Benefits of Dogs

Healthier Living

Most people know that people who own dogs live longer, have lower blood pressure, less anxiety and better immune systems.  They also have more social interactions, Alzheimer’s patients with dogs in the home have fewer outbursts and men with dogs have lower triglycerides and cholesterol.  These are the scientific conclusions of research about family pets that can be easily found. 

But there are even more benefits and some of them are pretty astounding.  Dogs are being trained to assist in the medical field.  For instance, dogs can be trained to sniff out low blood sugar in diabetics, picking up odors beyond human capacity.  Dogs can also be taught to prod the diabetic with a cold nose, fetch a blood glucose testing equipment or press a phone button that calls 911.

It could be scent or it could be a subtle change in behavior, but some dogs are able to sense a seizure coming on as much as 30 minutes before it occurs.  This means the dog may be able to alert the person, go for help, move objects out of the way and lay down next the person during the seizure.

More and more people with post traumatic stress disorders, such as soldiers returning from war zones, are benefiting from dogs as companions because they can they can ease anxiety in a number of ways.

Dogs also have the remarkable ability to detect certain kinds of cancers.  One example is being able to reveal the presence of bladder or prostate cancer cells in urine.  Some researchers have shown that dogs can recognize lung and breast cancers by smelling the patient’s breath, and they can spot melanoma by licking a person’s skin.

A dog’s brain may be only one tenth the size of a human’s, but his nose more than makes up for it: dogs have 40 times as many scent receptors as humans.  It is truer than ever that dogs really are man’s best friend. 

References: My Health News Daily; Web MD.

This article was originally published in Pathways Residential Care Journal - Issue 4.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Documenting and Billing for Care Plan Oversight

Home Health & Hospice

There is one service that is not face-to-face that physicians can be reimbursed for by Medicare—care plan oversight (CPO) of patients receiving home health or hospice.  Because the rules are complicated, many physicians simply don’t bill for this service.  Here we’ll try to break it down.  
To bill, CPO services must take at least 30 minutes in a calendar month. The services do not need to be provided on the same day, but the total services over the course of a month must add up to at least half an hour.  Medicare uses two HCPCS codes to pay for CPO:  G0181 is for home health, and G0182 is for hospice. 

YOU CAN BILL FOR TIME SPENT:

• Reviewing charts, reports and treatment plans
• Reviewing diagnostic studies that weren’t associated with a face-to-face encounter
• Phone calls with other health care professionals involved in the patient’s care who are not employees of the practice
• Conducting team conferences
• Discussing drug treatment and interactions (not routine prescription renewals) with a pharmacist
• Coordinating care if physician or non-physician practitioner time is required
• Making and implementing changes to the treatment plan

YOU MAY NOT BILL FOR THE TIME YOU SPEND:

• Renewing prescriptions
• Talking with fellow employees at the practice
• Travel time
• Preparing or submitting claims
• Talking to the patient’s family, even if discussing treatment plan changes
• Holding informal consults with physicians who are not treating the patient
• Working on discharge services
• Interpreting test results at an E/M visit

GOOD HABITS

• Keep a log of the patients you provide CPO to; use this as a reminder to pull those charts at the end of the month. 
• Keep a simple CPO log in each of these charts and document the date, total time and a brief description of the services as you provide.  Sign this documentation.
• At month end gather the logs, total the time and bill for those for whom you provided at least 30 minutes of CPO.  Put the beginning and end dates of the month as the dates of service and be sure to put the provider number of the home health agency or hospice on the claim form.

For more information or questions, or to receive written materials about billing for care plan oversight, call Kaye Holbrook at 408.773.4359 or email your request to kholbrook@pathwayshealth.org.

This article was originally published in Pathways Physician & Health Professional Bulletin - Issue 24.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Selecting & Using a Cane

When a resident has limitations in balance, joint motion, coordination or strength, a cane can sometimes be a useful tool in restoring mobility.  The first key is having the right ambulation aid for the user’s needs and abilities.  The second is gait training to achieve the safest walking pattern.

