarter test. vehicle in an enclosed area, such as a garage. This can Insert a quarter into the tire’s tread: If Washington’s lead to carbon monoxide poisoning and death.) head is showing, it is time to replace your tires.

• The correct seat position and the use of safety equipAvoid driving Replace any tire that has less than 3/32-inch of tread. ment help you see the road and perform the gentle, while you’re Uneven tire wear can indicate problems with alignsmooth, precise movements necessary for safe winter fatigued. ment, wheel balance, or suspension, any of which must Winter driving to page 17 be addressed to prevent further tire damage.

Check inflation pressure on all four tires and the spare more frequently in winter. As the average temperature drops, so will tire pressures, typically by one PSI for every 10°F. • Heating and cooling Make sure your vehicle’s cooling system contains enough antifreeze to prevent freezing in cold weather. Keep the mixture fresh by changing it regularly and having the entire system checked for leaks. Make sure you check the coolant level in the overflow tank when the engine is cold.

• Windshield wipers, glass, vehicle exterior, and washer reservoir Clean windows offer optimal visibility. Wiper blades should completely clear the glass with each swipe. Blades that streak the windshield should be replaced. To prevent damage to wiper blades or wiper motor, be sure wipers are free of ice and snow and are turned off before starting the engine. Keep the washer reservoir bottle full of antifreeze washer solvent.

• Vehicle preparation Clear snow and ice from the car to improve visibility. (Clear all windows, hood, roof, trunk, turn signals, taillights, and headlights.) Keep the gas tank at least half full to keep the gas line from freezing.

•Emergency road kit Carry an emergency kit equipped for winter weather. The kit should include: - Mobile phone preprogrammed with rescue apps and important phone numbers (including family and emergency services) and a car charger - Drinking water - First-aid kit - Nonperishable snacks for both human and pet passengers

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DECEMBER 2012 MINNESOTA HEALTH CARE NEWS

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December Calendar 8

11

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Juvenile Arthritis Meeting The Arthritis Foundation presents a Juvenile Arthritis Family Network (JAFN) meeting. Speakers and topics TBA. For more information, contact Liz at (651) 229–5371 or etruax@arthritis.org.

Saturday, Dec. 8, 10 a.m.–12 noon, Shriners Hospital, 2025 E. River Pkwy., Minneapolis Depression Coffee Talk Park Nicollet presents a coffee talk support group about depression.

This group will explore why talking about depression is difficult and what strategies can make coping easier. Call (952) 993–6789 for more information.

Tuesday, Dec. 11, 9:30–11 a.m., Park Nicollet Heart and Vascular Ctr., Conference Rm. B, 6500 Excelsior Blvd., St. Louis Park Heart to Heart Lakeview Health offers individuals and families who have experienced a cardiac event compassionate support and education with this group. Free. No registration required. Call (651) 430–4150 for more information.

Wednesday, Dec. 12, 2–3 p.m., Town Hall, Boutwell’s Landing, 5600 Norwich Pkwy., Oak Park Heights Bisexuality Support Group Bisexual Organizing Project (BOP) presents this support group, which will discuss the issues and rewards of openly discussing your bisexuality with children, siblings, and parents. Refreshments will be served.

Free. Register on www.meetup.com. For more information, email tcbop1@yahoo.com.

Thursday, Dec.13, 7–8 p.m., Outfront Minnesota, 310 E. 38th St., Ste. 204, Rm. 218, Minneapolis Caregiver Respite If you are a caregiver, FamilyMeans would like you to attend its Group Respite Program: Day Out! Activities, games, projects, and lunch will be provided. Cost is $40 per day, but scholarships are avail-

Healthy Holiday Eating As the holidays loom, many of us look forward to our culinary traditions— turkey, mashed potatoes, and plenty of desserts. While these delicious foods are worth anticipating, they can come with a hefty price to the waistline. This year, try a few simple ingredient switches to make your recipes healthier without sacrificing taste, courtesy of the website MayoClinic.com: • Cut sugar in half in desserts and eggnog. For sweetness, try citrus, vanilla, nutmeg, or cinnamon.

Molasses, honey, or turbinado sugar make good substitutes for sugar, since their flavor means you can use less but still get a sweet dessert. Try using unsweetened frozen fruit as a dessert topping, rather than frosting.

• Try cutting salt in half in your recipes, and substitute fresh herbs or flavored vinegars whenever possible. Rather than salty condiments such as catsup, pickles, and soy sauce, try fresh cucumbers or fruit salsas. Finally, always use lower-sodium formulas when possible, especially with broths.

• When baking, cut the fat in half by replacing it with unsweetened applesauce, prune puree, or mashed banana.

Use condensed skim milk rather than full-fat condensed milk in desserts and drinks.

For additional information on healthy holiday eating (including low-sodium gravy suggestions), view the entire post at www .mayoclinic.com/health /healthy-holiday-eating/MY01046.

able. For more information or to register, call Lisa at (651) 789–4004.

Friday, Dec. 14, 10 a.m.–2 p.m., 1875 Northwestern Ave. S., Stillwater

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Diabetes Meet-up A Partnership of Diabetics (A-POD) hosts this new Monday night meet-up for diabetics. This group is designed to support diabetics of all ages through mentorship, ideas, and shared experiences. Free. For more information or to register, contact Robert at ralbee4045@aol.com.

Monday, Dec. 17, 7–8 p.m., Phillips Community Center, 2323 S. 11th Ave., Minneapolis

18

Lung Cancer Education North Memorial presents this support group for lung cancer patients to help make sense of diagnosis and treatment.

There will be group discussion and educational topics. Free. Call (763) 520–5285 for more information or to register.

Tuesday, Dec. 18, 5:30–7 p.m., North Memorial Outpatient Ctr., Education Ctr., Birch Rm., 3435 W. Broadway, Robbinsdale

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Ability Support Group If you have a health challenge, We ‘R’ Able encourages you to come, listen, and share stories with others. Refreshments provided; a donation of $1 per meeting is encouraged. For more information, call Loreli at (320) 358–1220. Call Heartland Express for transportation needs: (800) 234–7840.

Wednesday, Dec. 19, 1:30–2 p.m., Chisago County Senior Center, 38790 6th Ave., North Branch

13

Holiday Heart Health Minneapolis Heart Institute invites you to enjoy the holidays with better heart health.

David Hurrell, MD, will discuss cardiovascular tests and what they mean. Appetizers provided. Free. Register at http:// holidayhearthealth-eac2.eventbrite.com/#.

Thursday, Dec.13, 6–8 p.m., Plymouth Creek Center, 14800 34th Ave. N., Minneapolis

Send us your news: We welcome your input. If you have an event you would like to submit for our calendar, please send your submission to MPP/Calendar, 2812 E. 26th St., Minneapolis, MN 55406. Fax submissions to (612) 728-8601 or email them to mmacedo@ mppub.com. Please note: We cannot guarantee that all submissions will be used. CME, CE, and symposium listings will not be published.

