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Med Monthly September 2011


geriatrics issue


A growing problem in health care

Can Google+ work for your practice?


Best cities

for seniors!

Expert advice on caring for the caregiver



Google+ for your practice

features 36 Caring for the caregiver The need for a care team

40 Moving Seniors to new homes Seniors adjust to care communities

44 Duke Integrative medicine Inside the state-of-the-art facility

48 Treat your feet

research and technology

Tips for diabetics with foot isssues

10 sleep health 12 new flu Vaccine 15 Stem Cell research

50 Caregiving cruises

Learn how caregivers can relax

in every issue 4 editor’s letter 8 news briefs 24 book reviews

your practice

56 for sale 62 top nine

18 Medical billing 20 google+

legal 22 Elder justice act

storytellers 28 day care daze 30 No place for ageism in health care 32 a call for dignity 34 helping the aging population

healthy living 52 senior yoga

the kitchen 54 eat more salt Moving on seniors


Cover photo by Robert Benson Photography



editor’s letter


eptember is my second favorite month after December, which is my birthday and my daughter’s birthday month and of course, the holidays. Not only is September a time for fair weather and fall fashion, it’s a time for new beginnings, which is appropriate since this issue focuses on geriatrics. As we age we encounter new challenges and new opportunities—it is a time of adjustment to bodies that don’t work as well as they once did, aging also means the loss of memory, friends and family. One of our newest contributors, Sonia Usatch-Kuhn wrote “Moving On” about seniors moving to lifelong communities and assisted living facilities. Many seniors initially struggle with moving out of the home they’ve inhabited for forty years, but once they become involved in the assisted living community, they usually have so much fun with their new friends to remain sad and lonely. We also wanted to focus on caregivers this month and how much time and energy they give to the people they love. Unfortunately, caregiving does exact a toll on the caregiver. Read George Cox’s story on “Reciprocating Love: How to Care for the Caregivers,” and well as my story on Caregiver Cruises and Megan Cutter’s book review on “Caring For a Distant Parent” by LaVerne Z. Coan. Our cover story is on Duke Integrative Medicine, where form meets function and eastern medicine meets western practices. As you read, you’ll learn how even the process to create the space was an integrative endeavor as varied practitioners work together to heal the whole person and never see patients as their disease. We’ve also included yoga exercises for older adults from yoga teacher, Patience Armstrong. Also new this month are first person stories from the health care front. Carol Long, Martha-Lee Ellis, Dr. Martin Janis and Carol Cooley all share their stories about elder care. We are currently accepting submissions for first person health care stories, as well as health care-related poetry. Please submit your work to my attention at Some of our regular sections include Kristy Stevenson’s story on stem cell research, a review of the Elder Justice Act from Kim Lacata and how sleep affects your memory from sleep expert, Lisa Feierstein, RN. For managing your practice we have an article about medical billing from Mary Pat Whaley and an introduction to Google + from Shauna Duty. Liberally enjoy our September issue and stay tuned for next month’s issue devoted to women’s health.

Alice Osborn Managing Editor

4 | September 2011


Med Monthly September 2011


Philip Driver

Managing Editor

Alice Osborn

Creative Director

Courtney Flaherty


Marketing Manager

George Cox Kristy Stevenson Lisa Feierstein Mary Pat Whaley Megan Cutter Patience Armstrong Shauna Smith Duty Will O’Neil

Kimberly Licata is an attorney at Poyner Spruill, who practices health law and participates on the Firm’s Emerging Technologies and Privacy and Information Security teams. She may be reached at or 919-783-2949.

George Cox moved to Raleigh, NC in 1983 and obtained an MA from NC State in 1990. He has ghostwritten two novels and a collection of blogs and short articles. Currently, George is preparing his own novel for publication, and enjoys the opportunity to freelance in his spare time. Besides writing, working, and raising two teenagers, George still finds time to fingerpick a few original compositions on his classical guitar.

Mary Pat Whaley, FACMPE Subscription information Subscriptions are $69 for one year or $89 for two years. Individual copies are $5.95 each. To subscribe call 919.747.9031 or visit Med Monthly is a national monthly magazine committed to providing insights about the health care profession, current events, what’s working and what’s not in the health care industry, as well as practical advice for physicians and practices. We are currently accepting articles to be considered for publication. For more information on writing for Med Monthly, check out our writer’s guidelines at

P.O. Box 99488 Raleigh, NC 27624 Online 24/7 at

is Board Certified in Healthcare Management and a Fellow in the American College of Medical Practice Executives. She has worked in healthcare and healthcare management for 25 years. She can be contacted at

Megan Cutter is a professional writer, editor and creative journaling instructor. In addition to providing writing, editing, coaching for writers and public relations services, she facilitates creative writing workshops, specifically in the areas of writing for health and wellness. To find out more about Megan, visit her at

Kristy Stevenson As an independent writing and editing professional she brings over fifteen years of experience serving as a researcher, networker, contributing writer and regular content provider to the lifestyle, entertainment, parenting and health care fields. Working with editors and corporate clients nationwide, she helps solve your business writing needs. To learn more about Kristy, visit |5

Our secret weapon against smoking?

Each other.

I first lit up a cigarette when I was 9. I started smoking at 16 and smoked for 15 years. When I wanted to quit, I found out the average person takes 3-4 efforts to quit because nicotine is so powerful. I learned that if you pick it up again, it’s part of a process. It’s not that you failed, that’s just how it works. When I finally quit, I had more weapons to help me — my pills, my support and my nurse practitioner to talk to. Now we have Tobacco Free Nurses to help, too.

Tobacco Free Nurses is a one-stop shop for all nurses, especially nurses who want to help their patients quit smoking and nurses who want to quit themselves. We are nurses who want to benefit nurses and patients, and promote a tobacco free society. Please visit our website or call for further information.

Toll Free: 877-203-4144 | Support for the Initiative was provided by a grant from the Robert Wood Johnson Foundation in Princeton, New Jersey, to the School of Nursing, University of California, Los Angeles in partnership with American Association of Colleges of Nursing, American Nurses Foundation / American Nurses Association, and National Coalition of Ethnic Minority Nurse Associations.

Photo: Todd Pickering

— Maria, RN

news briefs

Focus on Alzheimer’s New Alzheimer’s Drug May Be Safer Than Thought The drug bapineuzumab is used to clear Alzheimer’s-causing plaque from the brain. Beta-amyloid plaque buildup is an early indicator of Alzheimer’s seven to ten years before the cognitive decline. But early studies revealed bapineuzumab could cause brain swelling, loss of coordination, and even hallucinations as it reduced the plaque. Now there are new studies showing that this drug is not as dangerous as previously thought. Patients may experience brain swelling, which shows that the drug is working to eliminate plaque, but no additional symptoms. These positive effects are encouraging for bapineuzumab’s use because it can slow down brain tissue decline. Ongoing studies are necessary. Mary Sano, MD, of Mount Sinai School of Medicine in New York City, says that although the studies “help us to better understand the long-term safety of bapineuzumab, we still don’t know anything about its potential positive effects.”

Survey Finds Alzheimer’s Second Most Feared Disease After Cancer A new U.S. and European survey from the Harvard School of Public Health and Alzheimer Europe shows that Alzheimer’s is the second most feared disease after cancer. Other diseases on the list included stroke and heart disease. The study also showed that many of the respondents (one third to two thirds) didn’t know that Alzheimer’s is a fatal disease. Right now there are tests for early detection, but they are still in the experimental stages. Results also revealed that eight in ten people would have their loved one see a physician for early detection and that their expectations may be higher than what medical community can currently offer them. According to recent studies, Alzheimer’s develops a decade before the first symptoms appear. This survey shows that people are likely to come in for early testing. Alzheimer’s disease affects about 35 million people worldwide and in forty years the number of cases is expected to triple to 106 million.

Eye Test Spots Alzheimer’s Before Symptoms In a small eye test study for Alzheimer’s, researchers tested participants’ eyes using retinal photographs, the same technology in optometrists’ offices. The study included 13 people with Alzheimer’s disease, 13 people with mild cognitive impairment, and 110 healthy volunteers. Those with Alzheimer’s had different blood vessel widths than those without the disease and this difference matched up with their increased brain plaque. The researchers also combined the photographs with PET scans to detect the amount of brain plaque present. Study leader Shaun Frost, MSc, a PhD candidate at the Commonwealth Scientific and Industrial Research Organization in Perth, Australia, says the eye test study is not perfect on its own, but should be used with a blood test. “There is a close relationship between Alzheimer’s disease, changes in the retina, and plaque burden in the brain,” Frost says. 8 | September 2011

Exercising, solving the daily crossword puzzle, eating right, along with several other lifestyle choices may prevent Alzheimer’s in up to half of 35 million cases worldwide, according to a recent study. The other lifestyle changes include managing diabetes, obesity, high blood pressure, and depression. Smoking should be eliminated, and exercise levels need to increase, since a sedentary lifestyle contributes to 21% of preventable Alzheimer’s cases. Even a modest reduction in risk factors can show benefits. Increasing one’s brain work can also prevent Alzheimer’s and this can include taking classes and participating in intellectually stimulating activities. The researchers assumed a causal relationship between each risk factor and dementia, but they caution that this study is not conclusive since these risk factors have not been proven to prevent Alzheimer’s.

5.4 million


source: Photos courtesy, Katia Grimmer-Laversanne, Matt Willmann

Lifestyle Changes May Prevent Alzheimer’s

Americans have Alzheimer’s disease, the most common form of dementia If Your Mother has Late-Onset Alzheimer’s You May Have a Higher Risk Preliminary research shows that if your mother, not your father, has late-onset Alzheimer’s, you may be at a later risk for the disease. In this small study, the atrisk group showed a reduction in glucose metabolism and plaque buildup in the brain, showing reduced function. This study revealed that those in this risk group will benefit from early detection and from drugs, now in development, that will stop or lessen the disease’s progression. “People think that if they reach middle age and don’t have memory issues, they’re not going to be affected,” says study researcher Megan Cummings, research coordinator for New York University’s Center for Brain Health in New York City. “That’s not necessarily true.” Although more testing is needed, researchers are looking at how Alzheimer’s is passed through the mitochondrial DNA from the mother to the child.

Falls Are an Early Clue to Alzheimer’s Falls and weight loss can point to early Alzheimer’s, according to a new study with 125 older adults who recorded their falls. When older people fall, the consequences include early nursing home placement and even death. Someone with Alzheimer’s may fall more frequently because of balance and gait issues, along with visual and spatial perception. The participants all had to undergo positron emission tomography (PET) scans to see how much plaque they had in their brains, an early indicator of the disease. Those who had the plaque, indicated their fall rate was 66 %. Also factored into the study was alcoholism, age, education and the number of medications taken. According to these findings, if older people are experiencing more falls and showing more weight loss, they should be tested for memory problems.

research & technology

How to prioritize your sleep habits By Lisa Feierstein, RN, BSN, MBA

10 | September 2011


Four Suggestions for Sleep  Regular exercise of 20-30 minutes a day will help you sleep better, but be careful that you don’t exercise too close to bedtime  Avoid caffeine, nicotine and alcohol at least 6-8 hours before bedtime. Caffeine in coffee, chocolate, soft drinks, non-herbal teas, diet drugs, and some pain relievers will keep you up. Nicotine will turn you into a light sleeper and alcohol will rob you of deep sleep opportunities in REM sleep so you remain in the lighter stages of sleep. Also Lisa Feierstein is the founder of Active Healthcare, Inc.

Photo courtesy

More sleep can help improve memory

f you find yourself having a hard time remembering your children’s teacher’s names or your zip code, you may be sleep-deprived. Studies show that our memory improves once we get enough sleep every night, which is seven hours as recommended by the National Sleep Foundation. Thirty percent of Americans get six hours or less of sleep a night. Many times we don’t get enough sleep due to conditions such as sleep apnea, menopause, busy work lives, medication, diet or stress. MIT recently conducted a study that shows how vital sleep is for storing long-term memories. Why are long-term memories so important? By allowing sleep to consolidate our memories into the long-term memory bank, called the neocortex, we have more room for new information and have better recall of older information. As we fill up on facts throughout

our day, this new information crams our in-box, which can overflow our brain. If we get enough sleep, the brain realigns the new information. If you sleep well, you’ll experience four to five sleep cycles per night, which consists of light sleep, deep sleep and REM, where most dreams occur. REM recurs every 70-90 minutes. However, if you don’t get enough sleep, you will skip over the number and depth of the cycles. Without restorative sleep, you’ll lose the advantages of memory consolidation. Although our sleep needs and patterns change with age, older adults still need to make sure they get seven to nine hours of sleep to experience its therapeutic benefits. Chronic health issues that worsen as we age such as high blood pressure and gastroesophageal reflux disease (GERD) also make adequate sleep harder to attain. According to the National Sleep Foundation, older adults also have a higher incidence of insomnia. Older women going through menopause or with an undiagnosed sleep disorder may experience hot flashes and hormonal changes that keep them from getting a full night of restful sleep. Everyone’s memory and health can benefit from good sleep hygiene, or habits, even if you don’t suffer from sleep apnea. Here are several roadtested suggestions:

day?  Have you been told that you stop breathing during sleep?  Do you have a history of high blood pressure?  Is your neck size greater than 17 inches if you’re a man or greater than 16 inches if you’re a woman?

avoid eating a heavy meal two hours before bedtime.  Set and keep a regular schedule even on weekends. This means going to bed the same time each night and waking up at the same time each morning.  Make a habit with a relaxing bedtime ritual such as a warm bath, reading or listening to soft music. You’ll train your brain to associate these rituals with sleep. How You Can Take Action So how do you get more sleep to improve your memory? First try to see if any of the above suggestions work. If none of these are effective and if your family members frequently tell you that you snore, ask yourself the following five questions to determine if you have sleep apnea.  Do you snore?1/17/08 4:43 PM Page  Are you excessively tired during the

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If you say “yes” to two or more of these questions then visit your healthcare provider who may recommend that you have an attended sleep study at a sleep lab like Active Healthcare’s IntegraSleep. Your healthcare provider should also ask you what medications you’re taking that might interfere with your sleep. If sleep apnea is determined as the cause of your ragged sleep patterns, sleep therapy is recommended using a PAP device and mask to keep your airways open and give you your sleep back. With more sleep, your memory 1 will improve and you’ll get your life

back. Remember if you still are having significant sleep difficulties after trying to sleep more, don’t wait and hope that your situation will improve, be proactive with your health and body and take action today! About Active Healthcare Active Healthcare is an awardwinning industry leader in the treatment of obstructive sleep apnea, helping North Carolinians breathe easier for over 20 years. State-of-theart IntegraSleep centers in Raleigh, Clayton, and Smithfield provide all-inclusive sleep management programs to diagnose and treat this disruptive, dangerous condition. With a 98% customer satisfaction rate, Active Healthcare is passionately dedicated to patient care and quality of life through six customer service centers throughout the Triangle and in NC. For more information, visit