Considerations

The resident’s vision, balance and stability need to be considered, as well as his or her ability to learn new things and use good judgment.  If a cane is the right aid for the resident, it can provide support, balance, stability, safety, independence and relieve stress on the legs and feet.

A quad cane with four feet is the appropriate choice for a resident who is weaker on one side than another, such as after a stroke.

Measuring

Here’s one way to determine the right height for the cane:  Turn it upside down with the handle on the floor.  With the resident’s arms at his side the tip of the can should be level with the wrist.  Wooden canes can be shortened by removing the rubber tip and cutting with a saw.  Aluminum canes have holes and pins to adjust height by the inch; there are extenders for very tall people. 

Using a Cane

To use a cane, the resident should hold it on his or her stronger side.  When walking, the resident should move the cane and the weaker leg together.  When climbing up stairs, the resident should first step up with the stronger leg, then push to move the cane and the weaker leg up.  To go down stairs, the resident should first step down with the weaker leg and the cane.  Then, using the cane for support, he or she can lower the stronger leg down.

Great Catheter Care: Preventing Infections

Good catheter care is the biggest factor in preventing catheter-associated urinary tract infections.  Here are some tips for great catheter care.

• Wash your hands.  It sounds simple, but this is the single most important step in preventing infections.  Wash your hands BEFORE and AFTER putting on gloves.
• Use catheters sparingly—only when necessary.
• Use the smallest catheter that will do the job.
• When inserting the catheter, lay out a sterile field and maintain it.  If a person is obese or has contractures you may need two people to insert the catheter while maintaining a sterile field.
• Lubricate the tip of the catheter to prevent damage to the urethra during insertion.
• Use good lighting.  If you accidentally insert the catheter in the vagina, leave it there as a marker until you have placed a second, sterile catheter.
• Keep the system (catheter, tubing and bag) closed if possible.  The system should never be opened simply for convenience.
• Keep the drainage bag below the level of the bladder (but not lying on the floor).  Use clean technique when emptying the bag.
• Secure the catheter to prevent bleeding, trauma, tissue damage or bladder spasms that can be triggered by the catheter or balloon.  Tape can be hard on the skin; use a commercial device when possible.
• Keep the perineum clean.  Treat the catheter area like any other part of the body, washing as you would any other body part.
• If the resident is also incontinent of stool, check frequently to prevent stool from contaminating the catheter.
• Keep residents with catheters away from residents with infections.

Suspected infection:

If you suspect a urinary tract infection, remove the catheter and replace it with a new one.  Get a urine sample for culture and sensitivity from the new catheter.  Antibiotics should only be used for infections that are symptomatic.

Leakage

If catheter leakage occurs, check that the balloon is inflated and that the catheter is in the right place.  Make sure the balloon is inflated completely.  It is never acceptable to use a 30 cc balloon partially inflated.  Before changing to a larger catheter, keep in mind that constipation and fecal impaction may also contribute to leakage.  Larger catheters with larger balloons can damage the neck of the bladder.

YOU are the key to good catheter care that can prevent infections and discomfort, and save time and money.

Music Can Mean Less Pain

Focusing on music can distract people who have significant anxiety about pain enough that they feel the pain less acutely, according to a recent study done at the University of Utah Pain Research Center.  The study found that pain was reduced as the demands of focusing on the task rose.

Researchers had 153 volunteers concentrate on following a melody so they could identify the tones that stood out.  During the session small pain shocks were administered through fingertip electrodes.  The authors explained that the effects of the music resulted from competition with the participants’ pain pathways.

Interestingly, those who had registered the most anxiety about pain became more absorbed in the task and were more likely to experience reduced perception of pain.  The study authors suggested that, “Clinicians should consider patients’ personality characteristics when recommending behavioral interventions like music listening for pain relief.”

Pathways has volunteers that can provide music sessions to our hospice patients as part of our Integrative Therapies program of care for body and soul.