America's leading source of health information online 18

MINNESOTA HEALTH CARE NEWS DECEMBER 2012

Winter driving from page 17

of three to four seconds should be increased to eight to 10 seconds to provide more time should you need to motoring. Adjust your seat so that you sit no closer stop. than 10 inches from the steering wheel and can see the Slow down when visibility and road conditions road ahead. become impaired.

• Watch weather reports before a long-distance drive • Maintain control. Never use cruise control when drivor before driving in isolated areas. Delay trips when ing on any slippery surface. To prevent loss of tracsevere weather is expected. If you must travel, let If you become tion, you may need to reduce speed by lifting your others know your route, destination, and estimated foot off the accelerator, which cannot be accomsnowbound, time of arrival. plished when cruise control is engaged. stay with • Avoid driving while you’re fatigued. Getting the proUse “threshold” or squeezing braking when driving your vehicle. per amount of rest will help to reduce winter driving a car without antilock brakes (ABS). This means that risks. In addition, never drive when you’re emotionalyou apply the brakes to a point just short of lock-up, ly upset or rushed. According to traffic safety authorities, lack of then ease off the brake pedal slightly. For vehicles with ABS, continuattention is a major contributing factor to auto crashes. ous firm braking is necessary.

If you do skid, ease off the accelerator and don’t lock the brakes.

Winter driving techniques Carefully steer in the direction you want your vehicle to go and Knowing how to traverse winter’s challenging environment can straighten the wheel as soon as the car begins to go in the desired reduce your risk of a crash or becoming stranded. Practicing proper direction. winter driving techniques in adverse conditions will help you arrive • Stay with your vehicle. If you become snowbound, stay with your safely each time you take to the road. Apply these principles when vehicle. It provides a temporary shelter and makes it easier for resdriving in winter. cuers to locate you. Don’t try to walk in a severe storm because it’s • Go slow on ice and snow. Accelerate and decelerate slowly. easy to lose sight of your vehicle in blowing snow and to become Applying the gas slowly to accelerate is the best method for regainlost. Tie a brightly colored cloth to the antenna to signal distress. ing traction and avoiding skids. Take extra time to slow down To be a safer winter driver, use these driving techniques and make when coming to a stop. Remember, everything takes longer on snow-covered roads: accelerating, stopping, and turning. Give your- sure you and your vehicle are prepared for adverse conditions. self plenty of time to execute these maneuvers.

Increase your following distance. The normal following distance

Matt Hehl is the public relations and community outreach specialist for AAA Minneapolis.

Now accepting new patients

A unique perspective on cardiac care Preventive Cardiology Consultants is founded on the fundamental belief that much of heart disease can be avoided in the vast majority of patients, and significantly delayed in the rest, by prudent modification of risk factors and attainable lifestyle measures.

Elizabeth Klodas, M.D., F.A.S.C.C is a preventive cardiologist. She is the founding Editor in Chief of CardioSmart for the American College of Cardiology www.cardiosmart.org, a published author and medical editor for webMD. She is a member of several national committees on improving cardiac health and a frequent lecturer on the topic.

We are dedicated to creating a true partnership between doctor and patient working together to maximize heart health. We spend time getting to know each patient individually, learning about their lives and lifestyles before customizing treatment programs to maximize their health.

Whether you have experienced any type of cardiac event, are at risk for one, or

are interested in learning how to prevent one, we can design a set of just-for-you solutions.

Among the services we provide • One-on-one consultations with cardiologists • In-depth evaluation of nutrition and lifestyle factors • Advanced and routine blood analysis • Cardiac imaging including (as required) stress testing, stress echocardiography, stress nuclear imaging, coronary calcium screening, CT coronary angiography • Vascular screening • Dietary counseling/Exercise prescriptions

To schedule an appointment or to learn more about becoming a patient, please contact: Preventive Cardiology Consultants 6545 France Avenue, Suite 125, Edina, MN 55435 phone. 952.929.5600 fax. 952.929.5610 www.pccmn.com DECEMBER 2012 MINNESOTA HEALTH CARE NEWS

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DIGESTIVE HEALTH

R Gluten sensitivity and celiac disease Challenging diagnosis, straightforward treatment

By Joseph A. Murray, MD

ecent popular media and scientific publications have brought celiac disease and the health impact of eating gluten to public attention.

Concurrently, there has been a dramatic increase in the use of gluten-free food, now a major segment of the food market with sales over $2 billion annually. What is gluten? Who is affected by it, and how?

Gluten Gluten is a protein found in wheat, rye, and barley.

Some people have a not-yet-understood abnormal immune response to eating gluten that damages their small intestine. Genetics play a large role in this response, which runs in families and can occur in patients who have other diseases known to involve an abnormal immune response, including type 1 diabetes and autoimmune thyroid disease.

This gluten-sensitive response affects all ages and both genders, and is more common among Caucasians.

In fact, one in every 100 U.S. Caucasians is estimated to have the principal disease resulting from gluten sensitivity, which is celiac disease. That could be as many as 1.8 million Americans, according to research conducted by the National Institutes of Health (NIH) and Mayo Clinic, published in the July 2012 edition of the American Journal of Gastroenterology.

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MINNESOTA HEALTH CARE NEWS DECEMBER 2012

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Symptoms Because symptoms of celiac disease can be vague and nonspecific, such as joint pain and chronic fatigue, someone may live with this disease for years before it is identified.

All the while, damage to that person’s intestine continues.

Because the only treatment is strict, lifelong avoidance of gluten, it’s important to recognize symptoms of celiac disease Most people and to know what to do if you who have think you have them, so that a gluten-free diet can be initiated celiac disease promptly after obtaining a cordon’t know it. rect diagnosis.

Celiac disease symptoms include diarrhea, abdominal pain, bloating, and gas.

Because this condition affects the digestive tract, which is where people absorb nutrients from the food they eat, celiac disease can lead to malnutrition, unduly short stature, bone fragility, depressed resistance to bacterial and fungal infections, and reduced ability to respond to vaccinations.

Dermatitis herpetiformis is closely related to celiac disease and is an itchy skin rash that affects the points of the elbows, the knees, and the back. It is treated by a gluten-free diet, with the itch treated by the prescription medication dapsone.

Non-celiac gluten sensitivity shows up as chronic gastrointestinal symptoms, often associated with fatigue, that seem to improve on a gluten-free diet.

well as animal models of gluten sensitivity, suggest that gastrointestinal infection may trigger or facilitate the onset of celiac disease. However, there is currently no proof of an infectious trigger.

Interestingly, celiac disease is also occurring for the first time in adults who apparently tolerated gluten for decades without detectable symptoms. This is happening more among 30- to 50year-olds than among adults of other ages.