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Vaccine offers adults new immunization option this flu season By David Greenberg, M.D.


dults 18 through 64 years of age have some of the lowest influenza immunization rates in the United States, despite a recommendation by the Centers for Disease Control and Prevention (CDC) that everyone

12 | September 2011

six months of age and older should receive an annual influenza vaccination. In fact, in most years fewer than 30 percent of healthy adults 18 years through 49 years of age receive influenza immunization. Combined with pneumonia, in-

fluenza is the nation’s eighth leading cause of death. Vaccination is a safe and effective way to help prevent influenza. Influenza is a serious respiratory illness that is easily spread and can lead to severe complications, even death. Each year in the U.S. five to 20 percent of the population becomes infected with influenza, and an estimated 226,000 people are hospitalized from influenza-related complications. Depending on the specific influenza strains circulating and virus severity, annual deaths can range from a low of 3,000 to a high of about 49,000 people. According to the CDC, a large percentage of adults may be not heeding the call to get an annual influenza vaccination. Vaccination rates for adults ages 18 through 64 fall far short of national recommendations. According to a survey conducted last year by the National Foundation for Infectious Diseases (NFID), 43 percent of Americans who did not plan on being vaccinated cited several reasons for not receiving an influenza vaccine. These include mistaken beliefs that there are other ways to protect yourself from influenza (71 percent), the belief that they are healthy and influenza “doesn’t worry them” (69 percent), or the belief that hand-washing is as effective as the vaccine in preventing influenza (34 percent). To help safeguard adults ages 18 to 64, Sanofi Pasteur developed Fluzone® Intradermal (Influenza Virus Vaccine). For patients who fear needles, this product has a .006 needle that is 90 percent shorter than the typical 1 inch needle used for intramuscular injection. The vaccine incorporates a new, easy-to-use prefilled microinjection system designed to consistently deliver vaccine into the dermal layer Dr. Greenberg is the Senior Director of Scientific and Medical Affairs at Sanofi Pasteur

Photo courtesy Sanofi pasteur

research & technology

of the skin of adults. The dermal layer contains a high concentration of specialized cells known as dendritic cells, which serve a key role in generating an immune response. A similar influenza vaccine manufactured by Sanofi Pasteur with the same ultra-fine needle technology was introduced in Australia in 2010 and was preferred both by providers and by patients, according to a study published in “Advances in Therapy.” Fluzone Intradermal vaccine, which was recently licensed by the Food and Drug Administration, is the first influenza vaccine in the U.S. to use this new microinjection system for intradermal delivery of vaccine. The new vaccine will be available to health care providers in the fall of 2011 for use during the upcoming 2011-2012 influenza season. Fluzone Intradermal vaccine usage may lead to higher acceptance among healthy adults—a population that is often overlooked, but at risk to contract influenza and spread the virus to others, including persons who shoulder most of the morbidity and mortality of influenza illness, such as children younger than five years of age and adults 65 years of age and older. Everyone is at risk of contracting and spreading influenza, and it can strike seemingly healthy people with devastating illness; this was especially true with the pandemic H1N1 virus. Although influenza vaccination rates remain low, there is hope that new technologies, such as Fluzone Intradermal vaccine, can help increase those rates. Fluzone Intradermal vaccine could be an important tool in increasing adult immunization rates due to its ease of use for health care providers and the high level of interest expressed by patients for this less-invasive immunization option. For more information about the seriousness of influenza and the importance of vaccination, visit www.

Medvertising compound noun: 1. The action of calling attention to medical goods or services for sale. Exclusively refers to advertising in Med Monthly.

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What’s your practice worth? When most doctors are asked what their practice is worth, the answer is usually, “I don’t know.” Doctors can tell you what their practices made or lost last year, but few actually know what it’s worth. In today’s world, expenses are rising and profits are being squeezed. A BizScore Performance Review will provide details regarding liquidity, profits & profit margins, sales, borrowing and assets.

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research & technology

Stem cell potential From curing disease to curing aging Is “preventative geriatrics� the wave of the future? By Kristy Stevenson


Then, cells are differentiated into the proper cell type and put back into the patient, restoring the vitality and functionality of the organs. This process has been used to cure mice of sickle cell anemia, suggesting that it may one day work on humans. “In many cases, no modification is needed at all, only amplification,” says Aubrey de Grey, a British biomedical gerontologist and chief science officer of a foundation dedicated to longevity research. “In other words, the only problem is that the body is supplying too few such cells to the places they’re needed.” Building upon technology developed for bone marrow trans-

Cancer is arguably the most difficult part of aging to fix, and removing the ability for cells to divide indefinitely (which stem cells are normally supposed to be able to do) may be an important part of this,”

ized—or differentiated—cells that carry out specific functions. In contrast, a stem cell is undifferentiated. As non-specific cells without any tissue-specific structure, stem cells can easily replicate themselves to form multiple cell types that perform specific functions like cells for the heart muscle, sperm and nerves do. With their regenerative properties, stem cells are ideal for anti-aging therapy. Research shows that stem cells can stall the progress of selected high profile diseases by isolating cells from a patient with a genetic disorder and creating induced pluripotent stem cells. The defective gene is replaced with a functional copy. 16| September 2011

plants, researchers are mounting new ways to use adult stem cells. Tissue engineers are already working on growing patches for repairing damaged heart tissue. Animal testing is focusing on the ability to grow whole hearts, livers, lungs, and kidneys. Stem cell transplants also show promise for treating spinal cord injuries, as well as helping us learn about cancer. Like stem cells, cancer cells grow rapidly and remain undifferentiated. Learning how stem cell growth and differentiation are regulated, we may be able to develop new drugs for treating cancer. “Cancer is arguably the most difficult part of aging to fix, and removing the ability for cells to divide

indefinitely (which stem cells are normally supposed to be able to do) may be an important part of this,” says de Grey. De Grey, who works with an international advisory board, is making headlines with his claim that physicians might soon be able to “cure” aging altogether. If he’s right, the first person who will live to see their 150th birthday has already been born. “I’d say we have a 50-50 chance of bringing aging under what I’d call a decisive level of medical control within the next 25 years or so,” he said in an interview with Reuters. “And what I mean by ‘decisive’ is the same sort of medical control that we have over most infectious diseases today.” Skeptics call these musings pseudoscience. “Past and anticipated advances in geriatric medicine will continue to save lives and help to manage the degenerative diseases associated with growing older, but these interventions only influence the manifestations of aging—not aging itself,” say Doctors Olshansky, Hayflick and Carnes in a position statement on human aging. Dr. Olshansky is the senior research scientist and professor at the School of Public Health, University of Illinois at Chicago. Dr. Hayflick is the professor of anatomy at the University of California at San Francisco. Lastly, Dr. Carnes is the assistant professor of geriatric medicine at the University of Oklahoma. Advocates of what has become known as anti-aging medicine claim that it’s now possible to slow, stop or reverse aging through existing medical and scientific interventions. Olshansky et. al. caution, “There are no lifestyle changes, surgical procedures, vitamins, antioxidants, hormones or techniques of genetic engineering available today that

Photo courtesy


id you know that our bodies are programmed to live to about 120 years of age? In reality, most life spans are roughly around 80 years. Successful aging is defined as “changes due solely to the aging process, uncomplicated by damage from environment, lifestyle, or disease,” meaning that our ability to live longer can be disrupted by severe illness, severe trauma, and abnormal aging. There is increasing evidence, however, that the regenerative properties of stem cells can cure many age-related complications and delay the aging process. Our bodies contain many special-

have been demonstrated to influence the processes of human aging.” These doctors claim that preventive measures are an important part of geriatric care, and following medical advice on nutrition, exercise and smoking can increase your lifespan, however, these changes will not affect the process of growing old. As of today, anti-aging claims tied to specific drugs, vitamins or esoteric hormone mixtures aren’t supported by scientific evidence nor proven to modify the underlying processes of aging. To combat the opposing view, de Grey says the desired effect is to simply to replace cells that the body does not automatically replace (by

division and differentiation) when they die. He maintains that aging is basically the lifelong accumulation of molecular and cellular damage throughout the body. Through specialized treatment, physicians will one day be able to fix those problems before they can cause irreparable damage. De Grey envisions a time when “preventative geriatrics” require patients to go to the doctor for regular maintenance-type visits. While there patients will undergo a cocktail of gene and stem cell therapies, immune stimulation, and other medical advances to periodically stop their body’s molecular and cellular damage. “Stem cell therapies will almost

certainly not greatly postpone the ill-health (and consequent death) associated with old age by more than a few years on their own. However, in combination with a range of other therapies, they may do far more: indeed, I’m pretty sure that we will eventually develop a panel of regenerative interventions that allow us to postpone age-related ill-health indefinitely,” says de Grey. “This will have all manner of consequences for humanity, but I’m quite sure that none of those consequences, even in the absolute worst case scenario, could come close to outweighing the benefits of alleviating all the suffering that is currently associated with getting old.”

It was just a simple fall. Yesterday. Every year, one out of three Americans over 65 falls in the home. For older Americans, falls are the most common cause of injury. And the leading cause of potentially lethal hip fractures. Yet, almost half of home falls can be easily prevented. To learn how to make yourself, or a loved one, safer at home, visit

your practice

Re-engineering Billing Learn how to get your practice to spend less and collect more By Mary Pat Whaley, FACMPE

Clear Financial Policy If you don’t have a written financial policy, how do patients know when and how to pay? Your practice should have a very understandable (8th grade level or less) financial policy that explains what your practice will do and what the financial responsibilities of the patient are. Use the same financial policy to train your entire staff on your policies. If any employee does not support your policies, they Mary Pat Whaley is Board Certified in Healthcare Management and has worked in health care for 25 years 18| September 2011

should not work for you. How you save money: Everyone is on the same page, so there is no way a patient can game the system by claiming a staff member told them no payment was needed. By the time the patient receives a service, they should have heard verbally about the policy three times and should have received at least one written copy of the policy, which they’ve signed. Formal Financial Assistance Program You need a Financial Assistance Program if your practice discounts patients in financial need. You can

discount your fees to any patient without insurance who is paying cash at the time of service. You have the money in hand and you will not be spending anything to bill the insurance company or the patient. Most patients without insurance are very pleased to pay cash at time of service at a discounted rate. Patients without insurance who are unable to pay cash at time of service should be offered an application for financial assistance. Practices can set up discounting based on multiples of the federal poverty level—many use two or three times the published level. It can be as simple as a percentage off the retail rate, or it

Photo courtesy


ow does a medical practice meet the patients’ healthcare needs while operating a highly-regulated business on less income? Start by examining one of the most expensive processes in the practice—billing. Billing requires skilled employees, sophisticated technology, and constant vigilance from everyone in the office. Let’s explore processes that can reduce your billing expense as well as increase your collection percentage.

can be a sliding scale. Whatever you choose, needy patients are typically quite happy to produce information that qualifies them for medical care at a discount. My experience has been that patients who defer completing financial assistance applications don’t really need the program. How you save money: If you take the time to put a Financial Assistance Program in place, you will write-off the discounted amounts on the front end and do away with sending numerous statements and sending the patient to collections. Write it off to charity care, and if need be, place a limit on how much charity care the practice can support. Check Eligibility Check every patient at every appointment to make sure (as sure as you can be) that they have the insurance you think they do. Most practice management (PM) systems have eligibility built in or available as an add-on service. If your system can’t check eligibility, there are standalone systems that can extract appointment information from your software, or you can check the patient eligibility individually. How you save money: The time it takes to file the wrong insurance for a patient, have it rejected, while obtaining the correct information and refiling the claim will eat a hole in any profit attached to the service. Require Payment at Time of Service Your co-pay collections should be 100% every single day. I can think of very few reasons why you should see a patient who has not paid their copay. At every step of the way, patients should be told their co-pay will be collected before they receive the service. If the patient checks in without

a co-pay, staff should offer the patient the choice of leaving to get their co-pay (where is the closest ATM?) or reschedule the appointment. Yes, there are a few times when the patient should be seen despite not having their co-pay, but they are much, much more rare than you think. How you save money: Removes billing for copays, and collection efforts for small amounts of money. Collect Deductibles Many practices are afraid to collect deductibles. Or they don’t want to overcollect them and have to refund the patient. Or they don’t know how to find out what the patient’s deductible is. But as deductibles get larger, practices are leaving more and more money on the table. The best solution is to ascertain the deductible information during the eligibility process and collect the appropriate amount at check-out. Using a credit card, you can refund (with most web-based credit card systems) the patient if needed via their credit card — no need to write a check. How you save money: As soon as a patient walks out the door without paying, the value of that money has decreased, and the possibility that you will collect 100% of what is due starts to drain away. Don’t Accept Checks Very few people do not have credit or debit cards. Take all kinds of credit cards, but don’t take checks. They are time-consuming to handle, they have to be scanned or deposited and they bounce! A bounced check charge usually only covers the bank charge and so the time your staff spends collecting on a bad check is eating away at any profit. If a patient truly does not have a credit/debit card, ask them to bring cash or a money order. How

you save money: Reduce staff time, risk of bounced checks and bank transaction charges. Don’t Send Statements You knew I was leading up to this, didn’t you? I don’t think statements, unless they are email statements for reference, are cost-effective tools. Take credit/debit cards, and then adjust the amount due up or down when the insurance company pays. If the patient needs a payment plan for a larger, unexpected service, make it an electronic payment plan that drafts automatically without staff intervention. How you save money: No statements, no postage, no mail to process, no overdue payments, no self-assigned payments plans, reduced staff management. Outsource Billing Most practice administrators have very strong opinions on whether billing should be outsourced or not. About 50% believe it should and 50% believe it should not. What do I think? I think every practice is unique and the answer for each practice will be different. The good news is that outsourcing billing has never been easier or more feasible. There is a buffet of choices for every size and specialty, from small local companies to large national, even international companies. Some software companies offer free EMR (Electronic Medical Record) software when you use their billing services, which could be a boon for smaller practices shooting for the Medicare or Medicaid Incentive Program dollars. How you save money: Your billing will be done within guaranteed timeframes regardless of staffing, weather or internet outages. You reduce payroll, benefits and office space. You pay only on what is collected. |19

your practice

Google strikes again, but is it a plus?


ou may have noticed +1 icons in Google’s search results or on the websites you frequent. What does that little icon represent, and what relevance does it have to your life? What is Google+?