The results were published in the December, 2011 issue of the Journal of Pain.

Meds That Cause ER Visits

Four Culprits

Just four drugs and drug classes cause two thirds of the 100,000 annual emergency room visits for drug reactions in the elderly, according to recent research.  At the top of the list is warfarin (also known as Coumadin); it alone accounted for one third of the visits.  The other categories are insulins, oral hypoglycemic agents and oral antiplatelet medications.

With antiplatelet or blood thinning drugs, bleeding was the main problem. For insulin and other diabetes medications, about two-thirds of cases involved changes in mental status such as confusion, loss of consciousness or seizures.

Some of the common denominators in these drugs are that: they are commonly prescribed; there is a fine line between the therapeutic dose and a dangerous one; and they can all be difficult to use.  The researchers made note that none of the medications that were culprits were drugs that were labeled “high risk” for older adults, although some over-the-counter drugs like Benedryl are.

“Of the thousands of medications available to older patients, a small group of blood thinners and diabetes medications caused a high proportion of emergency hospitalizations for adverse drug events among elderly Americans,” said lead study author Dr. Daniel Budnitz of the Centers for Disease Control and Prevention (CDC). 

“We weren’t so surprised at the particular drugs that were involved,” Budnitz said. “But we were surprised how many of the emergency hospitalizations were due to such a relatively small number of these drugs.”

It is estimated that hospitalizations for accidental overdoses and adverse side effects are likely to increase as Americans live longer and the senior population grows.  Currently 40% of people older than 65 take five to nine medications; 18% take 10 or more.

Researchers at CDC published the study in the Nov. 24, 2011 New England Journal of Medicine.

How Morphine Can Help in Heart Failure at the End of Life

Morphine is most often used as a pain reliever.  But for heart patients, it is often used for shortness of breath.  There are several ways that morphine interrupts the cycle of breathlessness.

• Morphine lowers the breathing rate in the brain’s respiratory center. This means the heart doesn’t have to work so hard to supply blood to the chest muscles for breathing.  It reduces excessive breathing drive.
• Morphine widens blood vessels in the arms and legs.  Pooling blood in the extremities reduces the amount of blood that returns to the heart.  This means the heart doesn’t have to pump as often—it can rest more.  When the heart doesn’t have to pump so hard, it also needs less oxygen—so the resident doesn’t have to breathe as hard.
• It eases anxiety, and when a resident is less anxious, he or she will breathe more calmly.  If you breathe more slowly, you are less anxious.
• When we are in pain, we tend to breathe faster and harder.  So relieving pain also reduces respiratory rate.

Used correctly, morphine is safe.  Addiction is very, very rare.  The chance of becoming addicted is so small that it is considered unethical to withhold morphine because of a fear of addiction.

But if we don’t know how opioids like morphine, fentanyl, Vicodin or Dilaudid work, we may mistake initial responses.  If an opiod is new to a person, he or she may be sleepy for the first 2 or 3 days—especially if they have not been sleeping well (maybe because of shortness of breath or pain).  When symptoms are relieved, the resident may want to “catch up” on sleep.  After a few days, the sleepiness wears off.

At the end of life, morphine is the most important medicine for providing comfort to heart patients.  It reduces the breathless feeling that can be so frightening to people at the end of life.

Antidepressants in Dementia

As many as 20% of patients with dementia may also have depression.  The usual treatment is a selective serotonin reuptake inhibitor or a noradrenergic and specific serotonergic antidepressant.  But some research has questioned the effectiveness of these treatments.

In a study published in The Lancet, (volume 378, Issue 9789, pages 403 - 411, 30 July 2011), Sube Banerjee MD, a London-based expert in old age psychiatry, and his colleagues concluded that because there was an absence of benefit compared with placebo and increased risk of adverse events, the practice of using these antidepressants should be reevaluated.

“Depression is one of the most important co-morbidities in dementia.  It is a source of great distress yet the treatments we use are not proven,” said Dr. Banerjee.