Reasons for this trend have not been determined, but may relate to changes in wheat genetics caused by modern wheat-breeding practices and/or increased consumption of processed foods, which can contain gluten. And, similar to results from studies of infants, recent research by the U.S. Naval Medical Research Center and Mayo Clinic suggests that infectious gastroenteritis may precede diagnosis of celiac disease in active service military personnel.

Diagnosis Celiac disease can be detected readily by a blood test. People who think they may have celiac disease or symptoms suggestive of it should ask their physician about getting tested for celiac disease before removing gluten from their diet, Gluten sensitivity and celiac disease to page 22

Increasing incidence According to collaborative research by Mayo Clinic, University of Minnesota, and the Medical Follow-up Agency (MFUA), an organization that collaborates with qualified researchers from diverse backgrounds to obtain and analyze records data, the number of people in the U.S. with celiac disease—children and adults—has increased dramatically over the last several years. This increase is not due simply to better detection but is a true increase. Another 2012 American Journal of Gastroenterology report, this one from the Department of Defense, also showed a dramatically increased rate of new diagnosis of celiac disease.

Why this increase has occurred is unknown, but likely reflects pervasive changes in the environment. The increase in childhood celiac disease may be due in part to societal changes in feeding habits that include the introduction or high consumption of gluten, in the form of infant formula, early in life.

Infections early in life, especially those that overlap introduction of formula containing a high dose of gluten, may increase the likelihood of celiac disease. Increased risk of infection in early childhood could be associated with society’s trend toward the use of day care and an associated increased risk of infectious diarrhea.

Three or more bouts of infectious diarrhea in young children around the time they start drinking formula has been found to be associated with a substantially increased risk of being diagnosed with celiac disease during childhood.

It is possible that in genetically susceptible patients, an infection helps trigger the onset of celiac disease symptoms. Studies of humans who develop gluten sensitivity after infectious diarrhea, as DECEMBER 2012 MINNESOTA HEALTH CARE NEWS

21

Gluten sensitivity and celiac disease from page 21

since going gluten-free before testing can produce a false negative test.

People who have a close genetic relative with celiac disease should be tested, even in the absence of obvious symptoms. That’s because celiac disease can make itself known in many ways and impact health so gradually that many patients don’t realize they had symptoms until after they have gone gluten-free.

The frequency of non-celiac gluten sensitivity is unknown, but it may mimic irritable bowel syndrome and, while there are excellent tools for detecting celiac disease, there are not yet tools for detecting non-celiac gluten sensitivity. Patients with symptoms primarily of irritable bowel syndrome— which vary from person to person and thus should be identified by a physician—but in whom celiac disease has been ruled out should consider the possibility that they have non-celiac gluten sensitivity.

For these people, simply trying a gluten-free diet may be quite helpful in relieving their symptoms. If doing so keeps symptoms away, those patients may have non-celiac gluten sensitivity.

Treatment The only treatment for celiac disease is a gluten-free diet, now much easier to follow than in previous years due to the wider availability of gluten-free products. Unfortunately, this treatment is not being used by the estimated 1.8 million Americans who have celiac disease, since 83 percent of them are unaware they have it, according

to the NIH/Mayo research published in July 2012. In addition, the same research found that 1.6 million Americans eat gluten-free, the vast majority of whom do not have a diagnosis of celiac disease.

This presents an irony: Most people who have celiac disease don’t know it and are not on the gluten-free diet that would likely improve their health, whereas it’s unknown if most people who follow a gluten-free diet need to do so.

For more information: • Northland Celiac Support Group, www.northlandceliacs.fastmail.fm/

However, there is excellent support for patients who must follow this diet: statewide support groups, a wide array of gluten-free food in mainstream grocery stores, and increasing numbers of registered dietitians with expertise in educating people about gluten-free eating. Remember, though, that just because food is gluten-free does not necessarily mean it is healthy. Daily caloric intake and overall nutritional quality of your diet remain important.

Joseph A. Murray, MD, director of celiac disease research at Mayo Clinic, is a gastroenterologist who treats patients with celiac disease and studies why immune responses to gluten are altered in people with celiac disease and gluten sensitivity.

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A philosophy of caring is good. A history of it is better.

Caring. It would be nice if you could see it, like an amenity. Or tour it, like an apartment. But you can’t. All we can do is give you our definition: Caring is believing that everyone is someone who deserves to feel loved and valued, and be treated with dignity.

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INSURANCE

Appealing a denied claim

I

f you have been denied coverage by your health insurance plan for treatment your doctor has prescribed, you have a right to formally appeal your insurer’s decision.

Take people living with psoriasis, for example. Approximately 136,000 Minnesotans have psoriasis, a chronic disease of the immune system that makes the skin crack, itch, and bleed. As the nation’s most common autoimmune disease, psoriasis often causes insurance issues, and treatment for the disease can be difficult to obtain.

The advocacy department of the National Psoriasis Foundation, the world’s largest nonprofit patient advocacy organization serving the millions of Americans living with psoriasis, works to make sure that people with psoriasis have access to the treatments they need.

The National Psoriasis Foundation offers the following information for appealing a denial, which can be used to appeal denial of treatment for other conditions as well.

How to appeal a denied health insurance claim Start by obtaining a copy of your plan document and plan summary.

Request them from your insurance company or access them online.

Don’t take “no” for an answer

By Noe Baker

Read the denial letter from your insurance company for information on how to appeal.

Steps for filing your appeal: • File the appeal with your health plan quickly.

Many companies place limits on how long appeals may be requested after a claim is denied.

DENI

• Many health plans require you to write a letter to appeal the denied claim. For sample letters and tips, see the sample letter on page 25 and visit: www.psoriasis.org/access-care/insurance-center/appeal-a-claim/sample-letters • Have your doctor write a “letter of medical necessity” and ask him or her to call your health insurance provider on your behalf. Your doctor and his or her staff are qualified to explain your condition, medical history, and treatment plan.

• Keep copies of correspondence from your doctor and from yourself to the insurance company.

Read us online

wherever you are!

• Record the names and job titles of the health insurance representatives you speak with and the time and date of your calls.

If your insurer still denies your claim after you file an appeal: • Talk with your employer’s human resources (HR) department. Tell the benefits manager at your workplace that the health benefits they offer do not allow you to access medication that you need.

Your HR department may be able to influence the health plan to cover a particular treatment.

• Contact the National Psoriasis Foundation advocacy department.

It may be able to assist you with a psoriasis-related claim. Email advocacy@psoriasis.org or visit www.psoriasis.org/access-care.

Contact the manufacturer of your treatment.

• If you’ve exhausted your health plan’s appeal process, try an external or independent review. Consult resources like the Kaiser Family Foundation for its consumer guide to handling disputes with a health plan (www.kff.org /consumerguide/states.cfm), as well as www.health.state.mn.us /divs/hpsc /mcs/external.htm

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MINNESOTA HEALTH CARE NEWS DECEMBER 2012

• Contact your state insurance commission to speak with a consumer advocate about your case.