Google+ is Google’s most recent attempt at a social network. Before Google+, there were Google Wave and Google Buzz, which were failures in the scheme of social networks. There’s also Orkut, a site that has seen 20 | September 2011

success in Brazil and India, but not in the US. Google+ has features similar to Facebook, but with a few more advantages. Is Google+ Necessary? Facebook. Twitter. LinkedIn. Buzzle. StumbleUpon. Bebo. The “list of social networking websites” on Wikipedia is staggering—and it’s not an exhaustive list. There’s also a separate list for defunct social networking sites. Google wants in on the action because there is substantial

money to be made in social networking. Consumers are turning to their friends on Facebook for referrals on where to eat, what to wear, and which services to use. The big question is, will Americans embrace Google+ as they have Facebook? This Time is Different Google+ presents unique features that other social networks lack. For instance, by dividing your contacts into Circles, you can segregate your audience. When you publish a post,

Photo courtesy

By Shauna Smith Duty

you get to choose who sees it. When would this come in handy? Say you post an announcement about new financing options in your office. You may only want to show patients and team members—not old high school buddies or your colleagues (competitors). Circles let you choose who sees what. You can do the same thing on Facebook, but it’s more difficult and time consuming. Another difference is the Huddle feature. Let’s say you and your golf pals are planning a getaway. With Huddle, all of your pals can join a live chat on their phones and text their input as you plan the trip. It happens in real time. With a culture that’s constantly on the go, Huddle could revolutionize text. Want to Join Google+? You have to be invited, so check your email for an invitation from a friend who’s already on Google+. While Google+ isn’t officially in beta testing, Google cuts off the maximum number of invitees whenever it wants, so there’s no guarantee you’ll get in soon. If you have the opportunity, take it. Right now, Google+ is limiting users as the company identifies problems and implements fixes. There is no indication as to if or when the invitation-only system will be retired. What Does It Look Like Inside Google? Once you’re inside Google+, navigating the network is easy. As with other social networks, you simply complete your profile, upload photos, and invite friends. Be sure to follow friends as well so you can promote activity on your stream, which is the equivalent to your Facebook wall.

Americans are playing in Facebook’s yard and don’t want to hop the fence and learn Google’s new games. Google+ can feel pretty lonely at first until you find friends and engage. The Internet brings us new and exciting opportunities every day. Some are successes, like Facebook, while others are pitiful failures. Remember the .com bust? Consider Google+ as you would a member of the Kennedy family. It comes from a respected and wellknown background, so it has an advantage over other search engines. Still, it must prove itself to the masses and earn its place at the top. What Does Google+ Mean to Businesses? As a business owner, you need to know more about that little +1 button. It’s where social networking

and search engine marketing come together. Google+ users have the option of +1’ing or plus-one-ing websites they like. Google takes plus-ones seriously. The more plus-ones a site has, the more weight Google gives it in Search. For this reason alone, you should put the free +1 button on every website and blog you own, then plus-one your sites. Ask friends, family, employees, colleagues, and patients to +1 your sites, as well. A counter by your +1 button will show how many people have plus-one-d your site. Right now, Google+ and +1 are not completely connected, meaning that you can’t see what someone has plusoned by only viewing their Google+ profile. Strange, but true. Word on the web is, Google will hitch the two in the future.

More about Google+ Circles allow you to share certain information with certain people. Instant Upload connects with your phone so that photos and videos automatically upload to a private album in your Google+ world. Huddle is a group chat for texting.

Hangouts are chat rooms where you can live chat with friends. This feature allows video chat so you can share and converse about YouTube videos. Sparks is an intuitive tool that will connect you with information on the Internet that pertains to your interests. You tell Sparks what you like, Google delivers the information to you

Will Google+ Take Off? The problem for Google+ users, and Google in general, is that most

Take the Google+ Tour


Are you ready to be a police detective? Complying with the Elder Justice Act crime reporting requirements

By Kim Licata

22| September 2011

obligation not only on the part of the facility, but also every owner, operator or employee of the facility that has knowledge of the “crime.” Facilities had no explanation beyond a few pages of statutory text creating the reporting obligation and specifying the significant fines associated with failing to meet the reporting obligation until June 17, 2011 when the Centers for Medicare and Medicaid Services (CMS) issued a letter to state survey agency directors about the EJA’s obligations. While CMS’s letter is instructive on aspects of the obligation and on what CMS expects from a LTC facility, many questions still remain to confound LTC workers. Here are some basics about the reporting requirement:

or contractor. You may be asking who doesn’t have to make a report as an individual. Also know that the fact that one individual makes a report doesn’t relieve another individual from his or her own obligation to make a report. In fact, information about who reported an event and who knew of the event (and did not report) will be documented by the survey agency. Sound duplicative? It is, but you cannot limit any individual’s responsibility to report under this provision.

What facilities and individuals are affected by this obligation?

What obligations does a LTC facility have?

Nursing facilities, skilled nursing facilities, hospices providing services in a LTC facility, and intermediate care facilities for the mentally retarded. Individuals who are obligated to make reports include a facility’s owner, operator, employee, manager, agent,

To whom must a report be made? To at least one law enforcement agency and the state survey agency.

First, facilities must determine if they received at least $10,000 in federal funds in the prior year; if not,

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ou watch with horror as one nursing home resident hits another (a potential assault and battery in most places) or you witness one resident take an article of jewelry from another resident (a potential larceny or grand larceny depending on the item’s value). Once, you would have handled the issue internally and set the situation right. But now, in the wake of health care reform, you have an affirmative obligation to report the “crime” that you just witnessed if you are an employee of a long term care (LTC) facility. Do you know what you are required to do? Health care providers who work with the elderly population were left largely, but not entirely, out of health care reform. The Patient Protection and Affordable Care Act of 2010 included the Elder Justice Act (EJA), which was intended to protect the elderly population from abuse, exploitation and neglect. The EJA obligates LTC facilities to report any “reasonable suspicion of a crime” committed against a resident of that facility. This vexing provision of the Elder Justice Act (EJA) found in last year’s massive health care reform law triggers an almost impossibly short reporting

read no further (but that’s probably not too many of you). Second, facilities must notify covered individuals of his or her reporting obligations under the EJA (think training). Third, facilities must post yet another notice, in an appropriate location, for employees about the EJA, including an employee’s right to file complaints under the EJA (including with the state survey agency). Fourth, facilities should make sure their anti-retaliation policy covers reports under the EJA (it probably does if the policy was broadly written).

requirements. While these are not stated as “requirements,” you ought to assume they are.

What else does CMS think a facility ought to do?

What do you need to document when you make a report?

CMS states that covered facilities “effectively” implementing the EJA’s reporting obligation will also: (a) coordinate with law enforcement, (b) review adherence to existing CMS policies, and (c) develop policies and procedures specific to the EJA

Follow your policies and procedures and appropriately document your investigation, your findings, your response, and your report. Include dates, time, and names of individuals involved. Involve legal counsel as soon as possible. Be prepared to

When must the facility make a report? Reporting time frames are dependent on whether the resident experiences serious bodily injury; if so, report immediately, but not later than within two hours of the event. If there is no serious bodily injury to a resident, then report within twentyfour hours of the event (i.e., financial crimes against the resident).

discuss the event with your survey agency. While it is good to have some guidance on the EJA’s reporting requirements, reading the guidance won’t answer all your questions about your obligation. For example, the guidance does not clarify what is a “crime.” The EJA says that’s a matter of state or local law and there is no room for speculating whether a crime would ever actually be charged or successfully prosecuted or what a facility is supposed to do when an already overworked local law enforcement agency does not or cannot respond to the report. Remember, CMS and survey agencies are watching you and yours as you bounce between the health care world to the world of detectives and back again. The fines are significant enough that you must take your obligations seriously while standing by for additional guidance. |23

book review

“Caring For a Distant Parent” by LaVerne Z. Coan provides valuable insights for adult children Review by Megan M. Cutter


ccording to the American Association for Retired People (AARP), over 22.4 million households provide care to a family member over fifty. More and more health care professionals are speaking not only to the patients they care for and treat, but to their families who are providing care for them as well. “Caring For a Distant Parent” by LaVerne Z. Coan provides a roadmap for families caring for their loved ones from a distance, whether it’s in a different town or across the country. Coan utilizes her personal experience in caring for her mother, living over 250 miles away, and sharing the responsibilities with her sister who lived over 500 miles away to bring sound guidance and help direct families that now find themselves in similar situations. In “Caring For a Distant Parent,” we discover that “today, people have a good chance to survive to age 90. And over the age of 65, about 60% of people require some assistance with daily activities; about one-third of those need substantial help because of cognitive impairment or behavior problems.” From the beginning, Coan breaks

24 | September 2011

down the myths of caring for an aging parent and assures us that “there is no contract or rule that obligates a child to care for an aging parent” and “sacrificing your own well-being in caregiving does your parent no good.” Readers will find chapters broken up into “Care Tips,” offering unique insights into caring for an aging parent, specific resource lists, suggestions, and resource listings for additional reading material, Internet searches, and pivotal tips that anyone can implement right away. For example, Coan includes a reality checklist of physical, emotional and social aspects of an older relative, a list of vital documents and records that are most important to find, a guide to evaluating housing options, and a tool for creating a care team to ensure that you loved one receives the support they need among others. This comprehensive resource guide delves into why and how families need to become involved in a number of areas such as knowing their parent’s advance medical directives, working with medical staff, considering the array of financial resources available to them and how to work with social workers, an

At a glance Title: Caring For a Distant Parent: Tips From Daughters and Sons Who’ve Cared Vol. 1 Helping Your Parent Author: LaVerne Z. Coan About: A former librarian, Coan became a long distance caregiver for her ailing mother More info: Visit her website at

eldercare attorney, a hospital facility or nursing home staff. For example, many families have difficulty identifying quality care of their family members when they are in nursing home or the care of a facility. Coan ensures her readers, “Your parent does not give up his right just because he has lost the capacity to make adult judgments. Instead, you have become the person to protect those rights.” She includes information that families may not have thought of before. For example, we all know that conversations around driving may be a difficult and often touchy dialogue for older family members who are adamant they remain in the driver’s seat. To make the conversation easier and assist seniors in keeping their independence longer, Coan discusses new car technologies such as rearview sensors, high-intensity headlights, GPS systems and adaptive cruise

Careers Customer Service Day-to-Day Operations

control. Coan also includes what to expect when it is necessary to take intervention steps to discuss alternative transportation options. While “Caring For a Distant Parent” does not go in-depth into any of the issues or tips, it does provide an overall resource guide with an abundance of down-to-earth questions, recommendations and resources for a daughter or son just beginning the process of caring for their parents.


impact a patient’s care. “Caring For a Distant Parent” can assist a medical practitioner in understanding the range of issues as they come to light in working with patients and their families who implement a care team approach. Though “Caring For a Distant Parent” may not be useful for every physician, keeping a copy handy for families who are new to the experience of caring for their aging parent

From the beginning, Coan breaks down the myths of caring for an aging parent and assures us that ‘there is no contract or rule that obligates a child to care for an aging parent’”

As a physician or health care facility interacts with family members or other members of a care support team, it is beneficial to understand the complexity of emotional, financial and physical barriers issues that can

or recommending “Caring For a Distant Parent” as a resource for families can provide critical information they can use to navigate this unfamiliar and in many cases strained journey of caring for an aging parent. Your go-to resource for health-care practice management

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About the expert Mary Pat Whaley, FACMPE, is board certified in health-care management and a fellow in the American College of Medical Practice Executives. She has worked in health care and health-care management for over 25 years. Mary Pat is also a well-respected author and highly sought-out speaker and consultant.

Manage My Practice is the go-to online source of technology, information and resources for practice management professionals, and it is visited by over 10,000 medical-practice managers and medical providers each month.

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book review

Opening the end of life dialogue


onversations about the end of life still remain taboo, even after the foundational work of Elizabeth Kubler-Ross, who vocalized the process of death and grieving to the public. Families and the medical community alike still stumble through efforts to grapple with the physical, emotional and spiritual implications of death and dying. One new collection of stories, “Twelve Breaths a Minute—End of

26| September 2011

Life Essays” gathers stories from the sphere of perspectives exploring the personal impact of the loss of life. The collection includes not only experiences of family members, but nurses, physicians, a hospice chaplain, and many other professionals in the health care field who grapple with the inability to preserve life, even as their jobs call for the preservation of life above all else. Inside the pages, riveting stories compose the collection: a mother

who grapples with allowing the organ donation of her daughter, a daughter struggling with the process of institutionalized health care, a woman nearing the end of her hospital residency, a surgeon daughter who now faces the death of her own mother, an intern asked to turn off the ventilator, and a 911 dispatcher confronting death over the phone lines to name a few. Over twenty stories comprise the collection, each one exploring distinctive emotions or decisions facing caregivers, health care professionals, family members, and others who surround their patients or loved ones with compassion as they confront the decisions of death that speak to our humanity. Putting the collection together was a collaborative effort with the Jewish Healthcare Foundation. When the call went out for stories, editor Lee Gutkind, founder and editor of Creative Nonfiction, received 450-500 stories from all across the world. Since 1993 Creative Nonfiction has been the first literary magazine to publish, exclusively and on a regular basis, high quality nonfiction prose. While Gutkind did not anticipate the types of stories he would receive, there were two wars going on at the time, and he did expect to receive more stories relating to those experiences. Gutkind was looking for pieces that were dramatic and had something vital to impart to the reader.

Photo courtesy IVAN VICENCIO

“Twelve Breaths a Minute—End of Life Essays”

What was most exciting to him was featuring so many new voices and perspectives that have not previously been heard. Gutkind comments, “The mission of the collection is to discover essays that help other people go through the experience, and that others have walked the path before…we are all in this together. Each person feels so isolated, so alone [by death], every family or lots of people are involved by experience.” Through a process of screening stories, Gutkind was looking for new voices and writers that have not been published before. In a process of working with other editors and the Jewish Healthcare Foundation, they narrowed the collection to the final 23 stories that round out the collection. North Carolina writer Carol Cooley (she has another story on p.32) con-

tributed her story, “A Figurative Death,” which is about a woman she met as a physical therapist while working in a nursing home. Carol remarks, “Margaret’s story is one of many—a meaningful life full of choices that ends in a dependent state with limited options. Writing this story was an opportunity to open a discussion on the intimate challenges people like Margaret and her family experience in institutionalized elderly care.” Since the publication’s début, Lee Gutkind has been featured on Talk of the Nation airing on NPR in addition to receiving numerous e-mails and letters about how the book has opened up the conversation about death and dying. Lee writes from the foreword, “We often forget that the death of loved ones has a ferocious impact on the survivors—a burden that can con-

tinue long after funeral and mourning survivors. For readers and writers, these essays, no matter how sad aspects of each story might be, illustrate the power of the human spirit to heal, to become renewed, and to come to terms with grief and fear.” “Twelve Breaths a Minute—End of Life Essays” opens the door for us to talk about our own stories, the stories that we hold long after someone, known or unknown to us, has died. Through each story, we find entranceways to consider our own end of life beliefs, and discover that we are not alone in our encounter with the interconnection of human mortality. Editor’s Note: Creative Nonfiction will be obtaining rights to the book for the paperback version, which will be known by a new title: “At the End of Life—True Stories About How We Die.”