In their parallel-group, double-blind, placebo-controlled study of more than 326 patients with Alzheimer’s dementia, decreases in depression scores at 13 and 39 weeks did not differ between 111 controls and 107 participants allocated to receive sertraline (Zoloft) or 108 who received mirtazapine (Remeron).

“I am surprised by just how unequivocal our findings are,” said lead author Banerjee, professor of mental health and aging at King’s College London, Institute of Psychiatry, United Kingdom.  “The present practice of use of these antidepressants with usual care for first-line treatment of depression in Alzheimer’s disease should be reconsidered,” write the authors.

“The message is to think before using antidepressants for depression in dementia.  It may well be that these symptoms will resolve with the problem-solving and information-giving that is implicit in good-quality dementia care,” added Dr. Banerjee. The investigators suggest that antidepressants be reserved for “individuals whose depression has not resolved within 3 months of referral, apart from those in whom drug treatment is indicated by risk or extreme severity.”

Funding for this study was provided by the UK National Institute of Health Research HTA Programme.

Discussing Goals of Care with Very Ill Patients

“Words matter. What clinicians say and how they say it hugely affect patients. Communicating about emotionally and medically complex topics such as advance care planning, preferences for care, prognosis, and death and dying is challenging,”   Steve Pantilat, MD, Professor of Clinical Medicine and Director of the Palliative Care Unit at UCSF wrote in a 2009 JAMA article.

Pantilat recently spoke to an audience of more than 100 physicians and other health care professionals at a Nov. 29 ethics conference held at El Camino Hospital in Mountain View on “Better Words to Say: Communicating with the Very Ill Patient.”

“It’s not about the patient’s willingness to have this kind of conversation, but about [physicians’] willingness to have the conversation,” said Pantilat.
 
Discussing end-of-life issues with patients is not associated with depression, sadness, terror or worry according to research done by Wright and published in JAMA.  In fact, this sort of conversation leads to better quality of life, fewer invasive interventions and better outcomes for caregivers.  But how do we go about having the conversation?  Here are some of the highlights of that talk and some useful approaches Steve Pantilat has learned over the years.

Ask open-ended questions to establish what the patient and family know.
 
Examples of questions he asks are: “When you think about what lies ahead, what worries you the most?” and “When you think about the future, what do you hope for?”
 
The answers to these questions may be very different than you anticipated and may guide care decisions.  For instance, if a patient says he wants to have chemotherapy and visit his home town, the physician may recognize that the visit may not be feasible after chemotherapy, and that if it will not significantly change the outcome of the disease, perhaps the patient should take the trip first.

Listen and sit down.
 
Pantilat referred to a well known study done in the 1970s that demonstrated that patients perceived their physicians’ visits to be much longer than they actually were when the physician sat down to talk with them.

Pantilat suggests that physicians listen for at least two minutes before talking (which he admits may seem interminable at the time).  He emphasizes the value of not interrupting since most important things don’t come out at the very beginning of a conversation.

Avoid jargon, use simple language and check understanding.
 
Patients will often nod as though they understand although they are clueless to the meaning of what you are saying.  Pantilat says that the answer is usually “No” to the question “Do you have any questions?”  But he has noticed a distinct difference when he subtly rewords the question to say “What questions do you have?”

“Accuracy is not critical,” said Pantilat.  Patients and families don’t need to know an exact prognosis, but they do need a realistic frame of reference.  He suggests using ranges such as “hours to days,” “days to weeks,” or “weeks to months.”  One person may interpret “not long” as days while another may think it refers to a year.

Offer a prognosis. 

“False hope is not hope because it is not based in reality,” said Pantilat, reminding his audience of the research published in the NEJM that found that TV patients had a 79% rate of survival with quality life after CPR, whereas in real life the numbers are far grimmer.  The problem is that the public gets its information from television.
 
Discuss death explicitly.
 