• Contact the manufacturer of your treatment. For example, many manufacturers of psoriasis treatments, from biologics to home

Have your doctor write a “letter of medical necessity.” phototherapy units, have insurance specialists that can help facilitate your appeal. Get more information from the National Psoriasis Foundation financial assistance resources: www.psoriasis.org/accesscare/insurance/financial-assistance

A sample letter This sample letter from the National Psoriasis Foundation is an example of an appeal to a health plan that has denied a claim. Edit the letter to suit your needs and replace bold sections. Be sure to have your health care provider write a letter as well.

Sincerely, [Your name] [Address] [Phone number] [Member identification number, Group code or other case record numbers] CC: [State Insurance Commissioner] [Name of prescribing physician] [Name of your insurance plan administrator at your workplace]

While the sample letter above is psoriasis-related, it serves as a general model for a letter appealing any claims denial. Elements that are transferable to other denials are the letter’s polite yet matter-of-fact tone, its citation of fairly recent published scientific [Today’s date] research to back up the writer’s point of view (research citations [Name of insurance company medical should be available on request from your physician), written supdirector] port from the writer’s physician, the link to medical treatment [Name of insurance company] guidelines approved by the governing body of the relevant medical [Street address] discipline (for psoriasis, this is the American Academy of Dermatol[City] [State] [ZIP code] ogy; a letter appealing denial of a child’s treatment Dear [Name of medical director], could cite the American Academy of Pediatrics), and File the [Name of health plan] has denied sending copies of the letter to your state insurance my claim for [name of therapy/drug] commissioner and others. appeal with for my psoriasis [and/or] psoriatic arthriyour health Noe Baker is the public relations manager of the National tis. Psoriasis—and the psoriatic arthritis that accompanies it in up to 30 percent of cases—is a plan quickly. Psoriasis Foundation (www.psoriasis.org). chronic, autoimmune disease that appears on the skin and/or in the joints. There is no cure for psoriasis and psoriatic arthritis.

Psoriasis and psoriatic arthritis can have a significant negative impact on a patient’s health. There is an increased risk for psoriasis patients developing other serious conditions such as heart disease, stroke, hypertension, and diabetes. Research studies have established that the risk of premature death is 50 percent higher for people with severe psoriasis and that individuals with severe psoriasis die four years younger, on average, than those without psoriasis.

Access to treatment is important to prevent much of the disability and psychosocial impacts of the disease.

My physician, [name of prescribing physician], and I disagree with [name of health plan]’s denial of my claim [claim #]. Please consider this letter a formal, written appeal of your denial of this medically necessary therapy. My physician is sending a letter documenting [his/her] recommendations for access to this treatment.

[Describe in your own words your symptoms, treatment history, therapies you have tried, comorbid conditions, and why this treatment should be covered. If there are logistical considerations, such as long distances to travel, or problems with transportation, explain those factors as well.]

[Include copies of your health plan policy on the treatment and how you meet the pre-authorization requirements, if applicable.]

I request that you review the recently published evidence-based guidelines of care for psoriasis and psoriatic arthritis produced by the American Academy of Dermatology and available at www.aad.org/research/guidelines/index.html. These guidelines touch on the points raised in this letter and provide an overview of treatment protocols for psoriasis and psoriatic arthritis.

NIED

DECEMBER 2012 MINNESOTA HEALTH CARE NEWS

25

P O D I AT RY

Ingrown toenails

One of the most common preventable conditions a podiatrist encounters is an ingrown toenail, a situation in which part or all of a toenail grows downward into the flesh instead of resting on top of the skin. Symptoms include pain and redness where the nail pushes into the flesh, plus swelling, bleeding, and pus drainage from the affected area. Simple at-home treatment to reduce these symptoms may get rid of the associated infection and pain.

Treatment consists of soaking the toe in a solution of warm water and antibacterial soap or Epsom salts for five to 10 minutes once or twice daily to reduce the infection, followed by appliAvoiding ingrown toenails cation of an over-the-counter and related problems (OTC) antibiotic cream to

By Gerard Busch, DPM (doctor of podiatric medicine) eliminate infection. Often, a patient attempts “bathroom surgery” to cut out an ingrown toenail. This generally aggravates the condition, worsening the infection and increasing pain.

Foot care

A

podiatrist treats a variety of foot ailments, many of which can be prevented by proper foot care.

Avoidable problems include ingrown toenails and fungal infections, while some conditions, such as bunions, flat feet, and crooked toes, may not be totally preventable because they involve inherited genetic factors. But even inherited conditions can and should be treated to stop progression of the deformities they cause in order to limit damage to the foot and to relieve associated pain.

When to seek medical care

t Eat more fruits, vegetables, whole grains and less fat t Be physically active every day t Do not smoke t Eat smaller portions and lose 10 pounds if you are overweight t Know your ABCs: A1C, Blood pressure and Cholesterol t Take your medicines as directed t Talk to your doctor

Minnesota Diabetes & Heart Health Collaborative

26

© 2012 Minnesota Diabetes & Heart Health Collaborative

MINNESOTA HEALTH CARE NEWS DECEMBER 2012

If pain, redness, and swelling around an ingrown toenail persist, it’s important to see a medical professional. It is especially important for anyone diagnosed with type 1 or type 2 diabetes to be seen by a doctor for any infection on the foot. People with diabetes are susceptible to foot problems because this disease adversely affects tiny blood vessels in the feet, reducing blood supply to that area and making it harder for infections to heal. Consequently, for a diabetic, a simple infection such as an ingrown toenail can quickly become a serious health Foot care problem. should An example of this is a recent patient of mine who failed to keep a follow-up appointbegin at ment with his primary care doctor after treata young ment for an infected ingrown toenail. The infection recurred, as did the ingrown nail. By the age. time the patient was seen in my office, X-rays revealed an infection of the underlying toe bone.

He eventually had the end of his big toe amputated and was on IV antibiotics for several weeks.

This illustrates how important it is for an ingrown toenail to be completely removed in order to properly treat the infection and to allow healing to occur. Removal is a relatively quick procedure that is performed in the podiatrist’s office and allows the patient to drive a car and walk on the foot immediately afterward.

After the toe is anesthetized, the side of the ingrown nail is removed down to the nail root. (The nail root is the part of the nail that extends into the toe.) Next, an antibiotic cream and dry dressing are applied to the area where the nail was removed.

Depending on the severity of the infection, an oral antibiotic may be prescribed. Until this area heals, the patient applies antibiotic cream to it daily and covers it with a small adhesive strip. Because an ingrown toenail may recur, it’s important to monitor the toe for evidence of recurrence for six to 10 months after the ingrown nail has been removed.

Shoes to avoid

Shoes that predispose someone to ingrown toenails and other foot problems include dress shoes that have a small toe box—including pointy-toed women’s styles currently in vogue—and shoes, even those with broad toe boxes, that have heels greater For more than one and one-half inches tall. Other shoes to information, avoid are flip-flops; shoes with excessive wear and visit tear; and Ugg-style boots, which fail to provide adewww.APMA.org quate support. This does not mean you can never wear high heels or flip-flops.

