No one wants to go to a hospital, much less stay there. Unless it’s absolutely necessary, we would rather stay at home, living independently. And if we can, we should. This much we know for sure.
That’s why health-care professionals still make house calls. At this very moment, right in your own community, maybe even next door, some of your neighbors are quietly receiving health-care services at home. 
Each year, some 69 home health-care organizations in West Virginia send professional caregivers — nurses, therapists, social workers and others — to look after an estimated 22,000 patients.
That’s the good news.
Yet the value of health care at home — the lifeline it literally represents for millions of Americans, especially the elderly, the chronically ill, the homebound — remains little recognized, seldom appreciated and largely misunderstood.
It’s still a well-kept secret. In all the recent debate over health-care reform, all too many Americans, elected officials and citizens alike, have overlooked the advantages of health-care services delivered right to your doorstep.
As a result, vast needs are still going unmet. An estimated 12 million Americans currently receive health care at home, according to the National Association for Home Care & Hospice. Yet to the best of my knowledge, no organization tracks the untold millions of patients who are no doubt either going without health care at home or getting less than clinically needed.
That’s the bad news.
Consider the context. The aging of the American population is accelerating. And about three in four of Americans age 65-plus have multiple chronic conditions such as diabetes, high blood pressure and COPD.
More Americans, especially older ones, are living alone than at any time in history, too. Nearly a third of all households in the U.S. have just one resident — a total of 31 million of us, compared to just four million in 1950. And the Baby Boomers now turning age 65 at the rate of roughly 10,000 per day may well prefer to live alone more insistently than previous generations.
If the problem here is an aging, chronically ill America, one solution is health care at home. But before we can leap ahead, we have to take a few baby steps. The medical community, including physicians, medical schools and hospital administrators, will need to better define health care at home — exactly what it does, why it matters and how it makes a difference — in order to make it real and bring it to life for patients and family caregivers.
For example, health care at home is widely perceived, mistakenly, to be merely custodial, almost a matter of hand-holding and baby-sitting. In fact, home health is a multi-dimensional, multi-disciplinary provider of superior post-acute clinical service. The profession is increasingly adopting an innovative new model and getting more directly involved in patient care than ever before.
Plainly put, home health-care professionals routinely manage medications (our average patient takes 12 different kinds), change bandages, clean surgical wounds, administer essential therapy — sometimes in the form of injections and intravenous fluids — and do so compassionately, empowering patients (ours average 81 years of age) to live with dignity.
That kind of highly focused, deeply intimate attention, one-to-one and day-by-day, yields concrete rewards. Thanks to such services, according to the Centers for Medicare and Medicaid, patients under home health care sometimes move better, eat better, breathe better, suffer less pain, and generally function better.
In the best of scenarios, those unable to walk can once again climb to the top of the stairs. The man who lost the power of speech can once again tell his wife he loves her. We receive thousands of letters from grateful patients and families telling us as much.
Big picture, evidence is mounting that health care delivered at home may enable patients to live longer lives and, equally important, better ones. It can shorten hospital length of stay and lower readmissions. In the process, it is proving to do exactly what most needs to be done — namely, raise quality of care, improve patient outcomes and drive down costs.
As such, then, home health care is emerging as a microcosm of what the health-care system should be doing across the board. It gets us where we live. After all, true health-care reform should always start at home.

Robie practices family medicine with Nitro Primary Care. He is a regional medical director for Amedisys Home Health and Hospice.

Red Meat Scare

On March 12, 2012 a study was published in the Archives of Internal Medicine (http://archinte.ama-assn.org/cgi/content/full/archinternmed.2011.2287) which was then picked up by the media. The conclusion of the study states “Red Meat consumption is associated with an increased risk of total CVD (an abbreviation for heart attack and stroke), and cancer mortality. In layman’s terms it says if people eat fewer then 0.5 servings of red meat a day, 9.3% of deaths in men and 7.6% of death’s in women could be prevented.

SO if we look no farther the recommendation would be to live longer eat less Red Meat. However I have some issues with the study. First it was what we call a prospective cohort which is basically a survey of what you eat. It appears the questionaries were sent every four years and ranged from “never eat” to “eat 6 or more times a year.”