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Day care daze

By Martha-Lee Ellis


t felt like the first day of school, with me the anxious mother rehearsing a litany of what-if ’s. What if he did something weird? What if he said something unkind or took something that didn’t belong to him? But this wasn’t about school or my son at age six. It was about day care and my husband Michael, who Martha-Lee Ellis is the widow of a highly-educated man who suffered through 10 years of decline due to Alzheimer’s disease. She currently serves on the Board of the Frankie Lemmon Foundation for children with disabilities, the Meredith College Social Work Advisory Board, and the Board of the Ruth Sheets Adult Care Center, all in Raleigh, NC.

28| September 2011

was well past the age of seventy-six. The feelings were the same, oddly enough, even if the questions were different. Life certainly was. Michael had Alzheimer’s, and I had a career job. Michael’s career and ability to drive had recently come to a close, and my flexible summer schedule would resume full time hours and responsibilities next month. Keeping my job was essential, and it had become clear that Michael could not be left alone all day. He was going to adult day care today for the first time. The planning that had gone into this had not been easy for me. How in the world did you get someone like Michael to go to a day care center? The director of the center coached me about suggesting to Mi-

chael that he might like to volunteer somewhere since he was now retired. Fortunately, my husband agreed with enthusiasm that this would be a nice thing to do. His participation during the first weeks went well, and he began referring to our morning commute as “going to work.” I began to relax about his adjustment, but I still had to face my own. It was painful for me to acknowledge that Alzheimer’s was orchestrating every minute of our lives. I still moved through the motions of taking him to day care in a daze. Several weeks later, I arrived to pick Michael up and saw him carefully gluing small strips of patterned wrapping paper onto a box. He was engrossed and didn’t even notice my arrival. I was astonished that such

Photo courtesy

Adult day care gives purpose to an Alzheimer’s patient

10 Warning Signs of Alzheimer’s a childish activity could seem even mildly interesting to a grown man. I finally figured out that he thought he was looking at a drawing to wire one of the electrical panels he used to build in his engineering company. The colors and patterns on the paper must have represented schematics for the placement of intricate electrical wiring. I knew this was correct, but the relief of understanding was quickly overcome with dismay. How could such a brilliant man with a Ph.D. degree glue paper on a box with intent interest and think he was engaged in a productive task? He was becoming more and more a stranger to me, and I felt alone and isolated from him. But I was not giving him credit for having his own, now unique vision of productivity and success. On the way home one day, he suddenly asked, “Has my boss lady given you my paycheck?” Totally startled, I was sure now that he was going to find out it was really a day care center and not a job. Not knowing what in the world to say, I simply told him no, but that we would ask her about that the next morning. When we did so, she turned to him and said, “Oh, Michael, I’m so sorry if I forgot to tell you that we do direct deposit here. Everybody’s paycheck goes directly to their bank.” “Oh, well, that’s fine then,” was his response as he went over to his boxes. It was absolutely clear to me then that he really thought he worked there, that he thought he was building something, and that he felt productive. This day care was giving dignity and meaning to his daily life. As we were leaving the center one afternoon not many days later, a man who was almost non-verbal in a much later stage of Alzheimer’s than Michael’s, put out his hand as we passed him going to the door. They

shook hands, Michael said good-bye, and they smiled at each other. Once outside, Michael said, “Did you see that guy in there? He never used to say a word to me, but now he’s my friend.” A large lump formed in my throat as tears gathered in my eyes. It was at that moment that I realized Michael didn’t have any friends anymore, until now. The daze I had been in over his being in adult day care cleared. He now had a new job, a place to work where he made important things, and he had friends. I may not have realized it, but he was leaving me each day with independence and confidence, just as my young child had done many years before going to school. I could feel pride in Michael, too. There is something in the way we view our commitment to marriage that makes us feel responsible for the other person’s happiness. When something goes wrong with our spouse, it is up to us to take care of it. It’s what our vows mean. And when the “something wrong” is Alzheimer’s, it consumes both of you. I learned by having no choice that taking Michael to a safe place during the day not only allowed me to keep my job, but also to be able to keep him at home longer, perhaps, than I would have been able to otherwise. It was not something I was doing to him… it was something I was doing for him, and the benefits were a blessing. Michael spent almost two years in that wonderful place that kept him safe, gave him a job, found friends for him, and sent his paycheck directly to the bank. It couldn’t get much better than that. I was wrong in thinking it was for my convenience. He had found a useful existence, and it was through adult day care. It was a very significant thing that helped me survive living with Alzheimer’s.

 Memory loss that disrupts daily life This is more than forgetting names, and remembering them later  Challenges in planning or solving problems They have difficulty keeping track of monthly bills or following a much-loved recipe  Difficulty in completing familiar tasks at home, work or leisure They have trouble driving to a familiar location  Confusion with time or place They don’t know what year it is  Trouble understanding visual images or spatial relationships They don’t realize that the person in the mirror is them  New problems with words in speaking and writing They may stop abruptly in the middle of conversations or repeat themselves  Misplacing things or losing the ability to retrace steps They may place their keys in the flour or in the freezer  Decreased or poor judgment They may pay less attention to grooming and keeping themselves clean  Withdrawal from work or social activities They may forget how to keep up with a favorite hobby  Changes in mood or personality They may become easily upset at home or whenever they are outside of their comfort zone Courtesy of disease_10_signs_of_alzheimers.asp |29


No place for ageism in health care By Carol Long RN-BC


e had only been sitting in the hospital emergency room waiting area for several minutes when our name was called. “Did she call us?” I asked my husband, who was seated next to me. “I think so,” he muttered. I was surprised and a little alarmed, as it is not the norm to be called on so quickly. We had arrived at the hospital only minutes behind my mother-in-law, who was transported by ambulance with symptoms of confusion. Normally, we might wait thirty minutes or more before being called back by the receptionist, allowing us to join her. This time, we were escorted to a consultation room where an ER physician met us and began asking us about my mother-in-law’s symptoms. He inquired about her normal activity level and cognitive status and what our concerns were. The doctor was actually taking the time to talk with us! He immediately implemented a diagnostic and treatment plan. As we sat at her bedside, I relaxed, feeling secure with the care she would be receiving. The doctor had approached my mother-inlaw as a regular patient, an individual, rather than a confused 90 year-old. He Carol is a board certified gerontological nurse with over 30 years experience in diverse health care settings. She founded SOZO Senior Wellness, a nurse consulting business that focuses on senior wellness and geriatric care management. Being an advocate for the elderly is one of her most important roles. She can be contacted at

30 | September 2011

did not assume anything or generalize, nor did he attribute any symptoms related to her age. He also did not minimize her symptoms, which were fairly subtle by usual ER standards. On this same ER visit, my motherin-law had an efficient, experienced nurse about my age. She set about her patient’s care quickly and when she had completed her admission, I had my first opportunity to speak with her. To my amazement, one of the first things she said to me was to declare that my mother-in-law had a urinary tract infection which was causing her symptoms. It took me a moment to realize that she was not basing her “diag-


assumptions! My relaxation turned to attention as I resumed my advocate role. In actuality, my mother-in-law was having a stroke. In seeking treatment for the elderly in my family and for my clients, I often encounter ageism. It happens in all settings of society. In general, ageism can be defined as discrimination based on age. Dr. Lach, a well respected Harvard gerontologist denounces ageism in his book “Treat Me, Not My Age.” Some 20 years ago another pioneer in the field of gerontology, Dr. Robert Butler, coined the term ageism to apply to discrimination towards the elderly because of their age.

The ER nurse was not treating my motherin-law, the patient, but rather, making generalizations... based solely on her age.”

nosis” on labs or history-taking but on an assumption that she had made prior to any physical exam or testing. As a gerontological nurse, I knew that she had assumed it was a urinary tract infection because it is fairly common for the elderly to become confused when they have an infectious process. The ER nurse was not treating my motherin-law, the patient, but rather, making generalizations. She determined that my mother-in-law had a urinary tract infection by assumptions based solely on her age. This time it was the nurse who was exhibiting ageism by her

Ageism in present day society manifests itself in many ways. Sometimes it is blatant, like a doctor assuming that all 90-year-olds are confused or demented and treating them based on those assumptions. Other manifestations are more subtle and disguised like jokes or snide remarks such as, “What do you expect at your age?” Ageism may present as a lack of respect, generalizations about seniors, or intolerance of disabilities often related to aging such as difficulty hearing. Assumptions, ignorance and fear of our own aging probably contribute

Find out more about Senior Wellness to such prejudice and discrimination. Certainly, anyone can be ageist, even seniors themselves often are. The stress of an overloaded healthcare system can result in even the most caring doctors and nurses unconsciously allowing ageism to impact the care of their patients. Ageism, like any other type of discrimination or prejudice, should never be tolerated in healthcare. It prevents the elderly from getting the best available care. The wellness of seniors is threatened when anyone working in health care is ageist. No matter our age, there are basic things we want from our physicians, hospitals, clinics, and even other professionals. We want to be treated as the individuals. We want to be heard, respected and valued no matter our stage in life. We want professionals to know us well enough to know what is important to us and to use their expertise to help us accomplish it. We want them to be our advocate and “go

to bat for us” when necessary! Doctors, nurses and other healthcare workers have crucial roles in combating ageism and advocating for the elderly. Perhaps my mother-in-law’s ER nurse was a caring, competent person, but her ageism could have impacted her patient’s care. In order for the elderly to attain the highest state of general health or wellness possible for each of them, we must be prepared to actively support them in doing so. I am grateful that the ER doctor approached my mother-in-law as an individual to determine what was normal for her before proceeding with her treatment. All of us should be more aware and less tolerant of ageism. Every aging senior should be treated as an individual and their problems, medical or otherwise, approached as such. Every senior’s uniqueness should be celebrated, not ignored or disregarded. By doing so, we may also rediscover the beauty in the differences that sustain our society.

Sozo Wellness:   pages/SOZO-Senior-Wellness/116824841677497 General resource on aging:    Other resources:  Dr. Mark Lach’s site and book:  Info on aging and Dr. Butler lifepart2/watch/season-1/ pioneer-aging-dr-robertbutler | 27


A desperate call for dignity

One woman’s unfortunate stay in a nursing home

By Carol Cooley


met Mrs. Ramsey in October of 2008. I was working as a physical therapist for a home care agency when I received a referral for her evaluation. Mrs. Ramsey had just returned home from a nursing home stay due to a fall that fractured her wrist and pelvis. She underwent surgery with plates and screws to reset and stabilize her bones, then was transferred to Clear View Nursing Home* for rehabilitation. She had no idea how her experience there would affect her. Mrs. Ramsey was the widow of a prominent surgeon. Spending her productive years as a mother, she took pride in organizing local charity events and supporting her husband’s success. Now she lives alone in a faded-white southern mansion on a street lined with sturdy light posts and thriving oaks. When I arrived for our first meeting, Mrs. Ramsey opened the door wearing a peach housecoat. Her wiry silver hair was neatly combed, and beige foundation was evenly spread on her cheeks. She supported her five-foot-two inch frame with the help of a four-pronged cane as she invited me in. I asked her questions about her prior level of mobility in order to set reasonable goals

Carol Cooley is an essayist, short story writer, and health care professional. She aspires to bring depth and strong imagery to her writing. Her stories reveal universal truths, justice, and clarity. An advocate for seniors and adults with disabilities, her writing often reflects her work with the aging and health care. Visit 32| September 2011

for her treatment. She was very clear about what she intended to accomplish, including the length and frequency of her sessions. At her request, I would only see her four times. During our sessions we practiced going up and down the steps and took walks behind her home. She was a generous woman who lived her life as she wished, which only intensified the suffering related to the experience she was about to share with me. When I asked Mrs. Ramsey questions about her nursing home therapy, her mood shifted. She grew anxious and looked at the floor. I asked her if the therapy was uncomfortable. She assured me this was not the case, but there were “other things” about the nursing home that changed her life. “What about all those poor men and women still in there?” she’d say. I asked her if there was something specific that happened. She sighed, shook her head, and didn’t answer. On our final visit we reviewed her exercises and completed the discharge paperwork. When we finished, she told me she wrote a letter about her nursing home experience and was considering sending it to the state. She asked me if I would like to read it. As I read the letter, I visualized the entire scene as if I were watching a movie—Mrs. Ramsey, a frail eighty-five year old woman wincing in tremendous pain after breaking bones and having surgery, while strangers strapped an adult-sized diaper on her. I pictured

her helplessly lying in feces for over an hour while the staff ignored her calls. No compassion from the nurse; just an emotional slap and a hateful remark from a maintenance worker. When I finished reading I looked up at my patient. Mrs. Ramsey was staring at me with tight lips and defeated eyes. “I’m so sorry this happened to you,” I said. She nodded, stood up, and walked me to the back door. I told her I admired her courage to fight for herself. She gave me a copy of the letter to publish at my discretion, and chuckled that she had nothing to lose. Pain and fear clung to her psyche like uncomfortable companions. Still affected from such a violation of her basic humanity, she must have wondered what she would do if she ever needed skilled inpatient care again. What if she had another fall? Would she avoid calling for help? Would she say to herself, “No way I’m going back there,” and stay put until her last breath? Despite the possible ramifications for exposing her story, Mrs. Ramsey sent the letter to the state for investigation. I hope she was taken seriously and someone was accountable for what happened. Perhaps her courage will help change the quality of care at Clear View Nursing Home and in many other nursing homes to prevent her experience from happening to someone who doesn’t have a cell phone, a family, or a faded white house to return to; someone who must call Clear View home. *Name has been changed.

Mrs. Ramsey’s letter TO WHOM IT MAY CONCERN: It is with regret that I feel the necessity of reporting some of the inhumane incidences which I experienced while a patient at the Clear View Nursing Home facility during my recent partial recuperation. I do not want my name used in any way, but I do hope it will benefit others. I am 85 years old and was independent until a fall which resulted in a broken pelvis and broken wrist. When I was admitted to Clear View, with my left arm in a cast and pelvis broken, I was forced to lie on my back and unable to turn over for more than three weeks. On the night of September 26th, I was checked on and left—as usual—to go to sleep at approximately 8:00pm at which time my door was closed on that particular night. In my helpless state, I was in a hospital gown and diapers. I had been given a laxative which had finally done its intended purpose. I pulled my call light time and time again as I needed help desperately. No help came. I screamed and yelled for help, but none came. After receiving no response from my desperate calls for help, I screamed out three times, “If you don’t come help me, I’m going to call the police!” That made no difference, so I managed to get my half-working cell phone and tried to call 911. The phone did not work. I decided to try another number. God was with me! The number rang and I hastily told my friend to SEND HELP! In about 10 minutes—which was approximately 10:00pm —the nurse on duty and two maintenance men opened my closed door and she said in a curt tone of voice, “Is anything wrong?” whereas I replied, “There certainly is! I’ve had my call light on and have screamed for help for over an hour and no help has come. Where has everybody been?” She replied, “The floors had to be stripped and that took about two hours.” My response was, “Are the floors more important than the patients who are old and helpless and paying their money for you to take care of us?” I also said there should be a law against leaving not only me, but the entire hall unattended. One of the maintenance men remarked that the law took care of them. The nurse said they were moving me to another hall to be cleaned up and remain while they finished the floors which could take about another two hours as they had to wax and buff them. I was returned to my room AFTER 3:00am. I must give credit to the nurses and assistants who were truly concerned about their patients and did what they could with kindness and consideration. Clear View obviously needs more employees in order to provide care that is needed; furthermore, they need to be workers who are not merely “putting in time” and doing a sloppy job.