A person can wear dress shoes when going out for the evening or flips-flops at the beach. Just don’t make these your primary Prevention choice of footwear.

The best way to prevent an ingrown toenail is to trim nails propTips to remember erly: Cut nails straight across, and file the corners of the nails to match the shape of the toe. Do not let toenails grow too long. If Begin healthy foot-care habits at a young age to avoid problems in a fungus infection develops in a nail, it’s important to consult a the future, and wear the right shoes—it may be one of the most podiatrist or dermatologist because this situation makes it more important ways to avoid foot problems. Wear the right size of likely that the nail will become ingrown. Symptoms of fungal infecshoe and choose the correct shoes for a given activity. And, if a tion include a toenail that has become thicker, discolored, and, foot problem is identified, seek a doctor’s care to keep it from frequently, brittle. Ways to prevent fungal infection include comworsening. mon-sense measures such as drying the feet thoroughly after sweatEditor’s note: After this article was submitted for publication, Gerard ing or bathing, as well as wearing socks and footwear that allow Busch, DPM, unexpectedly passed away. We offer our condolences to the feet to breathe. It’s helpful to wear footwear in wet areas that his family, colleagues, and patients at InStep Foot Clinic in Edina. are frequented by many other people with feet, such as locker rooms, to decrease People with bare the chance of acquiring a fungus. Be sure diabetes are to wash your hands thoroughly and dry them completely after handling a toe that susceptible has a fungal infection, to avoid infecting to foot other toenails or fingernails.

Choose shoes carefully

Foot care should begin at a young age to avoid problems that could cause future pain and disability. It is important for a child to be fitted with proper shoes when he or she first begins to walk, and for people to wear supportive footwear throughout their lifetime. A shoe should fit comfortably and provide adequate support for the foot.

To select the proper shoe, buy one with a firm heel. The shoe should bend where the toes bend; if it bends in the arch, then it may not provide necessary support. Those who participate in sports that expose the feet to a lot of pounding, such as basketball, crosscountry running, or tennis, should make sure their shoes match the activity, since the correct athletic shoe can help the wearer avoid tendonitis and heel pain.

If a foot deformity, such as flat foot, is identified in someone already wearing appropriate shoes, then orthotics should be considered to help control abnormal movement of the foot inside the shoe, which may keep the condition from worsening. Orthotics are inserts that are worn inside the shoes to fine-tune the fit. OTC models are available at most drugstores and should be tried before spending money on a custom-designed model. While OTC orthotics are not covered by insurance, custom-fabricated orthotics, prescribed by a doctor, are covered by many insurance plans. Check your health insurance to see if orthotics are covered before purchasing them.

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27

B E H AV I O R A L H E A L T H

Addiction and the golden years

R

oger is an 82-year-old Korean War veteran.

Military service in his early 20s had a profound, devastating, and lifelong impact on his mental and physical health. Because his military duties were classified and therefore top secret, they were officially “off the books,” making him ineligible for care through federal programs. For some 50 years, Roger suffered anxiety and post-traumatic stress disorder (PTSD). He coped with his panic attacks, anger, irritability, and insomnia by drinking heavily and taking large doses of Xanax, a prescription tranquilizer. By the time he sought treatment for addiction, Roger was in his 70s, and his entire family had been alienated.

Darlene, a 69-year-old woman who lives alone, was having difficulty with balance and thinking clearly. She’d had numerous falls and had trouble remembering commitments and events. She made the rounds of physicians, neurologists, and psychologists, and many

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It’s never too late to find freedom

By Marvin D. Seppala, MD

family members were fooled into thinking that she had early onset dementia. Perhaps she was even fooling herself: The truth is that Darlene’s forgetfulness and frequent falls had largely to do with her hidden alcoholism, a problem that was eventually uncovered by a physician, who referred Darlene to treatment. By that time, most people near to her had been driven away by her inexplicable and baffling behaviors.

Both Roger and Darlene represent a growing trend in our country: an increase in the number of elderly people who suffer from drug and alcohol addiction.

• Seventeen percent of adults over age 60 abuse prescription drugs or alcohol, according to the Center for Substance Abuse Prevention.

• People age 65 and older comprise 13 percent of the population, yet account for more than 33 percent of total outpatient spending on prescription medications in the U. S., according to the National Institute on Drug Abuse.

• The elderly use one quarter of the prescription drugs sold in the U.S., often for problems such as chronic pain, insomnia, and anxiety. The prevalence of prescription medication abuse may be as high as 11 percent, the National Institutes of Health estimates.

• In 2008, an estimated 118,495 emergency room visits involved illicit drug use by older adults, the federal Substance Abuse and Mental Health Services Administration reports.

This problem is large and has the potential to increase. The U.S. Census Bureau reported approximately 40.3 million people age 65 and older in 2010, and that age group is growing.

Reasons for abuse

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MINNESOTA HEALTH CARE NEWS DECEMBER 2012

These statistics, while disturbing, make sense. Older people experience an increasing number of hardships as they age, including the loss of friends and loved ones, loneliness, boredom, physical disabilities, and pain. They frequently have multiple prescriptions, which increases the risk of overdose or misuse, especially when medication is consumed with alcohol. An aging metabolism makes two or three beers at age 65 equivalent to seven or eight beers at age 20. Because of generational differences in attitudes toward mental health care, elders very often have not sought treatment for co-occurring problems such as post-traumatic stress or anxiety and depression.

All of this is compounded by the fact that drug or alcohol abuse in older people is difficult to detect. If an elder lives alone, no one notices if he or she passes out in front of the TV. Because this age

Seventeen percent of adults over age 60 abuse prescription drugs or alcohol. group is typically retired, they don’t have employment problems associated with addiction. If they aren’t driving anymore, they don’t risk exposure by a DWI. And if someone comes to visit, an elder can claim illness as an excuse for not answering the door.

Believe it or not, when the truth surfaces about an older person’s addiction, more than one anguished family member has said to me, “Why bother? How can you teach an old dog new tricks?” Part of the problem is that family members don’t see addiction as a disease; they see it as a choice that their parents or grandparents are making. They don’t realize that the very nature of addiction prevents its sufferers from making rational choices.

Treatment It’s important—and encouraging—to understand the efficacy and benefits of treatment. Older people have the highest recovery rates of all age groups. Benefits include improved cognition, greater social connectedness, and more interest in hobbies and activities. If there is an older person in your life who is suffering from addiction, there is much you can do to help steer that person toward treatment.

• Educate yourself about addiction. Part of understanding includes being able to distinguish between signs of aging and signs of alcohol or drug addiction. Some signs of addiction include losing interest in activities that used to bring pleasure, neglecting personal appearance, increased depression or hostility, and drinking despite warning labels on prescription drugs. To learn more about signs and symptoms, download the free pamphlet “How to Talk to an Older Person who has a Problem with Alcohol or Medications” at www.hazelden.org.