So imagine doing a survey asking you how often you eat beef, pork, etc… I am not sure how accurate I would be. I can’t even remember what I ate yesterday.

Most physicians would feel comfortable preaching a diet of moderation and a diet that is well balanced. I don’t think anyone would recommend six servings of red meat a day but I think red meat is still very safe in moderation.

If you are concerned about your diet or want some personal diet education contact your physician today.

Most people are not aware that they have Diabetes Mellitus, often simply referred to as diabetes, when first diagnosed. Some of the first symptoms a person has are sometimes subtle. The classic symptoms of extreme weight loss, excessive thirst, and urinating all the time only happen when your blood sugars get extremely high. If you fall into a pre-diabetic area then your symptoms maybe nonexistent. So what is one to do?

Are You High Risk?

Well first off if you are high risk, meaning overweight, seditery lifestyle, heart disease, or high blood pressure then you likely need to get a HgA1C (hemaglobin-A-1-C). The HGA1C will give you a percentage that your doctor can tell what your blood sugars over the last three months has been. The HGA1C works by calculating the percentage of sugar on a blood cell. Think of sweet tea, the more sugar in the water the higher amount of sugar will attach to each tea molecule. The great thing is a blood cell only lives for about three months, so every three months you get a new picture of what has been going on.

Now with this HgA1C number your doctor will put you in one of three areas: Normal, Pre-diabetic or Diabetic. If you are normal you are good to go, but if you are high risk as mentioned above you should still work on lifestyle modification and recheck your HgA1C in one year.

Diet and Exercise with Diabetes

If you are in either a pre-diabetic stage or actually diabetic this is where the hard work starts. First, you need to assess your diet closely. Take away all simple sugars including sweets, candy and non-diet drinks. After getting rid of these you need to focus on carbohydrate management. Start by switching all grains to whole wheat. If looking for a bread, sour dough is the best for having a low sugar load but if you don’t like the taste a good whole wheat will work well. After diet changes you also need to increase your daily activity and exercise. Finally, as a pre-diabetic your physician may start you on a medication if you are at high risk for heart attack or stroke. The most common medication for this is glucophage. Glucophage simply makes your insulin work better.

Of course if you are diagnosed with diabetes it can get a little more complicated. Over the next several weeks we will address different areas of diabetes including treatment, lifestyle changes, and preventative health practices for the diabetic.

As many enjoyed a weekend of great NFL football, some people may have asked what all the pink was about. The pink was the NFL’s way of promoting breast cancer awareness to the casual football fan.

Like many other organizations, the NFL has decided to take part in National Breast Cancer Awareness Month. The first NBCAM started in 1985 as a week-long event to raise awareness of breast cancer. According to the American Cancer Society, 2.5 million people in the U.S. can claim to be breast cancer survivors.

One of the amazing statistics about breast cancer is the power of the physician. In one study 94% of women whose physicians recommended mammograms had obtained 1 in the last two years, while only 36% of women whose physician had not made the recommendation had done so.

Breast Cancer Prevention

One of the earliest signs of breast cancer in women can be a subtle finding on mammogram before it can even be felt. Because of this the American Cancer Society recommends:

1. Women over the age of 40 obtain regular mammography
2. Obtain annual clinical breast exams
3. Perform monthly self breast exams
4. Obtain a risk assessment from a physician

Early Signs of Breast Cancer

A women should also be aware of the early signs of breast cancer which include

1. Any new, hard lump or thickening in any part of the breast
2. Change in breast size or shape
3. Dimpling or puckering of the skin
4. Swelling, redness or warmth that does not go away
5. Pain in one spot that does not vary with your monthly cycle
6. Pulling in of the nipple
7. Nipple discharge that starts suddenly and appears only in one breast
8. An itchy, sore or scaling area on one nipple

As with any type of cancer prevention mammograms and breast exams are not perfect. Thats why it is important to talk to your physician to develop any individual prevention plan that takes into account your family history as well as other influencing factors.

For more information on Breast Cancer please take a look at the following links:
- NBCAM.org ~ Celebrating 25 years!
- Breast Cancer Research and Facts from the CDC
- CancerCare ~ Free, professional support for anyone affected by cancer

October is Breast Cancer Awareness Month – Please pass this on!