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Geriatric physician never gives up on unfinished projects Helping the aging population is a social calling By Dr. Martin Janis

34| September 2011

and your resolve. Like the mountain climber, who climbs the mountain “because it’s there,” well, aging is “there,” and unlike the mountain, aging looms in the distance for each of us. That distance will invariably and inexorably grow shorter. Consider something as mundane as recurrent falling. A fall? You need to go to medical school to deal with a fall? But imagine the complexity. An old woman has recurrent falls, which you, of course, never witness. She has memory problems, so she can’t describe. Sure, she could have some kind of medical problem. Nerve dysfunction, low blood pressure, arthritis, inner ear disease, visual disturbance, to mention a few. Maybe bladder problems cause her to race too quickly to the bathroom. But maybe it’s just her eyeglasses;

those bifocals tend to make the floor look blurry. So she’s going to need a sophisticated evaluation of many systems. She has some bruises. Is she being abused? What’s the family situation? She lives with her grandson. Was that alcohol I smelled on

Dr. Martin Janis is a native of Brooklyn. He received his undergraduate degree from Columbia and his MD from New York University. He has been a board certified geriatrician for 23 years. Before relocating to Raleigh, he practiced in Northern California. In addition to geriatrics, his passions are poetry, art history, and long distance motorcycling.

Photo of Dr. Janis Courtesy Dr. Janis


ood thing I’m a hard skinned guy, because I’m so often being asked something like this: “How come you chose such a difficult and unrewarding specialty? Your office visits last twice as long and you get paid half as much. Much of the stuff you see is incurable, like Alzheimer’s disease. Your cell phone’s buzzing with calls from concerned families. And sooner or later, after you’ve done your best, your patients die. Doesn’t that depress you? You could’ve picked something like pathology or radiology and had a life!” Well. I wish I could avoid some syrupy idealistic response to a valid question. There’s something invigorating about encountering a challenge which taxes your strength and your intellect

his breath? Or just my imagination? Are her floors too slippery? Too many throw rugs? Inadequate lighting? Soles of her slippers too smooth? Family pooches at her feet too frisky? So much to consider. So little time. It’s mundane, it’s complex, it’s life. You become a detective for a while. And maybe for a few minutes a philosopher: Why does life end up like this? And good grief…this aging…it’s going to happen to me! It is happening to me! And suppose her falls turn out to be so multifactorial that there’s little I can do to prevent the next? How do I manage the inevitable? What do I say to the tearful family after she’s fallen and broken her hip? What can I do to ameliorate what I am unable to prevent?

“Existential” is an overused and under-understood word, but many of these problems are just that, problems inherent in basic existence at a certain time of life. And they demand a holistic, humanistic response. In addition to pills they demand compassion, sympathy, and yes…some wisdom. And where does wisdom come from? After dealing with the elderly for many years you develop insights and feelings and attitudes not to be found in any journal or text. This is part of the reward of caring for the aged. Centuries back, a philosopher remarked that the secret to enduring happiness is to find work that you love but which you’ll never be able to complete. In this respect, I’m very happy.

And the encounters with death, which is, all said, an intrinsic aspect of life. These encounters provide us the long view, a glance at the big picture. And perhaps a vantage point to better conceptualize what it means to be here. Mankind’s encounters with death have long stimulated a creative, an artistic response. Think of of the books, the music created in the passion of this encounter. I’m ever mindful of Ingmar Bergman’s great movie about death, “The Seventh Seal,” wherein Max Von Sydow, the Knight, plays chess with Death. We all play chess with Death on one level or another. I guess I’ve been afforded the opportunity to watch the game up close.

Unfortunately, its motor is inside playing video games. Kids spend several hours a day playing video games and less than 15 minutes in P.E. Most can’t do two push-ups. Many are obese, and nearly half exhibit risk factors of heart disease. The American Council on Exercise and major medical organizations consider this situation a national health risk. Continuing budget cutbacks have forced many schools to drop P.E.—in fact, 49 states no longer even require it daily. You can help. Dust off that bike. Get out the skates. Swim with your kids. Play catch. Show them exercise is fun and promotes a long, healthy life. And call ACE. Find out more on how you can get these young engines fired up. Then maybe the video games will get dusty. A Public Service Message brought to you by the American Council on Exercise, a not-for-profit organization committed to the promotion of safe and effective exercise

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A M E R I C A’ S A U T H O R I T Y O N F I T N E S S

TM |35


Reciprocating love accomplish the task. What exactly will we need to do? Of course, every situation will differ; however, there are some basic considerations we must make, preparations that will ensure they receive the quality care they need. Besides the obvious medical needs of the elderly there are several other significant aspects of care we must consider. According to LaVerne Z. Coan, in her book “Caring for a Distant Parent: Care Tips from Daughters and Sons Who’ve Cared,” (see the book review p. 24) there is a “framework of seven areas of need to maintain fullness of life” for the elderly patient. Coan, a professional medical reference librarian, encourages caregivers to build “a strong care team, a group of people who will work together to provide your parent with the best medical, financial and social support for the time, money, and resources available.” In order to successfully care for the aging parent, your care team should consider not only the physical, medical, legal, and financial aspects of health care, but also the social, emotional, and spiritual elements of life.

By George Cox 36| September 2011


ur parents—they supported us, loved us in spite of our shortcomings and prepared us for the world. But as they enter their golden years, our roles reverse and we are called on to care for them. Whether they need daily assistance with household chores or significant medical care and treatment, our parents will eventually require our help as they age, and we need to be prepared to

Financial Insurance may help with medical costs, but what about day-to-day expenses? Whether your parents want or need your financial assistance, they probably could use some objective advice from experienced professionals to help them formulate a new (or modify an existing) strategy for their retirement nest egg. Your aging parents’ care team should include someone with sound financial ideas, some-

Photo courtesy

The importance of caring for the caregivers, the seven areas of need for fullness of life and the reason caregivers need a care team

Your Care Team

Helpful Caregiving Resources one who can offer honest, appropriate advice. A care team member must be available for setting up weekly budgets for groceries and paying bills, help with anticipating unforeseen expenses, and assist with correspondence through email, telephone, and postal mail. Relieving your aging parents of the stress of daily financial concerns will give them the peace of mind they worked so hard in life to achieve during their golden years. Social, Emotional, Spiritual Three of Coan’s framework areas could be covered together—social, emotional, and spiritual. As we age, our outlook on ourselves, society as a whole and our place in the universe changes. However, we remain social creatures who need interaction with others similar to ourselves. Churches or synagogues have senior groups who will welcome your aging parents, providing them with companionship and a way to increase spiritual awareness and emotional serenity. Encourage the aging parents to find friends through senior events and activities advertised in local newspapers or bulletin boards at local retirement communities. If your parents are independent and outgoing, urge them to plan fun events and invite others to participate. Getting your parents to commingle with others their age will not only keep their minds and bodies active, but will satisfy their souls’ longing for fulfillment in life. Legal Our elderly parents will undoubtedly need doctors and access to medicine to combat physical ailments they may endure; however, they will also need to consider many legal matters, such as life insurance policies, execution of wills, and distribution of property and estates. If circumstances warrant, the care team should employ and remain in contact with a reputa-

ble attorney who can track and maintain all of your parents’ legal needs. Even though they may already have a will or have made definitive property disbursement decisions, your parents may not have accounted for certain changes in the law or legal ramifications involved in insurance claims, medical costs, or outstanding bills. If hiring an attorney is cost prohibitive, then employ a dependable care team member to do the research necessary to ensure your parents are free from any unforeseen legal tangles. Caregivers Helping Caregivers Many elderly singles or couples live close to one another in retirement communities or neighborhoods that attract the over-sixty crowd. These folks can spend time together, get to know each other’s needs, and monitor any health concerns within their community. While these retirement communities may not be attractive to all aging people, they still need someone with whom to share memories and have some fun. You can help by persuading your aging parents to find others in their community to interact with on a regular basis. One group of sixteen friends living in Kerrville, Texas, has the right idea—they have fun keeping in touch. On Friday nights they meet at a different friend’s house for hors d’oeuvres and games (usually cards or a board game); on Saturday nights they meet for dinner at a local restaurant or someone’s back yard for a barbeque; and on Sunday mornings they attend church services. During the work week, they help each other with chores where appropriate: some of the men take care of home repairs, the women coordinate shopping excursions and visits to the doctors, and some individuals volunteer to be designated drivers for those who no longer operate automobiles. In short, they are an extended family that stays,

ParentCare 101 was founded by LaVerne Z. Coan, a professional public speaker and entrepreneur whose book “Caring for a Distant Parent” helps caregivers find balance between the various aspects of caring for the elderly. LeadingAge members will find the support they need to enhance the quality of life during their later years. Visitors to the LeadingAge website can search for information about assisted living, nursing homes, continuing care retirement comminutes, or home-based services. Community Care of North Carolina (CCNC), initiated by Allen Dobson, MD, transforms the health care experience with its medical home model. This approach addresses the health care needs of the patients by pairing them with a primary care physician who manages the health care team. http://www. The Family Health Network bridges technology and services programs to create a network of support that connects the patient and the care team. Learn more about how to get Connected for Life at http://www. HAPPYneuron is an online brain fitness program providing visitors fun opportunities to sharpen their memory and cognitive awareness while playing games. |37

plays, and prays together. According to Jeanne Pike, the group’s event coordinator, “We keep each other busy, keep an eye on each other, and keep each other young at heart.” Professional Help As Assistant Secretary of Health and Human Services for North Carolina, Dr. Allen Dobson has formed the Community Care of North Carolina (CCNC), a Medicaid managed care program with an extensive body of physicians and case managers that changes “the health care experience by changing the way health care is delivered.” According to the CCNC website, “the best system is rooted in the communities it serves . . . directed by doctors and focused on local patients [to] make quality care more efficient and cost-effective.” One association dedicated to “ex-

panding the world of possibilities for aging” is LeadingAge, an alliance of over 5,000 non-profit organizations that “promote practices and conduct research that supports, enables and empowers people to live fully as they age.” The LeadingAge association changes the way older adults receive care, developing “cutting-edge initiatives” that serve the needs of the aging and advance their consumer interests. One innovative way to maintain long-distance relationships with aging relatives is through Connected for Life, a fee-based service offered by the Family Health Network. This easy to use Internet-based format allows users to share information, pictures, and videos, as well as manage health care records and medications. Your care team will need help, so familiarize yourself with the many organizations that are connecting people and

resources to enhance the health care delivery system for the elderly. Final Word Our parents shared their love and lessons with us, prepared us for what’s to come, and built a wealth of joyous memories. While they may feel fully capable of taking care of themselves, the fact that you are offering help may encourage them to accept it in other areas. So encourage them to create bonds with others in their age group through weekly dinner parties or senior outings. Keep them laughing and smiling by sharing a romance or comedy book, or watching an old movie that brings out a nostalgic feeling for the “good old days.” Take them to visit an old friend or introduce them to a new family member. Keep alive the idea that getting older shouldn’t get in the way of living. And remember—the best gift you can give is you.

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Seniors adjust to living in inclusive communities of care

By Sonia Usatch-Kuhn

The need to accommodate our senior population Factors such as economics, a diminished need for large homes, “stuff ” collected that is no longer necessary and a person’s state of health are considerations in determining where people 40| September 2011

might move on to as they contemplate the next chapters of their lives. Retirees may downsize to more manageable living quarters—smaller homes, apartments or communitytype living designed to meet personal needs. Seniors may now be ready to develop new lifestyles that afford time and freedom to play, travel, attend classes, give back to community, engage in the arts and even pursue dreams not realized in the past. Many cities, including New York, Philadelphia and Atlanta are creating “lifelong communities” geared to older individuals’ specific needs such as wide door frames to accommodate wheel chairs, elevators and ramps for handicap accessibility, geographic areas located close to amenities and tram bus service for local shopping. In

the Triangle area of North Carolina, DHIC, Inc, (Downtown Housing Improvement Corporation) is a non-profit organization dedicated to strengthening neighborhoods and families by providing affordable housing, homebuyer education and counseling and community building work. Thriving low wealth neighborhoods Sally Haile, Community Development Specialist, explains that DHIC aims to strengthen neighborhoods and families by expanding homeownership opportunities, providing quality affordable rental housing for families, seniors and individuals with limited income. “We endeavor to enhance the economic well-being of DHIC residents by creating communities with

Photo courtesy MorningSide assisted living


oving evokes a gamut of emotion from excitement to apprehension, depending on how you are moving on in your life and where you are moving to. The fastest growing population in cities and urban areas throughout the United States are our “silver soldiers” comprised of empty nesters, baby boomers and those who have attained octogenarian through centenarian status.

low-wealth neighborhoods in partnership with Wake County’s Resources for Seniors,” says Haile. Maintaining independence and enjoying the life “In the Town of Cary, DHIC offers senior and family living apartments, townhomes and housing for people with disabilities,” says Haile. Approximately fifty percent are seniors have relocated to the Triangle. They are seeking affordability, comfort, stability and the chance to be surrounded by grandchildren. On average they range in age from 70 on up. They are active, independent adults who can participate in activities such as leisure trips, arts and crafts, cultural venues and computer classes offered at centers such as the Cary Senior Center. Living in a community with other like-minded seniors enhances their quality of life by removing isolation. Most consider themselves a socially connected family group under one roof. “DHIC encourages residents to

lend their collective voice in engaging legislators and other elected officials to pay attention to the explosion of seniors coming of age,” says Haile. Assisted living facilities honor memories and create new ones There is another choice for seniors who are no longer able to manage living on their own, perhaps due to declining health or memory impairment. An assisted living facility provides a safe atmosphere, eliminates being alone and offers socialization opportunities. Debbie Hart, executive director of Morningside Assisted Living in Raleigh, North Carolina says that people 60 to 100 years old occupy Morningside’s living quarters. “During the transition process of leaving the home where seniors raised their children undiagnosed depression often occurs. My thought is that folks become depressed due to a loss of independence, driving privileges,

home mobility and managing their finances. With these losses comes the grieving process. It is necessary for professionals to acknowledge the process and provide support to help residents honor their memories and create new ones,” says Hart. The Hospitality Committee New residents are paired with a buddy who is responsible for shepherding the new person around their new home. They also receive a committeesigned card. Experienced residents inform the new resident about what’s what and who’s who. The peer level approach allays fear and removes the presence of the authority figure. NonSonia Usatch-Kuhn is a poet and freelance writer. Her story “The Birthday Party,” is about the sandwich generation and appeared in the Winter 2010-2011 issue of Main Street Rag. She facilitates Gray Matters—mental aerobic workshops for seniors. Contact her at |41