Drug or alcohol abuse in older people is difficult to detect.

Never too late Roger has been sober for 12 years. It was not easy. Because of the heavy doses of tranquilizers he was taking, detox took nearly a month and he suffered post-acute withdrawal for nearly six months afterward. For the first time in his life, with the help of mental health professionals, he was able to disclose his wartime experiences and receive help for PTSD. He’s now involved in a veterans’ group, regularly attends Alcoholics Anonymous meetings, and has reconciled with his family.

Once Darlene was free from alcohol, she recovered her balance and cognition. Though some of her forgetfulness was and is attributable to older age, she does not suffer from early onset dementia.

When people stop drinking or using, they do learn new tricks, and that includes people age 65 and up. Older people deserve the same quality of life as anyone else, and they deserve to enjoy the final years of their lives free from addiction. There are stories to tell, grandchildren to entertain, bicycle trails to try, and sunsets to enjoy.

Marvin D. Seppala, MD, is chief medical officer at Hazelden Foundation and author of “Prescription Painkillers: History, Pharmacology and Treatment” (Hazelden, 2010).

• Consult a professional for evaluation.

Before speaking up, it’s helpful to consult a counselor, psychologist, clergy, social worker, doctor, or other health care professional who is knowledgeable about the needs of older adults.

To prepare, make a list of medications that the elder takes (including over-thecounter medications), write a brief life history of the older adult that includes major life events, and make a list summarizing the elder’s present situation: Can this person live alone? How is drinking or drug use affecting quality

of life? Who are some friends or family members willing to help?

• Get the conversation started. A loving, respectful, and nonjudgmental tone can go a long way when you approach a family elder.

It’s important to avoid stigmatizing, while at the same time being direct and specific. If the elder isn’t ready or the conversation doesn’t go well, don’t despair. You have planted a seed.

I can’t emphasize enough that it’s never too late. Remember Roger and Darlene?

DECEMBER 2012 MINNESOTA HEALTH CARE NEWS

29

PA L L I AT I V E C A R E

Bereavement Moving through grief

By James Heymans, MSW, LICSW

When someone we know dies, we grieve that loss and enter bereavement, the stage where we process and move through grief. Grief is a personal journey, which everyone travels differently and at an individual pace, but there are common features of processing loss.

WHO’S GOT BETTER MOVES ON THE DANCE FLOOR, YOU OR ME? Every day is a reason for a person with Down syndrome to smile. And find joy in things the rest of us often overlook. To learn more about the richness of knowing or raising someone with such an enthusiasm for life, call your local Down syndrome organization. Or visit ndsccenter.org today.

It is the mission of the Down Syndrome Association of Minnesota to provide information, resources and support to individuals with Down syndrome, their families and their communities. We offer a wide range of services, programs and materials at no charge. If you are interested in receiving one of our information packets for new or expectant parents, please email Kathleen@dsamn.org or For more information please call:

(651) 603-0720 • (800) 511-3696 30

MINNESOTA HEALTH CARE NEWS DECEMBER 2012

©2007 National Down Syndrome Congress

Anticipatory grief

for, as this can facilitate meaningful communication.

Bereavement actually begins before our loved one dies, during a 3. “Thank you.” Take time to say thank you for what this person’s stage called anticipatory grief. Here, we anticipate life without that life has given you. It is a good time to share family photos and person. During this stage, communicating with the dying can reduce reminisce. the length of bereavement and the amount of grief associated with 4. “Good-bye. I’ll be okay,” is the hardest thing to say but possibly it. This can be a difficult task but it helps to reduce the degree of the most important, since dying people often need permission to shock after the death, especially if the relationship with the dying let go. Acknowledge that you will grieve but also that family and person has been tenuous or rocky. Making the effort to communifriends will support each other. cate in this stage affords survivors less regret and These four topics help patients and families comresentment after the time for communication has municate things they wish to say before the patient “Good-bye. passed. dies. Family members are encouraged to spend one-onEven if the dying person is unresponsive, comI’ll be okay,” one time with their loved one who is dying, ideally munication is beneficial in two ways. First, even while the patient can still verbalize what he or she is the hardest though the dying person may not respond, we are would like to say. thing to say never sure what they hear and experience. It is said Hospice that the last sensations to go are touch and hearing, but possibly Sometimes, part of the bereavement process takes so simply holding the patient’s hand, stroking their the most place while the patient is in a hospice program. This arm, or telling them about your day may comfort is a setting in which pain is aggressively treated so the them and you. Second, communicating with the important. patient is able to focus on what he or she wishes to dying allows survivors to say what needs to be said. do before death.

The regret of not having said anything important Hospice is a philosophy of health care that can intensify survivor grief after the person dies. provides care and support for people facing life-limiting Communicating with the dying illness. It regards dying as a normal process and neither Some patients will not discuss dying, which is their hastens nor postpones it. Instead, it offers physical, right. We can communicate in other ways by just emotional, and spiritual support to patients and their being present—reading to them or keeping them Bereavement to page 32 company, for example—or by partnering in their activities.

Others talk openly about dying, which helps survivors know what the dying person’s wishes are. This is a good time to reminisce, complete undone business, and plan. Planning includes hearing what their hopes are for others. This can be challenging, since survivors may not be comfortable discussing dying.

Some people who are dying begin to see or hear things we cannot.

Bereavement Asking them, “What do you see or actually begins hear?” or, “What are you more aware of now?” can help them feel more at before our ease. They may or may not be able to loved one dies. share with us, but it’s important to affirm their experiences even if they don’t seem rational to us.

In the next issue..

Four gifts Four topics that can be discussed any time during someone’s life become almost imperative to discuss when someone is dying, and can serve as gifts to all parties in the discussion.

1. The survivor asks if there is “anything that I have done to hurt you,” and says, “I am sorry, please forgive me.” This creates an opportunity to settle misunderstandings by sharing thoughts, forgiveness, and reconciliation. It also affords the dying person the chance to say the same thing.

• Shingles • CPR • Beta-blockers

2. “I love you” may be difficult to say when there is conflict in the relationship, but I encourage people to find something about the dying person or the relationship with him or her to be grateful DECEMBER 2012 MINNESOTA HEALTH CARE NEWS

31

These 13 months of support and education are provided to a member of the patient’s family who has been identified as bereaved by the interdisciplinary team and the patient’s caregivers. This support period includes mailings, phone calls, and support groups, and is provided in the bereaved survivor’s residence. In addition, a bereaved survivor may request bereavement services for other family members, including children. Also during this period, hospice staff provides referrals to therapists and other supports that survivors can use after the 13 Medicare-funded months have ended.

Bereavement from page 31

families. Hospice services are provided by an interdisciplinary team of nurse case manager, social worker, spiritual care provider, aide, and volunteer.