A well-planned day of out-of-office visits can be as productive as a day in the office, and with great reward.

Nitro Primary Care is one of the few practices in the area that offers home visits. I truly enjoy visiting patients that are homebound or in personal care homes and assisted living facilities in order to provide a level of care to them that they would not receive otherwise.

Years ago physicians did home visits as part of their normal daily routine. But as the pressure from managed care and government payers increased, practitioners felt the pressure to decrease overhead and modify patient visits.

In my opinion, a well-planned day of out-of-office visits can be as productive as a day in the office, and with great reward. The patients I see, by definition, are homebound. Medicare has developed fairly strict guidelines but, in essence, if it is a taxing effort to leave the house and on a regular basis the patient does not leave the home, they are considered to be homebound. Medicare has put in exceptions such as religious events, short trips to the hair dresser and such.

I prefer to do the home visits in conjunction with a home health company. This allows for a whole team approach to care and for multiple disciplines to be involved in the care of the patient. Most home health companies offer physical, occupational and speech therapy as well as skilled nursing and social worker consults.

With modern technology there is little we can’t do in the home. I can easily check blood pressure, pulse, oxygen levels, and glucose. We can draw any blood work you may need, as well as have a portable X-ray technician come to your house and perform X-rays. With the use of smart phones and iPads we can do EKGs and review your medical records from our office or even get your records from local hospitals.

Home visits also allow us to reduce readmission to the hospital. Recent studies published in the New England Journal of Medicine (Jencks SF et al. N Engl J Med 2009;360:1418-1428) showed that over 50% of those readmitted in Medicare did not have an outpatient visit. We know that a comprehensive transition to home discharge plan that includes nurse visits, as well as good physician follow-up, can reduce readmissions.

If you or a family member are homebound I encourage you to find a physician that is willing to do home visits. A great source is the American Academy of Home Care Physicians.

Finding the right fit and availability in your area may be a challenge, but physicians do still make house calls.

PSA stands for Prostate Specific Antigen, and until recently we would recommend a PSA for all men over the age of 50. However the times, they are a changing. If you are contemplating whether or not to get a PSA, read on.

First lets look at the basics.

Prostate cancer is, of course, cancer of the prostate. But what is the prostate? It is a walnut-sized gland that makes the fluid that carries sperm. A man has a 16% chance of being diagnosed with prostate cancer and a 3% chance of dying from it. When ranked for men over the age of 45, prostate cancer ranks fifth behind heart disease, lung cancer, stroke, and emphysema.

African Americans and people with a family history of the disease are at higher risk of developing prostate cancer.

The symptoms of prostate cancer as well as many benign prostate disorders can include:

• blood in urine
• the need to urinate frequently
• weak or interrupted urine flow
• pain or burning when urinating
• inability to urinate
• constant pain in the lower back, pelvis,or upper thighs

The current screening techniques include digital (finger) rectal exam, and PSA.

How accurate are these screening tests?

If 100 men over the age of 50 get a PSA

• 85 will be normal and 15 will be elevated
• of those 15 only 3 will actually have cancer

So what is a man to do?

I believe that the medical literature is starting to show the downside of checking PSA. Imagine yourself to be one of those 12 men who had an abnormal PSA. You would undergo weeks of uncertainty and multiple biopsies to find yourself cancer-free. The flip-side of this is if you happened to be one of the three patients whose life could have been potentially saved.

Due to the very nature of prostate cancer, it is very likely that these patients would not die from the disease. But in any case, what is the right answer?

It is important that you talk to your doctor, look at your risk factors, look at your life expectancy and together, make an informed decision. For more information, take a look at the the CDC prostate cancer handout.

Today was a first for me. For the first time in my short career I admitted three patients to Hospice. I have admitted dozens of patients to them over the years but never three in one day. The word ‘Hospice’ can evoke different feelings for different people, and today each patient evoked a different feeling for me.