Senior Celebration The week of September 11 through the 17 is National Assisted Living Week. Celebrate a senior! Celebrate a senior for their:  Wisdom and experience  Compassion and kindness  Knowledge and expertise  Style and charm  Sense and sensibility

verbal communication techniques such as a simple smile indicate that the new person is wanted and welcome. The whole package People living in an assisted living setting have a short list of what defines their place and most of them frequently want to know where they fit in the puzzle. They question where their room is, what they are allowed to do and what still belongs to them. Family members have a longer list, expecting more detailed and complex information regarding the analytical data to validate their decision and to remove the inherent guilt involved in making the choice, especially for their parents in primary stages of memory loss and diminished capacity. The “sandwich generation” sits on the fence of conflict. Hart explains, “When a person changes their address, their background and life experiences dramatically affect the shift—those who have always been outgoing and optimistic flourish under new conditions. Those who have been reclusive, shy and introspective and more solitary, acclimate well, even if they stay in their room. The hardest hit, are those who have been prominent citizens who feel the loss of that distinction. For those who are used to being in charge, the table is now turned. “Our staff is trained to honor former selves and 42| September 2011

preserve feelings of worth,” says Hart. Featured at Morningside is “Reach to Rediscovery,” the Montessori approach program, which follows the concepts of Maria Montessori for memory impaired residents. The focus is one-on-one on the resident’s ability to do whatever they can or cannot do to strengthen skills, provide comfort and a sense of accomplishment. Activities are conducted purposefully in small settings with familiar objects. “Despite much bad press surrounding senior living, there are lovely family-oriented thriving environments for seniors where learning, growing and creating new memories live,” concludes Hart. Involving residents begins with a smile Director of Activities, Mandy Chalk, heads the Healthy Generation program. “Our monthly calendar reflects events desired by residents gleaned from the individual Resident Survey,” says Chalk. Requirements comprise weekly group activities that include trips to Wal-Mart, restaurant dining and personal appointments. State law requires that an invitation be extended to the Resident Council where old and new business is discussed monthly. An action/solution report is written up. “Social networking is created by pairing folks up in the dining room and building a trust by a friendly knock at the door as a reminder to attend an event. The real hook-up though comes by word of mouth, one resident to another,” explains Chalk. Favorite activities are bingo, Bible study and happy hour. Musical presentations are well-attended and most preferred. Families are quite involved at Morningside. Church and choir members, grandchildren and great grandchildren visit and bring joy to the residents.

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Integrative health is the wind beneath patients’ wings


oberta Cutbill, 70, of Cary, NC, wishes she would have known about Duke Integrative Medicine sooner before she suffered a severe hearing loss—a side effect of taking a second medication to reduce the massive dose of steroids she was given for a rare auto immune condition. “There are no side effects from integrative medicine!” she says. Integrative medicine heals the patient through a combination of mainstream and complementary practices. Mainstream medicine helps with diagnosis and crisis intervention while complementary medicine focuses on the mind-body connection through stress reduction, movement and exercise, nutrition and therapies such as acupuncture, hypnosis, Reiki, massage and supplements. At Duke Integrative Medicine (Duke IM), the focus rests on health optimization and not on disease management. In other

44| September 2011

Duke Integrative Medicine treats the whole person not just the disease By Alice Osborn

words, a patient is seen as a whole person and not as a symptom of their condition, which is a paradigmatic shift in the way most people think about health care. Cutbill is now a third year member of Duke IM who regularly attends gentle yoga, mindfulness and nutrition classes, she also sees an acupuncturist and her health coach. She loves the fact that everything she needs to stay healthy is under one roof. “There are wonderful cooking classes

so you can learn how to cook in a heart healthy and anti-inflammatory way. The nutritionist recommended supplements and also a way of eating that’s anti-inflammatory to avoid sugar and no red meat. Here I can really commit to my health and it’s been an awesome experience. I feel very seen there, that I matter. They are the wind beneath my wings.” Cutbill continues, “We have a weekly support group within Duke IM where we share resource and experiences from workshops we’ve taken there. We’re building a community of like-minded people—we all believe in integrative medicine. Some use it to maintain what they already have, but most come with a condition of some sort and they are addressing it through integrative medicine. Some people only want to take a pill but those who are willing to work, we need the support and help and have all it one place in order to access it.”

Alice Osborn in the Managing Editor of Med Monthly Magazine 46| September 2011

everyone sees you in this lens through every aspect of your life. A typical doctor visit here is between 50 and 80 minutes because the doctor takes the time to really understand who the patient is, not what the patient has. In a situation where a patient is dealing with cancer, many different aspects of health come into play and what we have in this building is almost every practitioner that patient would need right here.” All Under One Roof Roberta Cutbill’s health improved

dramatically once she could find all of her health practitioners under one roof. She knew about Duke IM before the LEED-certified building, designed by Duda/Paine architects of Durham, NC, opened in 2006 but felt she couldn’t manage going to a nutritionist, a mindfulness coach and acupuncturist in various locations. This one stop shop support is expressed in the physical place from the dramatic arcade the patient first enters to the river rocks in the meditation pavilion, to the use of water walls and bamboo gardens. Everyone

Photos by Robert Benson Photography

Having the support of doctors, nurses, health coaches, massage therapists, acupuncturists, yoga and mindfulness instructors all in one 27,000 square-foot space supports the mission of Duke Integrative Medicine, which is to transform the way health care is delivered in America. Isabel Geffner, Director of Communications states, “We have a huge charge. We are expressing that in some ways through the place we live in here at Duke IM. We have a clinical setting, which we often refer to as a living laboratory. We are experimenting, in a very thoughtful and intentional way, new models of patient care. In order to prove their efficacy we have a robust research division which looks at the treatments we practice to see if they improve patient outcomes, do they reduce the costs of health care, etc. We have a division of medical education because we’re committed to teaching the next generation of health care professionals. We had to define our medical model which informs all of work that every practitioner does here: the Wheel of Health.” The Wheel of Health is the lens through which everyone who touches a patient sees their role. At the center is the patient, not the doctor, nor the treatment. Surrounding the patient most intimately is the idea of mindfulness where being present in the moment without any judgment enriches the patient’s life and immediately makes her more engaged in the process of living. Continues Geffner, “The idea is to focus on the patient and to support the patient by providing information and resources so that he or she can make decisions on what can enhance and optimize their health in the least invasive and most effective way. One of things that distinguishes our clinical care is that no one here sees you as your disease;

who enters is invited to experience the building with all of their senses: sight, sound, taste, touch, and smell. The color scheme in the building represents the four seasons of the year from autumn/winter to spring/ summer. This is a building you look forward to experience and touch, unlike most doctors’ offices. Turan Duda, design partner of Duda/Paine Architects states, “We’ve heard that when patients come to check in, they’ll be talking to the receptionist while they’re rubbing their hands along the surface of her desk. This is quite intentional.” All of the materials used are native to North Carolina and the building itself has no right angles: branch-like corridors radiate out from the central living room/library, which looks like an enchanted forest. Duda manifested the building from a vision of what integrated health should look like. “It was the most unusual process for us as architects,” states Duda. “I realized it was unusual because when we started the project I first asked the doctors where I could find other facilities I could go look at where they are combining traditional and innovative medicine like this for ideas and they said there weren’t any since Duke Integrative Medicine was the first of its kind. I knew right from the start that we needed a unique approach in terms for how we would deal with the project. This was not just another building you occupy, it’s been customized to a mission statement and that’s always a challenge. We can all use words but how you interpret these words into real architecture that resonates is really very different. We were forced to listen that much harder, to explore ideas even further.” After asking his client group to describe the building in terms of adverbs, they gave him embracing, sharing, reflecting, enlightening, transforming, nurturing, and balancing. Duda also wanted to create a space

that blurred the boundaries between inside and outside, and between traditional and innovative medicine. “I had done three projects in Japan and certainly after experiencing Japanese architecture you begin to realize what how much you can bring nature into a building and how soothing, pretty and relaxing it is be looking through a window at a forest as opposed to watching CNN while you’re waiting your appointment. That aspect of getting you in the right frame of mind of what you’re going to experience with the facility is at the forefront of our thinking.” Importance of the Health Coach All patients at Duke Integrative Medicine work with a health coach who has a core competency in behavior change. The health coach learns about what matters to the patient, their health goals and gives them a solid plan for long-term health success. “Patients need support to enact changes and approaches to their lifestyle which are endemic to their ability to optimize their health. Ninety percent of chronic disease is most often a function of lifestyle,” says Geffner. “We want the cardiologist to fix your heart, the endocrinologist to manage your diabetes, the orthopedist to fix your rotator cuff, but we need to have expertise in behavior change if we want medical and biotechnical interventions that the doctors prescribe to be effective. The sustainability of the change to endure it has to come from within the patient.” Cutbill’s health coach broke down her health program into manageable parts to avoid that feeling of overwhelm. She says, “The most important part of my program at Duke Integrative Medicine is having a coach which has been essential for keeping me on track. We ate pretty well to start, but we could eat even better. But after

all of the suggestions from the nutritionist I felt overwhelmed. My coach said ‘hold on.’ She gave me one new recipe a week, when I wanted to try one new recipe a minute! By doing one new recipe a week, I just repeated those dishes and that made it easy. The coach helps you to keep things manageable for a major life change and she constantly reminds me of my successes and praises me, which I used to never do that for myself.” Embracing an integrative lifestyle means taking the responsibility to work hard to achieve optimal health, rather than taking a pill to make the pain go away. It also means entering the practice of mindfulness and of being fully in the present moment, which the Duke Integrative Medicine building creates just by walking into its doors. Says Duda, “I hear feedback from doctors, health practitioners [at Duke Integrative Medicine] and patients when they arrive who say, ‘I already feel at peace and relaxed and we haven’t even started yet!’ It tells me that the facility is doing what it was meant to do.” For more information about Duke Integrative Medicine, visit http://

Duke Integrative Medicine’s Signature Services: The Health Immersion Experience: This is a three-day experience which begins with a 90 minute examination and is good choice for patients living outside North Carolina. $2,995 Annual Membership: Over the course of a year, members partner with a personal integrative health care team to help guide them through treatments to gain optimal health. $2,995


diabetic foot and ankle issues. It is important to note that almost 10 percent of North Carolinians have diabetes and a very high proportion of these patients will sooner or later develop a foot problem. The problems that patients with diabetes can encounter range from those problems also seen in the general population such as corns and ingrowing nails—which require more serious attention in the diabetic—to ulceration, and in severe cases gangrene resulting from poor blood flow. Complicating the issue, often patients with diabetes also have visual problems and cannot thoroughly inspect or treat their own feet. Unfortunately, as with most of us, patients with diabetes often think that they will not be the patient to develop a serious problem. We all like to think that problems happen to other people and not to us. I frequently see patients with more advanced diabetic foot complications because of this attitude.

By Dr. Bob Hatcher


ost people are aware that diabetes is a serious disease and can affect many areas of the body but some are not aware of the fact that many of the most significant complications associated with diabetes occur in the feet. We see

48| September 2011

an increasing number of diabetic patients with serious foot problems, and fortunately, there are also more and more new and effective treatments. Our office tries to stay on the cutting edge of diabetic foot care, and we are constantly evaluating new methods of treating our patients with

Warning signs of potential diabetic-related foot problems include:  Skin color changes  Swelling of your feet or ankles  Numbness in your feet or toes  Pain in the legs  Opens sores which may be slower than normal to heal  Corns or calluses which bleed or

Photo of Dr. Bob Hatcher courtesy Denmark photo

Treat your feet well when you have diabetes

drain  Dry, cracked skin, especially around the heels These are particularly important if you have a family history of diabetes. The fortunate truth is that many of the foot and ankle problems associated with diabetes can be prevented. General recommendations include:  a comprehensive yearly foot and ankle evaluation. This can be done by a podiatric medicine specialist, your family physician, or any other doctor who has training and interest in the foot and ankle  keeping very tight control of your blood sugar. That extra piece of cake really does make a difference in your future!  Wash and inspect your feet every day and dry thoroughly between your toes to prevent athlete’s foot. If you can’t see the bottom of your feet, use a mirror. “What is not inspected is not detected.” Follow with a cream or lotion to keep your skin soft and supple.  Trimming your own nails is fine as long as you can see them and get to them. If you have difficulty, get a qualified and trained nail care individual to do it for you. More problems than you might think begin with a patient cutting their skin while doing their own nail care. Raleigh Foot and Ankle Center has a full-time medical nail care technician for help in this area.  Make sure that you are wearing appropriate footgear. Shoe specialists called pedorthists are experts in this area. They can assist with proper fitting, adjustments, or any other shoe related matter. It’s really worth your time to get this right and no, they won’t necessarily recommend ugly oxfords. We have a full-time pedorthist on our staff for this very reason.

 Have someone who specializes in foot care evaluate any problems you experience immediately. A small scratch, tender nail edge or cracked callus can quickly and easily become infected. Make a habit of checking out foot problems even if you feel they are minor. It is much easier to prevent a problem than to treat one. A recent study at Duke Medical Center indicated that having a podiatric specialist as part of your diabetes treatment team significantly reduces diabetic complications.  Wear shoes and socks at all times when you are up and about. Never go barefoot, even inside your house. We have taken everything from toothpicks to chicken bones out of patients’ feet—all preventable just by wearing shoes or slippers when walking. Also look or feel in your shoes before you put them on, especially if you have numbness in your feet.  Protect your feet from hot and cold. Wear shoes at the beach or on hot pavement. Don’t put your feet into hot water. Test water before putting your feet in it just as you would before bathing a baby. Never use hot water bottles, heating pads, or electric blankets. You can burn your feet without realizing it.  Regular exercise. This helps to control weight, regulate blood sugar, and it can even help improve the circulation in your lower extremities.  Lose pounds if you are overweight. Among other things, losing weight takes pressure off your feet. Most foot problems are aggravated by extra weight and some are even caused by it. I have seen many foot problems disappear when patients lose their extra weight.  If you smoke, stop! This just can’t be overstated. Smoking in EVERY case reduces the circulation of blood to your feet and legs. Over 65,000 limbs are amputated each year due

to complications of diabetes. Including a podiatrist in your diabetes care reduces the chances of amputation by 85 percent!  Get started now. Begin taking good care of your feet today.  Set a time every day to check your feet. Don’t wait until you develop a problem. There is nothing like a complication to motivate you, but why wait until that happens? Here is my challenge to you. Pick one of the recommendations above that you are not currently doing and discipline yourself to do it daily for two weeks. When you achieve that success, move on to another one. You’ll be glad you did. It’s hard to talk about diabetes and foot related problems without almost scaring our patients, but the truth is that the complications really are scary. BUT here’s the good news: you don’t necessarily have to ever have one of these issues. If you’ll just follow the recommendations above, you will most likely not be the person who has to be treated for a serious problem, but we’re there if you do!