Talking about death can be a great relief, says Pantilat.  He suggests practicing difficult conversations and in this setting suggests phrasing such as, “Many patients with lung cancer tell me they think about the possibility of dying.  They have questions about this.  How about you?”

Remain sensitive to the patient’s culture.
 
Pantilat cautioned about assuming all persons of a particular culture have similar beliefs and suggests the solution lies in asking, “In your family how do you make medical decisions?”  His experience has told him that patients often know much more than physicians or families realize.   Although they may never have been spoken to directly about their disease, the visits to a cancer center, increasing treatment, arrival of family members from afar and a host of other clues tell them about their condition.

Pantilat does caution that we should always ask how much the patient wants to know, regardless of what the family has said.  To be sensitive he often asks, “I have information about your condition.  Some patients want to know the details, others prefer to have me talk to someone else.  How do you feel?”

Use better words.
 
There is never a time when it is appropriate to say, “There is nothing more we can do.”  Pantilat suggests instead, “There is no more we can do to cure your disease.”  And rather than arguing with family members about the futility of treatments, Pantilat likes to put himself on their side by saying, “I wish there was something we could do to make your cancer go away.”

Ask helpful questions.

Questions such as, “Would you like us to do everything possible?” are not helpful and will always be answered “Yes.” However, “everything” may mean all possible curative medical treatments to the physician, while the family interprets it to mean all possible efforts aimed at keeping their loved one comfortable.  Pantilat finds it clarifying in this situation to ask, “How were you hoping we could help?”

Be aware of your non-verbal communication.
 
Asking someone if they have any other questions while your hand is on the door sends a loud message and the answer will usually be, “No.”

Pantilat concluded by acknowledging that this process is usually more than one conversation and that physicians should share the responsibility with others such as the palliative care team, social workers, and chaplains.  Discussions about goals of care are good for patients and families: Use better words.

A Quick Review of COPD

A Progressive Disease

Chronic Obstructive Pulmonary Disease is a lung disease that causes a blockage or narrowing of the airways.  This results in decreased ability to move air in and out of the lungs. The disease has a slow, progressive course and is irreversible.

Statistics

COPD is the 4th leading cause of death in the US: 120,000 Americans annually.  It is expected that by 2020, COPD will become the 3rd leading cause of death worldwide.  Men are more likely to have COPD than women, and it usually occurs in those over 40 years old.

Types

There are three types of COPD and all of them require the patient to work very hard at breathing.

• Emphysema: Air sacs (alveoli) of the lungs are damaged and enlarged.  This reduces the amount of surface area for the exchange of oxygen and carbon dioxide.  Less oxygen can move into the body and less carbon dioxide can be expelled.
• Chronic Bronchitis: Inflammation of the bronchial tubes which can cause them to swell.  This can leave less room for air movement.
• Bronchiectasis: Permanent widening of the large air tubes which begin at the bottom of the trachea and branch into the lungs.

Causes

The most significant risk factor is, of course, smoking.  The American Lung Association estimates that 80% to 90% of people diagnosed with COPD are chronic smokers.  Secondhand smoke is also a major factor, causing 3,400 lung-related deaths annually.  Research also shows a link between air pollution and work-related exposure, such as coal mine dust, silica, cotton and grain dust.

Symptoms

Most symptoms include: breathlessness with any activity, chronic cough, increased sputum production, wheezing, chest tightness and frequent chest infections.

Other signs and symptoms may include swelling, weight gain and obesity, (which may be a side effect of medication therapy), a round barrel chest, coughing blood, and cyanosis (bluish coloring often seen around the mouth).

Diagnostic Testing

To make a diagnosis of COPD, a complete assessment must be taken including family history, environmental and occupational exposure and smoking history. Additional tests may include:

• Blood work such as arterial blood gases, hemoglobin and hematocrit levels
• Chest x-ray
• Pulmonary function tests
• Bronchoscopy
• Pulse oximetry

Treatment

The main treatments for COPD include medications (bronchodilators, expectorants, antibiotics and corticosteroids), oxygen therapy, pulmonary rehabilitation, and at the end of life, morphine to ease shortness of breath.