Big Heart

The morning began with rounding in the hospital. This is where the word Hospice evoked a feeling of failure for me. I have been treating a women for almost seven years now. She was one of the first patients I began to see as an intern in residency. Over the years she has had multiple health issues but at this time her COPD had finally won. This patient who we will call Mrs. BH for (Big Heart) has at times put her health to the back burner to take care of her daughter who has down syndrome. Mrs. BH told me today that she was done and just wanted to go home. The problem was that I wasn’t done…I wasn’t ready for her to go home. I wanted to save Mrs BH. I could keep her in the hospital, continue IV medications and even help her breathe if she needed it. However, her soul was done fighting.

As her name states, Mrs. BH’s biggest concern was her daughter. She had me promise to her that I would take care of her and watch over her when Mrs. BH was no longer here on earth. I found myself writing the order for Hospice and thinking Mrs BH must not understand. I am usually a big advocate for hospital at home situations and moving patients to Hospice when they are ready. But for the first time, the patient was ready before the doctor. I went back in the room twice to reconfirm that Mrs BH understood and each time the answer was the same.

Severe Dementia

As I made it to the office a wife of one of patients called to ask us if we could refer her husband who we will call Mr. SD (severe dementia) to Hospice. Mr. SD has recently had several hospitalizations and, like Mrs. BH, did not want to go back. The idea of Hospice was comforting with this patient. Mr. SD would be able to remain at home with his wife as his multiple health issues slowly take his earthly body from him. In my opinion, allowing patients to die with dignity at home is the greatest benefit of home care and Hospice.

Breast Cancer

The final emotion evoked today was that of frustration with our medical community. It was late in the day when Mrs. BC (Breast Cancer) called, with tears in her voice. Mrs. BC had only recently become a patient as she was homebound and needed a physician to see her at home. I did only a few home visits at that point but each time felt sincere gratitude from the family. Mrs BC had been suffering from metastatic breast cancer for several years and was told on the last admission that there was nothing else that could be done.

Mrs. BC was recently admitted to the tertiary care center where it was determined that Hospice was her only option. The reason the patient had called crying is that she felt alone. Whether it was a misunderstanding on the patient’s part or a miscommunication between the discharge planning team, the patient felt that her oncologist, as well as myself, had left her to face this part of her cancer alone. This was very frustrating to me as I was not aware of the patient being discharged, let alone to sent to Hospice. We quickly comforted Mrs. BC, called Hospice to switch attending and set up a home visit to check on her.

Situations like these allow me to gain a better understanding of what patients and their families feel when Hospice becomes involved. As each patient has a different story, a physician’s perspective is ever-changing.

That’s my Hospice from a Primary Care Perspective.

Care to share your thoughts?

About two years ago I was reconnected with a person from my past. I wasn’t best friends with this guy but knew him and his family well.

It had probably been a year or two since I had seen him when I got a call from the ER. It was my day on unassigned and God decided to recross our paths. It was the very common ER call of a man who says he got bit by a spider in the elbow area. In case you are not familiar, in WV we have a huge problem with “spiders” that bite people right over top of a vein in the elbow. It is the same type of abscess you see when someone uses a dirty needle to inject opiods.

As usual this patient told me he was cleaning out the barn and got bit. I knew the patient had trouble in the past with drugs but I gave him the benefit of the doubt. In the coarse of his hospital stay I continued him on the narcotics he was prescribed for a previous, work-related lower back injury.

When he got out of the hospital I agreed to continue to see him but told him we had to try to start decreasing some of his narcotics. He was “behaving himself,” never asked for refills early and always passed his drug screens. The last time I saw him we continued to decrease his dosage. I then received a call that the patient had overdosed and died with a needle in his arm. An empty bottle which he had filled two days prior with my name on it was found in his room.

I couldn’t help but feel responsible for his death. This gave me a great desire to study addicts and try to help them.

Suboxone is a drug used to aid the symptoms and cravings one has as they begin withdrawal. In my program, it is mandatory that they receive counseling at the same time as the suboxone therapy.

I explain to the participants that if they broke their leg a doctor would perform surgery and give them crutches. The surgery fixes the problem and the crutches help support you while the body heals. I believe that when dealing with drug addiction, the Suboxone is the crutch and the counseling is what heals the patient.

My ultimate dream is to develop a non-profit that would have a farm where these patients can recover in the safe and friendly Christian environment that will maximize their success.

This is why I started a Suboxone program.