More information  Raleigh Foot & Ankle Center  American Podiatric Medical Association http://www.  American Diabetes Association  Pedorthic Footcare Association  cond_diabetic_foot.jsp


Cruises provide break for caregivers After restful cruises caregivers return tanned and ready By Alice Osborn

50| September 2011

typical East Coast five-night Western Caribbean cruise will include stops in Fort Lauderdale, Belize, and Cozumel. The price of a Caregiver Cruise is the same if you were to buy it from the cruise line, and all of the workshops and programs are free. T. Patrick Toal, MSW is the event manager of Caregiver Cruises and has worked with people living with dementia for 25 years. He says, “We overstaff these cruises because we want the caregiver to be the care receiver for the duration of the cruise and it’s hard for most caregivers to do.” He also adds that the cruise is not meant for care receivers since the caregiver wouldn’t be able to relax,

making the cruise more stressful than staying at home. Cruises are the ideal getaway because everything’s included—there’s no worry about finding hotels, restaurants, nor is there any car travel/GPS stress. Another great thing about the Caregivers Cruise is that the caregiver can meet people from all over the U.S. and Canada in a similar situation. Toal adds, “A lot of the caregivers I’ve met along the way feel that only other caregivers understand them and when they talk about traveling they really want to be around people like themselves. They want to not just solve the problems of caregiving, but they want empower each other by sharing in

Photo courtesy Caregiver cruises


aregivers need a break from their everyday demands, yet most of them don’t know how to take one. That’s where Durham, NC-based Caregiver Cruises steps in. They call themselves “the caregiver’s life preserver” because the demands on a caregiver can be overwhelming, and the time away on the cruise allows the caregiver to better handle everyday stresses when they return. These four to five day Royal Caribbean cruises allow the caregiver, who works the equivalent of two full time jobs, a chance to receive both support and respite. During the cruises, which are offered several times a year on both coasts, caregivers and their friends have the option of attending presentations, Workshops at Sea seminars coordinated by a geriatric social worker, group shore excursions and massages. The caregiver’s only homework is to relax and renew. A

their own stories.” Toal and his team have been actively promoting the cruises for the last three years and have found that caregivers only want to be away a maximum of five days. “We’ve found that with caregiver guilt, no matter how much money a person has they don’t want to be away from the person they care for that long.” When caregivers leave on their cruise, usually their families co-care with a rotating schedule since they know how much work the caregiver does on an everyday basis. The care receivers also know how much their caregiver must sacrifice for them and oftentimes, they are the ones who are loudest advocates for Caregiver Cruises. Toal tells the story of how Judy, a care receiver thanked him for helping her caregiving husband, Paul, on the cruise. She says that when Paul left he was a crabby, mean old man and when he came back he was the loving husband he used to be. Toal says, “We remind you of how much better you are when you have a break during your cruise. We post ‘Warning! This Is a Stress-Free Zone’ on your cabin door along with other funny reminders of what we need to do as caregivers so we can be the best we can be while we are caring for our loved ones.”

Learn more For more information about Caregiver Cruises, visit www. Home Instead Senior Care hosts a contest and the prize is a Caregiver’s Cruise. Home Instead Senior Care will provide care for the care receiver while the caregiver takes his or her vacation.

Finally! A prescription with side effects you want. Blueberries and red beans, just a few of the many foods rich in antioxidants, are powerful remedies in the fight against cancer. Research shows that fruits, vegetables, and other low-fat vegetarian foods may help prevent cancer and even improve survival rates. A healthy plant-based diet can lower your cholesterol, increase your energy, and help with weight loss and diabetes. Fill this prescription at your local market and don’t forget—you have unlimited refills!

For a free nutrition booklet with cancer fighting recipes, call toll-free 1-866-906-WELL or visit |51

healthy living

Yoga therapy creates more youthful living for seniors Simple exercises increase energy and flexibility


hen I mention that I teach yoga and yoga therapy the most frequent response I hear is “Oh, I can’t do yoga, I’m not flexible.” This always strikes me as odd because one of the benefits of doing yoga is increasing flexibility regardless of where you are starting. Everyone, especially seniors, can improve their range of motion by doing yoga postures that are appropriate for what their body can accomplish using proper alignment. In individual yoga sessions designed for specific therapeutic needs, yoga postures can be tailored to the abilities of the client to help them heal injury and overcome limitations. Practicing yoga will create a greater sense of well-being and higher quality of life. Yoga therapy has a wide range of physical and emotional benefits that can be experienced immediately and progress over time. Yoga postures create more space in the joints which heals injury, increases range of motion, improves physical function and reduces pain. Increased mobility is empowering and therefore emotional well-being is enhanced. In addition, yoga postures strengthen the upper back and open the chest which allows for better posturereversing or slowing the bending of aging. Opening the chest and upper back

52| September 2011

and using the breath circulates oxygen through the cells and enhances the flow of energy. Physically this improves the function of the circulatory system and all the organs of the body. Emotionally, when the heart and chest are open we feel uplifted; the increased flow of energy and oxygen create relaxation and relieve tension that leads to stress and depression. Yoga therapy sessions contain two primary teaching components. After spending a few minutes learning about the client’s health history and injuries, I look at their general posture. Then I first briefly help the student to understand the healthful alignment for his or her body which is called “the optimal blueprint” and how to create it. This simple understanding usually causes an immediate shift in the way the student then moves and stands. This alignment starts from the ground up and it may not be natural at first. Once it is felt and understood, most students will continue to implement it in their daily lives to constantly improve their posture and general well-being. The second necessary part is learning a small set of manageable exercises that will help the student maintain the optimal blueprint. I design a few poses according to the particular ability of the client to lengthen and strengthen

muscles so that they can successfully achieve the optimal blueprint after having held themselves in ways that were not well aligned for the majority of their lives. Usually it is best to do four or five things on a daily basis rather than a long detailed workout once or twice and week. I focus on major areas like the muscles in the chest and upper back, and hips and upper legs so that the spine has more ability to line up properly, unrestricted by the shoulder girdle and pelvis. Just fifteen minutes doing four or five exercises a day can greatly increase the range of motion in the hips, upper and low back, neck and chest-reducing pain and increasing mobility, breath and circulation. Seniors are living longer lives than ever before and it is important that their lives stay active and healthy. The more we limit our movement the less range of motion we will have. It is never too late to start where you are and increase the potential for more physical and emotional well-being. Even people who are fairly restricted in their mobility can do poses from chairs that will improve their health in many ways. Yoga therapy is the perfect solution because it tailors the program to the individual needs of the specific student and offers solutions to any range of issues that are manageable, uplifting and empowering.

Model: Judy Frederick

By Patience Armstrong

Your turn

Outer hip stretch Chest stretch (1) To perform a great simple stretch for the chest and shoulders, start by standing facing a wall with one arm extended shoulder height, palm upward. (2) Take a breath and lengthen the sides of your waist, then externally roll the shoulder back so that the shoulder blade is flat on the back—this part is very important because doing this exercise with the shoulder rolled forward will strain the rotator cuff.

(3) Next, lightly press the outer edge of the hand into the wall and rotate your body slightly away from your extended arm. (4) Hold for several breaths lifting your chest with the breath on the inhale and slightly drawing the center of the head back on the exhale. (5) To come out of the pose, on an inhale, turn back toward the wall before bringing your arm down. (6) Repeat on the other side. (As you become more open you will be able to turn your body farther but be sure to keep the upper arm externally rotated so the shoulder blade is flat on the back.)

Back of leg stretch (1) To do this hamstring stretch start standing with your hands on a chair back or tabletop. Step one leg back and turn the heel of the back foot inward so the toes point slightly out. (2) Draw your front hip crease back to square the pelvis and straighten both legs shifting your weight back into the back leg—be careful not to lock your knees. (3) Then on your inhale, lengthen through the spine and on your exhale bend from the hips folding forward. Remain for several breaths. (4) To come out bend your front leg and step the back leg forward. (5) Repeat on the other side. (As you become more open you will be able to bend farther forward.)

(1) Start by sitting with your hips to the back of your chair, feet facing forward and your spine vertical (don’t lean back). (2) Draw your low back up and in so that there is a natural curve. (3) Then cross one ankle across the other knee. Flex your foot and spread your toes. Use your hand to encourage the leg to open pressing the knee gently downward. (4) Repeat this pose on the other side. (As you become more open, your shin will be more parallel to the floor and you may be able to fold forward over the leg—our model had a hip replacement on the hip she is using so she does this regularly to increase her range of motion).

Note: Even with medical permission, do not continue to do these poses if something doesn’t feel right.

Patience Armstrong is the founder and owner of the Artful Heart Yoga Studio and the North Raleigh School of Yoga. She is a certified Anusara yoga teacher and a Yoga Alliance registered teacher at the E-RYT500 level. Patience’s teaching emphasizes selfhonoring, loving-kindness and aspiring to the highest that is within each of us. www.

the kitchen

Salty warning Lack of salt can be hazardous to your health


udrey Baker grew up watching her mother put table salt on nearly everything — steak, potatoes, even gravy. Believing the nutrition myth that salt is bad for health, Baker sometimes scolded her mom for her salty, old-fashioned ways. As an adult, Baker carefully monitored what she ate, putting herself on a low-salt diet with lots of water. But one day at home, she became lightheaded. Her heart raced, her chest pounded. She called 911 and was rushed to an emergency room. The problem: hyponatremia, a more-common-than-you-mightthink condition in which the blood level of salt (sodium) in your body becomes abnormally low. “That’s when I realized my body does need salt,” says Baker. “They gave me a saline solution drip with sodium in it. It perked me right up. I felt terrific.” Baker isn’t the only person surprised to learn that salt is an essential nutrient. In many ways, it’s this simple: without it, you die; with it

54| September 2011

you can thrive. Still, controversy remains about the best level of sodium in our bodies. Baker’s experience illustrates an important message when it comes to low-sodium diets: Don’t assume a low sodium diet is beneficial to everyone in general and to you in particular. Also, don’t adopt a lowsodium diet until you’ve discussed its


specifically, the study found that even modest reductions in salt intake are associated with an increased risk of cardiovascular disease and death. The study debunks claims made by anti-salt advocates that a populationwide reduction in sodium consumption would benefit public health. In their conclusion, the study’s authors

But I know... that your body does need a certain amount of salt, and it can be harmful to you if you don’t consume enough of it.” potential risks and benefits with your doctor. A May 2011 study published in the Journal of the American Medical Association (JAMA) confirmed that cutting back on salt can indeed be hazardous to your health. More

were clear, if not blunt, that trying to get everyone to cut back on salt is a bad idea: “Taken together, our current findings refute the estimates of computer models of lives saved and Article courtesy of ARA content.

health care costs reduced with lower salt intake. They do also not support the current recommendations of a generalized and indiscriminate reduction of salt intake at the population level.” This is hardly the first medical study at odds with the conventional wisdom of the anti-salt movement. Other studies show:  A low-salt diet leads to higher mortality: An examination of the largest U.S. federal database of nutrition and health (NHANES), published in the Journal of General Internal Medicine, found a higher rate of cardiac events and death with patients put on lowsalt diets — a result perfectly consistent with the latest study.  Risk of diabetes: A 2010 Harvard

study linked low-salt diets to an increase in insulin resistance, the condition that is a precursor to Type 2 Diabetes. Recent studies out of Australia show that individuals with type I or type II diabetes die in much greater numbers when placed on a salt restricted diet.  Falls, cognitive problems among elderly: Because of declining renal function in the aging body, the kidneys retain less sodium. Recent studies have shown that elderly people with hyponatremia have more falls and broken hips and a decrease in cognitive abilities.  Low birth weights, poor brain development: A 2007 study found that babies with low birth weight are also born with low sodium in their blood

serum because their mothers were on low-salt intakes. Another study found that infants with low sodium may be predisposed to poor neurodevelopmental function a decade later between the ages of 10 and 13. No one has to convince Baker about the dangers of a sodiumrestricted diet. Working with her doctor, Baker has changed how she eats, choosing products with sodium throughout the day and, yes, using table salt, just as her mother used to. “It depends what your particular health situation is and what your doctor advises,” says Baker. “But I know from personal experience that your body does need a certain amount of salt, and it can be harmful to you if you don’t consume enough of it.”

You don’t need magic to help kids get healthy Order a free brochure packed with kid-friendly vegetarian recipes and watch their fruit and vegetables disappear —like magic. 1- 8 7 7- 6 8 5 -k i d s or w w w. K i d s G e t H e a l t h |55


Classified To place a classified ad, call 919.747.9031

Physicians needed

Physicians needed

North Carolina

North Carolina (cont.)