Combating Fatigue in Cancer

Pilot Study

A team of researchers from Australia and New Zealand conducted a small pilot study to help determine an appropriate dose of methylphenidate hydrochloride, a central nervous system stimulant, to treat fatigue in patients with advanced cancer.

They reported in Journal of Palliative Medicine that 5 mg twice daily would be an appropriate dose to test in a definitive study. Ten patients provided consent.

After a three-day assessment, patients received titrated methylphenidate hydrochloride at doses ranging from 5 mg a day to 15mg twice a day. Nine patients completed eight days and five received the maximum dose at day 15. Three patients were satisfied with the results at a lower dose and were not willing to increase it.

The team noted a pattern of rapidly improving fatigue and depression at 5 mg twice daily.

Journal of Palliative Medicine, Volume 13, Number 10, Oct. 2010

Care at Home vs. Hospitalization

Home Fares Better for Heart Failure Patients

Hospitalization, the standard venue for short-term medical care, may be hazardous for the elderly according to a study reported in the Archives of Internal Medicine in September, 2009.*  The study evaluated the feasibility and effectiveness of physician-managed home care for selected patients with acute decompensation of chronic heart failure.  The prospective, single-blind, randomized trial followed patients 75 years or older who had been hospitalized.  They were randomly assigned to a Geriatric Home Hospitalization Service or a general medical ward.

Overall Improved Status

Findings demonstrated no significant difference in the number of deaths or subsequent hospitalizations, but the mean time until the first additional admission was longer for the patients cared for in their own homes.  Only the home patients experienced improvements in depression, nutritional status and quality-of-life scores.

The research concluded that home care is a viable alternative to traditional hospital inpatient care for elderly patients with acutely decompensated CHF.
  
*Arch Intern Med. 2009 Sep 28;169(17):1569-75.

For more information about Pathways Home Health services for patients with chronic heart failure, please visit www.pathwayshealth.org/home-health.

Research Confirms Many Live Longer with Hospice and Palliative Care

Higher Quality of Life Reported By Palliative Care Patients, Study Reports

A recent study published in the New England Journal of Medicine found that among patients with non-small-cell lung cancer, those who received palliative care lived, on average, almost two months longer than those who received standard care. Researchers also found that the patients receiving palliative care reported a higher quality of life through the final course of their illness.

They also found that when patients received palliative care services, they were more likely to elect hospice services. "With earlier referral to a hospice program, patients may receive care that results in better management of symptoms, leading to stabilization of their condition and prolonged survival," wrote the authors of the study released August 18, 2010. 

Pathways Provides Palliative Care

Pathways has a unique and vibrant Palliative Care program that is provided through Home Health. The criteria are that the patient has a prognosis of 12 months or less, has a skilled need (such as symptom management), and that he or she finds leaving home a considerable and taxing effort. (Patients may occasionally visit the barber, attend a special event, go for a drive or attend religious services and still be considered homebound, thus meeting the CMS criteria.) Patients may be receiving active, curative treatment simultaneously with Palliative Care. 

“There’s an inaccurate perception among the American public that hospice means you’ve given up,” said J. Donald Schumacher, president and CEO of the National Hospice and Palliative Care Organization. “Those of us who have worked in the field have seen firsthand how hospice and palliative care can improve the quality of and indeed prolong the lives of people receiving care.” Schumacher added that “The time to learn about these services is before a person is in a medical crisis. Patients and families must learn about these options of care as soon as possible.” 

A Growing Body of Evidence

A 2004 study found patients with 16 of the most common terminal diagnoses lived around 20 days (Journal of Pain and Symptom Management, September 2004). In 2007 a study of 4,493 patients found patients lived an average 29 days longer with hospice (JPSM, March 2007). This latest study adds to the body of evidence showing that many patients live longer with hospice and palliative care, and as a rule both patients and surviving families report better quality of life.