How does someone access hospice care? The patient’s physician must order it. To be eligible for hospice, the patient’s referring doctor provides a diagnosis of terminal illness that has a life expectancy of six months or less if the disease follows its normal course.

How much does it cost? Hospice is a Medicare benefit reimbursed at a per diem (daily) rate. It covers medications and treatments related to the terminal illness, durable medical equipment, and acute or respite care if needed. Hospice The survivor’s is provided in the patient’s residence: home, nursing home, assisted living, group home, task ... is to or prison. establish a Medicare also provides support and education before the patient’s death for new normal. those experiencing anticipatory grief, whether they are children, teenagers, or adults. Bereavement support services used before the time of death do not count toward the 13 months of Medicare-reimbursed bereavement support services that start at the time of death.

After death The survivor’s task during this stage is to establish a new normal. The relative ease and speed with which survivors accomplish this is directly affected by the quality of communication they had with the dying person.

Some say the first year after a loved one dies is the hardest; some say the second.

It is individual.

At some point in time there will be a new normal, and survivors will be okay.

James Heymans, MSW, LICSW (licensed independent clinical social worker), is social services manager for HealthEast Care System Hospice and a therapist who practices at River City Clinic, St. Paul.

Minnesota

Health Care Consumer November survey results ...

Association

Each month, members of the Minnesota Health Care Consumer Association are invited to participate in a survey that measures opinions around topics that affect our health-care delivery system. There is no charge to join the association, and everyone is invited.

For more information, please visit www.mnhcca.org. We are pleased to present the results of the November survey.

3. How often does your employer communicate with you about improving your health?

40

33.3% Percentage of total responses

Percentage of total responses

25 20

16.7%

16.7%

15 10 5

50 40 30 20 11.1%

11.1% 5.6% Weekly

Monthly

Weekly

Monthly

Quarterly Annually

27.8%

25 20 15 10 2.8% 0.0%

0

Never

Weekly

MINNESOTA HEALTH CARE NEWS DECEMBER 2012

Quarterly Annually

Never

38.9%

40 35

40 30 20

16.7%

19.4% 13.9%

10

30

27.8%

25 20

19.4%

15 8.3%

10

5.6%

5 Never

Monthly

5. How interested would you be in receiving more of this kind of communication if it were customized to your personal health status?

50.0%

5.6% Quarterly Annually

33.3%

30

5

0.0%

0

Percentage of total responses

60

36.1%

35

66.6% Percentage of total responses

Percentage of total responses

32

33.3%

50

70

0

35

2. How often does your doctor’s office communicate with you about improving your health?

30

4. How useful do you find this communication?

80

10

1. How often does your health insurance company communicate with you about improving your health?

0

0.0% Very useful

Useful

No Somewhat Not at all opinion useful useful

0

Very Interested interested

No Somewhat Not interested opinion interested at all

Minnesota

Health Care Consumer Association

Welcome to your opportunity to be heard in debates and discussions that shape the future of health care policy. There is no cost to join and all you need to become a member is access to the Internet.

SM

Members receive a free monthly electronic newsletter and the opportunity to participate in consumer opinion surveys.

www.mnhcca.org

Join now.

“A way for you to make a difference�

DECEMBER 2012 MINNESOTA HEALTH CARE NEWS

33

Winter safety from page 13

• Remove outdoor lights carefully. Never yank them.

• Plug outdoor lights and decorations only into circuits with ground fault interrupters (GFIs).

Everyday risks Hypothermia. Exposure to extreme cold can cause hypothermia, meaning your body temperature drops below 95°F and you’re at high risk of death. Survivors frequently have liver, kidney, and pancreas problems. Signs of hypothermia include drowsiness, disorientation, delirium, incoherence, and severe shivering. This is a lifethreatening condition. Seek medical attention immediately!

Frostbite. Being outside in the winter can also produce frostbite, or freezing of the skin, which deprives skin of oxygen and nutrients.

Areas most susceptible are the ears, nose, hands, and feet.

Symptoms include progressive numbness of the area, a tingling or burning sensation, and a change in skin color to red or white-purple. If not treated promptly, frostbite can result in infection and, sometimes, amputation. If you suspect frostbite, get out of the cold and re-warm the affected area by immersing it in warm water. Do not rub frostbitten skin; this could destroy already damaged tissue.

To avoid hypothermia and frostbite, dress in layers and be aware of wind chill. Wind chill is a measure of how the combination of cold temperature and wind feels to exposed skin. Avoid cotton clothing because it gets wet easily and doesn’t maintain warmth. Wool and other fabrics (especially waterproof ones) designed specifically for the cold weather are better. Masks can warm the cold air you breathe, making you feel warmer and reducing breathing difficulties.

Blisters. The combination of wet socks and friction from activity can cause blisters on toes, feet, and heels. Most require only a simple bandage to heal, but if a blister turns red or oozes greenish fluid, see your physician.

Sunburn. Wear sunscreen and sunglasses. The sun can burn in the winter, especially when reflected off snow. Sunburned eyes can be painful, watery, and produce temporarily blurred vision. See your physician if you have these symptoms.

Slipping. To prevent broken bones, sprains, and head injuries, put salt on ice, install handrails along steps, and keep walking paths clear and well lit at night.

Scott Benson, MD, is a board-certified family medicine physician at the Apple Valley Medical Center.

The American Heart Association suggests a check-up prior to the first anticipated snowfall.

Chemical dependency in older adults is hard to recognize We help them live a healthier life Alcohol and drug abuse by seniors often goes unnoticed because of isolation and loneliness. As a result, the older adult continues to suffer in silence.

Senior Helping Hands is a program of St. Cloud Hospital Recovery Plus and a recognized national leader providing support and services to stop the suffering.

Senior Helping Hands serves individuals age 55 and older.

Services • Outreach service and consultation with family or concerned persons • Evaluation and assessment for chemical dependency and/or mental health issues completed by qualified professionals • Volunteer support for older adults who are chemically dependent • Support from peer volunteer counselors for older adults with mental health issues Programs Older Adult Chemical Dependency Primary Treatment Program A comprehensive program that involves physical/psychosocial/chemical use assessments performed by professionals trained in chemical dependency and mental health, including a full time Medical Director who is an addictionist.

The program provides a slow pace, holistic approach to recovery. Transportation and temporary housing are available if needed.

Contact Us 713 Anderson Ave., St. Cloud, MN 56303 (320) 229-3762 • (800) 742-HELP toll-free www.centracare.com (Search: Senior Helping Hands)

34

MINNESOTA HEALTH CARE NEWS DECEMBER 2012

• Serious low blood sugar (hypoglycemia) may occur when Victoza® is used with other diabetes medications called sulfonylureas. This risk can be reduced by lowering the dose of the sulfonylurea.