Occupation Health Care Practice located in Greensboro, North Carolina has an immediate opening for a primary care physician. This is 40 hours per week opportunity with a base salary of $135,000 plus incentives, professional liability insurance provided and an excellent CME, vacation and sick leave package. Send copies of your CV, NC Medical License, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail:

physician. This established and beautiful facility offers the ideal setting for an enhanced life style. There is no hospital call or invasive procedures. Look into joining this 3 physician facility and live the good live in one of North Carolina’s most beautiful cities. Send copies of your CV, NC Medical License, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, Email:

Family Practice physician opportunity in Raleigh, North Carolina. This is a locum’s position with 3 to 4 shifts per week requirement that will last for several months. You must be BC/BE and comfortable treating patients from 1 year of age to geriatrics. You will be surrounded by an exceptional, experienced staff with beautiful offices and accommodations. No call or hospital rounds. Send copies of your CV, NC Medical License, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail: Methadone Treatment Center located near Charlotte, North Carolina has an opening for an experienced physician. You must be comfortable in the evaluation and treatment within the guidelines of a highly regulated environment. Practice operating hours are 6:00 a.m. till 3:00 p.m. Monday through Friday. Send copies of your CV, NC Medical License, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail: Family Practice physician is needed to cover several shifts per week in Rocky Mount, North Carolina. This high profile practice treats pediatrics, women’s health as well as primary care patients of all ages. If you are available for 30 plus hours per week for the remainder of the year, this could be the perfect opportunity. Send copies of your CV, NC Medical License, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail: Cardiology practice located in High Point, North Carolina has an opening for a Board Certified Cardiovascular 56| September 2011

Board Certified Internal Medicine Physician position is available in the Greensboro, North Carolina area. This is an out-patient opportunity within a large established practice. The employment package contains salary plus incentives. Please send a copy of your current CV, North Carolina medical license, DEA certificate and NPI certificate with number along with your detailed work history and CME courses completed to; Physician Solutions, P.O. Box 98313, Raleigh, NC 27624. Email: or phone with any questions, PH: (919) 845-0054. Locum Tenens opportunity for Primary Care MD in the Triad Area, North Carolina. This is a 40 hour per week on-going assignment in a fast pace established practice. You must be comfortable treating pediatrics to geriatrics. We pay top wage, provide professional liability insurance, lodging when necessary, mileage and exceptional opportunities. Please send a copy of your current CV, North Carolina medical license, DEA certificate and NPI certificate with number along with your detailed work history and CME courses completed to; Physician Solutions, P.O. Box 98313, Raleigh, NC 27624. E-mail: or phone with any questions, PH: (919) 845-0054. Internal Medicine practice located in High Point, North Carolina, has two full time positions available. This well-established practice treats private pay as well as Medicare/Medicaid patients. There is no call or rounds associated with this opportunity. If you consider yourself a well-rounded IM physician and enjoy a team environment, this could be your job. You would be required to live in or around High Point and if relocating is required, a moving package will be extended as part of your salary and incentive package. BC/BE MD should forward your CV, and copy of your North Carolina Medical License to View this and other exceptional physician opportunities at or call (919) 845-0054 to discuss your availability and options.

ď‚Ą Research and technology articles

Classified To place a classified ad, call 919.747.9031

Physicians needed

Practice sales

North Carolina (cont.)


Locum Tenens Primary Care Physicians Needed If you would like the flexibility and exceptional pay associated with locums, we have immediate opportunities in family, urgent care, pediatric, occupational health and county health departments in North Carolina and Virginia. Call us today to discuss your options and see why Physician Solutions has been the premier physician staffing company on the Eastern seaboard. Call 845-0054 or review our corporate capabilities at

Pain Management Practice located in Indiana is now listed for sale. The main practice has been serving the community with two satellites located about 30 miles from the main practice. All three practices are being offered for $785,000 with the main practice building offered for $950,000. The two satellite practices being leased for a very reasonable monthly rent. If you are interested in a Pain Management practice that will generate impressive profits from month one, this could be your opportunity. Contact Medical Practice Listings at (919) 848-4202 for more information. View additional listings at;

Virginia Urgent Care opportunities throughout Virginia. We have contracts with numerous facilities and 8 to 14 hour shifts are available. If you have experience treating patients from Pediatrics to Geriatrics, we welcome your inquires. Send copies of your CV, VA Medical License, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail: Pediatric Locums Physician needed in Harrisonburg, Danville and Lynchburg, Virginia. These locum positions require 30 to 40 hours per week, on-going. If you are seeking a beautiful climate and flexibility with your schedule, please consider one of these opportunities. Send copies of your CV, VA Medical License, DEA certificate and NPI certificate with number to Physician Solutions for immediate consideration. Physician Solutions, P.O. Box 98313, Raleigh, NC 27624, and PH: (919) 845-0054, E-mail:

Medical Practice Listings Medical practice sell - buy View national practice listings or contact us for a confidential discussion regarding your practice options.

919.848.4202 in-house practice experts and attorney 58| September 2011

North Carolina Impressive Internal Medicine Practice in Durham, NC; The City of Medicine. Over 20 years serving the community, this practice is now listed for sale. There are 4 well equipped exam rooms, new computer equipment and a solid patient following. The owner is retiring and willing to continue with the new owner for a few months to assist with a smooth transition. Contact Medical Practice Listings at (919) 848-4202 for more information. View additional listings at: Modern Vein Care Practice located in the mountains of North Carolina. Booking 7 to 10 procedures per day, you will find this impressive vein practice attractive in many ways. Housed in the same practice building with an Internal Medicine, you will enjoy the referrals from this as well as other primary care and specialties in the community. We have this practice listed for $295,000 which includes charts, equipment and good will. Contact Medical Practice Listings at (919) 848-4202 for more information. View additional listings at: Family Practice located in Hickory, North Carolina. Well established and a solid 40 to 55 patients split between an MD and physician assistant. Experienced staff and outstanding medical equipment. Gross revenues average $1,500,000 with strong profits. Monthly practice rent is only $3,000 and the utilities are very reasonable. The practice with all equipment, charts and good will are priced at $625,000. Contact Medical Practice Listings for additional information. Medical Practice Listings, P.O. Box 99488, Raleigh, NC 27624. PH: (919) 848-4202 or E-mail:

Practice for Sale in Raleigh, NC


Primary Care practice specializing in Women’s care

North Carolina Family Practice located about 30 minutes from Lake Norman has everything going for it.

Raleigh, North Carolina The owning female physician is willing to continue with the practice for a reasonable time to assist with smooth ownership transfer. The patient load is 35 to 40 patients per day, however that could double with a second provider.  Exceptional cash flow and profitable practice that will surprise even the most optimistic practice seeker.  This is a remarkable opportunity to purchase a well-established woman’s practice.  Spacious practice with several well-appointed exam rooms, tactful and well appointed throughout.  New computers and medical management software add to this modern front desk environment.   

Medical Practice Listings For more information call (919) 848-4202. To view other practice listings visit

Excellent medical equipment, staff and hospital near-by, you will be hard pressed to find a family practice turning out these numbers.

List price: $435,000.

Call Medical Practice Listings at (919) 848-4202 for details and view our other listings at

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Gross revenues in 2010 were 1.5 million and there is even more upside. The retiring physician is willing to continue to practice for several months while the new owner gets established.

Listing price is $625,000.


OCCUPATIONAL HEALTH CARE PRACTICE FOR SALE Greensboro, North Carolina Well-established practice serving the Greensboro and High Point areas for over 15 years. Five exam rooms fully equipped, plus digital X-Ray. Extensive corporate accounts as well as walk-in traffic. Lab equipment includes CBC. The owning MD is retiring, creating an excellent opportunity for a MD to take over an existing patient base and treat 25 plus patients per day from day one. The practice space is 2,375 sq. feet. This is an exceptionally opportunity. Leased equipment includes: X-Ray $835 per mo, copier $127 per mo, and CBC $200 per mo. Call Medical Practice Listings at (919) 848-4202 for more information.

Asking price: $385,000

Also available online 24/7

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Classified To place a classified ad, call 919.747.9031

Practice for sale

Practice for sale

North Carolina (cont.)

South Carolina (cont.)

Internal Medicine Practice located just outside Fayetteville, North Carolina is now being offered. The owning physician is retiring and is willing to continue working for the new owner for a month or two assisting with a smooth transaction. The practice treats patients 4 and ½ days per week with no call or hospital rounds. The schedule accommodates 35 patients per day. You will be hard pressed to find a more beautiful practice that is modern, tastefully decorated and well appointed with beautiful art work. The practice, patient charts, equipment and good will is being offered for $415,000 while the free standing building is being offered for $635,000. Contact Medical Practice Listings for additional information. Medical Practice Listings, P.O. Box 99488, Raleigh, NC 27624. PH: (919) 848-4202 or E-mail: medlistings@

your own boss and make the changes you want, when you want. Physician will to stay on for smooth transition. Hospital support is also an option for up to a year.  The listing price is $395,000 for the practice, charts, equipment and good will. Contact Medical Practice Listings for additional information. Medical Practice Listings, P.O. Box 99488, Raleigh, NC 27624. PH: (919) 848-4202 or E-mail:

Primary Care practice specializing in women’s care. The owning female physician is willing to continue with the practice for a reasonable time to assist with smooth ownership transfer.  The patient load is 35 to 40 patients per day, however that could double with a second provider.  Exceptional cash flow and profitable practice that will surprise even the most optimistic practice seeker.  This is a remarkable opportunity to purchase a well-established woman’s practice.  Spacious practice with several well-appointed exam rooms, well-appointed throughout.  New computers and medical management software add to this modern front desk environment.   This practice is being offered for $435,000. Contact Medical Practice Listings for additional information. Medical Practice Listings, P.O. Box 99488, Raleigh, NC 27624. PH: (919) 848-4202 or E-mail:

South Carolina Lucrative E.N.T. practice with room for growth, located three miles from the beach. Physician’s assistant, audiologist, esthetician, and well-trained staff.  Electronic medical records, Mirror imaging system, established patient and referral base, hearing aids and balance testing, esthetic services and Candela laser.  All aspects of otolaryngology, busy skin cancer practice, established referral base for reconstructive eyelid surgery, Botox and facial fillers.  All new surgical equipment, image-guidance sinus surgery, balloon sinuplasty, nerve monitor for ear/parotid/ thyroid surgery.  Room for establishing allergy, cosmetics, laryngology & trans-nasal esophagoscopy.  All the organization is done, walk into a ready-made practice as 60 | September 2011

Practice wanted North Carolina Pediatric Practice Wanted in Raleigh, North Carolina Medical Practice Listings has a qualified buyer for a Pediatric Practice in Raleigh, Cary or surrounding area. If you are retiring, relocating or considering your options as a pediatric practice owner, contact us and review your options. Medical Practice Listings is the leading seller of practices in the US. When you list with us, your practice receives exceptional national, regional and local exposure. Contact us today at (919) 848-4202.

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Exceptional North Carolina Primary Care Practice for Sale


Established North Carolina Primary Care practice only 15 minutes from Fayetteville, 30 minutes from Pinehurst, 1 hour from Raleigh, 15 minutes from Lumberton, and about an hour from Wilmington. The population within 1 hour of this beautiful practice is over one million. The owning physician is retiring and the new owner will benefit from his exceptional health care, loyal patient following, professional decorating, beautiful and modern free standing medical building with experienced staff. The gross revenue for 2010 is $856,000 and the practice is very profitable. We have this practice listed for $415,000. Call today for more details and information regarding the medical building. Our Services: • Primary Health • Well Child Health Exams • Sport Physical • Adult Health Exams • Women’s Health Exams • Management of Contraception • DOT Health Exam • Treatment & Management of Medical Conditions • Counseling on Prevention of Preventable Diseases • Counseling on Mental Health • Minor surgical Procedures For more information call Medical Practice Listing at (919) 848-4202. To view our other listings, visit

Great opportunity for anyone who wants to purchase an established business.  One of the oldest Locums companies  Large client list  Dozens of MDs under contract  Executive office setting  Modern computers and equipment  Revenue over a million per year  Owner retiring  List price is over $2 million

Please direct all correspondence to Only serious, qualified inquirers.

Practice For Sale

Large Louisiana Pediatric Practice

Practice at the beach Plastic Surgery practice for sale with lucrative E.N.T. specialty Myrtle Beach, South Carolina Practice for sale with room for growth and located only three miles from the beach. Physician’s assistant, audiologist, esthetician, and well-trained staff. Electronic medical records, Mirror imaging system, established patient and referral base, hearing aids and balance testing, esthetic services and Candela laser. All aspects of Otolaryngology, busy skin cancer practice, established referral base for reconstructive eyelid surgery, Botox and facial fillers. All new surgical equipment, image-guidance sinus surgery, balloon sinuplasty, nerve monitor for ear/parotid/thyroid surgery. Room for establishing Allergy, Cosmetics, Laryngology & Trans-nasal Esophagoscopy. All the organization is done, walk into a ready made practice as your own boss and make the changes you want, when you want. Physician will to stay on for smooth transition. Hospital support also an option for up to a year. The listing price is $395,000. For more information call Medical Practice Listing at (919) 848-4202. To view our other listings, visit

This Louisiana Pediatric Practice treats an average of 30 plus patients per day and is open 4 ½ days per week. The owner/MD treats patients and she has a part time physician assistant that provides a second provider 2 to 4 days per week. Fully equipped and staffed, this practice is ready for the new owner to accept a full patient load. The MD that owns the practice will be moving to join her husband in California during the summer or as soon a proper transfer in ownership takes place. She is more than willing to continue with the practice for a few months to assist with a smooth transfer. Asking price: $165,000 Call Medical Practice Listings today and we will be happy to provide more details regarding this pediatric practice opportunity! (919) 848-4202 | |61

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San Antonio, Texas A low cost of living, large military presence and rich culture make San Antonio more than the site of the Alamo. Its strong health care system, Fortune 500 companies, and national and international attractions perpetually boost this region’s value.


Bellingham, Washington Sitting on Bellingham Bay and overlooked by Mount Baker this town is only 21 miles south of the Canadian border and 90 miles north of Seattle. Bellingham offers water sports, snowboarding, historic tours, hiking and a vibrant art and music scene during the drier summer months. 62 | September 2011


Asheville, North Carolina Asheville boasts a freespirited and rejuvenating culture. Active seniors can enjoy fly fishing, hiking, road cycling, trail running and more in the Pisgah National Forest or the nearby Smokey Mountains.

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Charleston, South Carolina Many retirees settle outside of Charleston in Mount Pleasant, Summerville and Isle of Palms to enjoy more space and still take part in the downtown’s cultural scene. A strong health care system, mild winters, golf and boating make this town a favorite for seniors.

Fayetteville, Arkansas On the outskirts of the Ozarks, Fayetteville is home to the University of Arkansas. With its low cost of living, thriving business environment, postcardworthy views, Fayetteville is a hidden gem.


Fort Collins, Colorado Because of Colorado State University, many high tech companies have relocated to this town that also boasts strong small business and entrepreneurial initiatives. At the base of the Rocky Mountains, the area offers hiking, fishing and of course, skiing.


Raleigh/Durham/Chapel Hill North Carolina This area is anchored by three well-known universities: NC State, Duke University and UNC-Chapel Hill and some of the best health care and research facilities in the world, as well superb cultural attractions. The Triangle has a lot to offer seniors and visitors alike.


San Diego, California Residents say that their town has the best weather on earth and they’re right. Besides seeing wild animals in its world famous zoo, this city is also rich in museums, art galleries, outdoor activities, libraries and sports teams.


Sarasota, Florida This town is a boater’s, sport fisherman’s and golfer’s paradise. Nestled along the Gulf Coast, Sarasota hosts an opera company, art museums, a symphony, the Sarasota School of Architecture and an annual film festival.

Photos of TX, NC courtesy:, SC: Nate Brelsford, CAli: Martyn E. Jones

fter working hard and raising their children, discerning seniors want a retirement location with comfortable seasons, accessible health care, and numerous cultural events. Thanks to AARP and our own polling we’ve gathered our Top 9 list of cities that any senior would be proud to call home!

best cities for seniors


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Med Monthly September 2011  

The September geriatrics issue of Med Monthly magazine.

Med Monthly September 2011  

The September geriatrics issue of Med Monthly magazine.

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