Important Patient Information This is a BRIEF SUMMARY of important information about Victoza®. This information does not take the place of talking with your doctor about your medical condition or your treatment. If you have any questions about Victoza®, ask your doctor. Only your doctor can determine if Victoza® is right for you.

WARNING During the drug testing process, the medicine in Victoza® caused rats and mice to develop tumors of the thyroid gland. Some of these tumors were cancers. It is not known if Victoza® will cause thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people. If MTC occurs, it may lead to death if not detected and treated early. Do not take Victoza® if you or any of your family members have MTC, or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).

This is a disease where people have tumors in more than one gland in the body.

What is Victoza® used for?

• Victoza® is a glucagon-like-peptide-1 (GLP-1) receptor agonist used to improve blood sugar (glucose) control in adults with type 2 diabetes mellitus, when used with a diet and exercise program.

• Victoza® should not be used as the first choice of medicine for treating diabetes.

• Victoza® has not been studied in enough people with a history of pancreatitis (inflammation of the pancreas).

Therefore, it should be used with care in these patients.

• Victoza is not for use in people with type 1 diabetes mellitus or people with diabetic ketoacidosis. ®

• It is not known if Victoza® is safe and effective when used with insulin.

Who should not use Victoza®?

• Victoza should not be used in people with a personal or family history of MTC or in patients with MEN 2. ®

• Victoza® may cause nausea, vomiting, or diarrhea leading to the loss of fluids (dehydration). Dehydration may cause kidney failure. This can happen in people who may have never had kidney problems before. Drinking plenty of fluids may reduce your chance of dehydration.

• Like all other diabetes medications, Victoza® has not been shown to decrease the risk of large blood vessel disease (i.e. heart attacks and strokes).

What are the side effects of Victoza®?

• Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath while taking Victoza®. These may be symptoms of thyroid cancer.

• The most common side effects, reported in at least 5% of people treated with Victoza® and occurring more commonly than people treated with a placebo (a non-active injection used to study drugs in clinical trials) are headache, nausea, and diarrhea.

• Immune system related reactions, including hives, were more common in people treated with Victoza® (0.8%) compared to people treated with other diabetes drugs (0.4%) in clinical trials.

• This listing of side effects is not complete. Your health care professional can discuss with you a more complete list of side effects that may occur when using Victoza®.

What should I know about taking Victoza® with other medications?

• Victoza® slows emptying of your stomach. This may impact how your body absorbs other drugs that are taken by mouth at the same time.

Can Victoza® be used in children?

• Victoza® has not been studied in people below 18 years of age.

Can Victoza® be used in people with kidney or liver problems?

• Victoza® should be used with caution in these types of people.

Still have questions?

What is the most important information I should know about Victoza®?

• In animal studies, Victoza® caused thyroid tumors. The effects in humans are unknown. People who use Victoza® should be counseled on the risk of MTC and symptoms of thyroid cancer.

• In clinical trials, there were more cases of pancreatitis in people treated with Victoza® compared to people treated with other diabetes drugs. If pancreatitis is suspected, Victoza® and other potentially suspect drugs should be discontinued. Victoza® should not be restarted if pancreatitis is confirmed. Victoza® should be used with caution in people with a history of pancreatitis.

This is only a summary of important information. Ask your doctor for more complete product information, or • call 1-877-4VICTOZA (1-877-484-2869) • visit victoza.com Victoza® is a registered trademark of Novo Nordisk A/S. Date of Issue: May 2011 Version 3 ©2011 Novo Nordisk 140517-R3 June 2011

FOR TYPE 2 DIABETES

Victoza® helped me take my blood sugar down…

and changed how I manage my type 2 diabetes.

Victoza® helps lower blood sugar when it is high by targeting important cells in your pancreas—called beta cells.

While not a weight-loss product, Victoza® may help you lose some weight.

And Victoza® is used once a day anytime, with or without food, along with eating right and staying active.

Model is used for illustrative purposes only.

Indications and Usage: Victoza® is an injectable prescription medicine that may improve blood sugar (glucose) in adults with type 2 diabetes when used along with diet and exercise.

Victoza® is not recommended as the first medication to treat diabetes. Victoza® is not insulin and has not been studied in combination with insulin. Victoza® is not for people with type 1 diabetes or people with diabetic ketoacidosis.

It is not known if Victoza® is safe and effective in children. Victoza® is not recommended for use in children.

Important Safety Information: In animal studies, Victoza® caused thyroid tumors—including thyroid cancer—in some rats and mice. It is not known whether Victoza® causes thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people which may be fatal if not detected and treated early. Do not use Victoza® if you or any of your family members have a history of MTC or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). While taking Victoza®, tell your doctor if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer.

Inflammation of the pancreas (pancreatitis) may be severe and lead to death. Before taking Victoza®, tell your doctor if you have had pancreatitis, gallstones, a history of alcoholism,

If you’re ready for a change, talk to your doctor about Victoza® today.

or high blood triglyceride levels since these medical conditions make you more likely to get pancreatitis.

Stop taking Victoza® and call your doctor right away if you have pain in your stomach area that is severe and will not go away, occurs with or without vomiting, or is felt going from your stomach area through to your back. These may be symptoms of pancreatitis.

Before using Victoza ®, tell your doctor about all the medicines you take, especially sulfonylurea medicines or insulin, as taking them with Victoza® may affect how each medicine works.

Also tell your doctor if you are allergic to any of the ingredients in Victoza®; have severe stomach problems such as slowed emptying of your stomach (gastroparesis) or problems with digesting food; have or have had kidney or liver problems; have any other medical conditions; are pregnant or plan to become pregnant. Tell your doctor if you are breastfeeding or plan to breastfeed.

It is unknown if Victoza® will harm your unborn baby or if Victoza® passes into your breast milk.

Your risk for getting hypoglycemia, or low blood sugar, is higher if you take Victoza® with another medicine that can cause low blood sugar, such as a sulfonylurea. The dose of your sulfonylurea medicine may need to be lowered while taking Victoza®.

Victoza® may cause nausea, vomiting, or diarrhea leading to dehydration, which may cause kidney failure. This can happen in people who have never had kidney problems before.

Drinking plenty of fluids may reduce your chance of dehydration.

The most common side effects with Victoza® include headache, nausea, and diarrhea. Nausea is most common when first starting Victoza®, but decreases over time in most people. Immune system-related reactions, including hives, were more common in people treated with Victoza® compared to people treated with other diabetes drugs in medical studies.

Please see Brief Summary of Important Patient Information on next page.

If you need assistance with prescription drug costs, help may be available. Visit pparx.org or call 1-888-4PPA-NOW. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit fda.gov/medwatch or call 1-800-FDA-1088.

Victoza® is a registered trademark of Novo Nordisk A/S. © 2011 Novo Nordisk 0611-00003312-1 August 2011

To learn more, visit victoza.com or call 1-877-4-VICTOZA (1-877-484-2869).

Non-insulin • Once-daily