Department of Developmental Services
Office of Quality Management

Living Well
FALL/WINTER 2015-2016

	

Department of Developmental Services 
Office of Quality Management

Living Well Fall/Winter 2015-2016

Welcome to the Fall/Winter 2015-2016 issue of "Living Well", a publication of the Department of Developmental Services, Office of Quality Management.   "Living Well" is published on a semi-annual basis and features important information for individuals and their supporters.  

In this edition, you will find helpful information to assist people you support to enjoy winter activities in a safe and healthy manner.

"Living Well” represents one component of DDS's continuing commitment to share information which will safeguard and improve individuals’ quality of life.  Information and knowledge is a powerful tool.  We hope that this and future editions of "Living Well" will be used effectively to enhance the health and well-being of individuals we support.

We'd welcome your feedback and suggestions regarding content areas for future editions of the publication.  Please submit your suggestions to Sharon.Oxx@state.ma.us.  Thank you!

Elin M. Howe, Commissioner
Department of Developmental Services

DDS  Medicare Part D 2016 Update

Information about the 2016 Medicare Part D prescription plans is available at www.medicare.gov. Plan enrollment can also be done from this site.

No 2015 Low Income Subsidy (LIS) plans will be terminating or will no longer be LIS plans in 2016. So anyone already enrolled in an LIS plan from 2015 can remain in that plan for 2016 unless they want to change. There will also be one new LIS plan in 2016.

Any individual that we support who has Medicaid (Masshealth, Commonwealth) and Medicare is considered dually eligible and should be enrolled in one of the 6 Low Income Subsidy (LIS) plans available in 2016 in Massachusetts. They are:
•	Humana Preferred RX Plan 
•	Wellcare Classic 
•	Aetna medicare RX Saver (Formerly called: Aetna CVS/Pharmacy Prescription Drug Plan) 
•	United Healthcare: AARP Medicare RX Saver Plus 
•	Silverscript Choice
•	Symphonix Value RX  * NEW	

Enrollment starts Oct.15 – Dec. 7, 2015 and the plan will be effective Jan.1, 2016

Remember:

•	Dually eligible individuals (those with both Medicare and Medicaid) can change their plans as often as they want (monthly).

•	All duals should be in a LIS plan if they want to avoid monthly premiums and have copays reduced/ limited copays. Duals living in DDS funded community residences should have no copays with a LIS plan.

•	If you need any help, contact Sharon Oxx at Sharon.Oxx@state.ma.us or call 617-624-7792.

     WINTER  WEATHER  SAFETY

Snow can be beautiful as it falls, but dangerous as it accumulates on the ground.  So…

•	Make sure equipment for shoveling is in good repair and readily accessible.
•	Make sure outdoor lighting is operating properly. Darkness falls early in winter and navigating icy paths without proper lighting can be treacherous.  
•	Have salt or sand handy to use after a snowfall or when icy. Place it in readily accessible places both inside and outside.
•	Now that the equipment is handy, shovel quickly after a snowfall and use salt or sand on icy surfaces to ensure that all exits, not just the main exit from the home, are clear and safe to travel at all times.  Also remember that wet leaves and grass can be slippery too.  
•	Keep a couple of blankets in the trunk in case you break down or get stuck. It will keep people warm while you wait for help to arrive. Remember, people who are not able to move around much on their own will feel the cold much more quickly. Never leave anyone unattended in the vehicle for any reason.
•	Have flashlights strategically located in the event of a power outage.
•	Individuals should be dressed warmly with properly fitting clothing. Several thin layers will help keep them dry as well as warm. Clothing should include long johns, turtlenecks, one or two shirts, pants, sweater, coat, warm socks, boots, gloves or mittens, and a hat. 
•	Do not let individuals stay out in the cold too long.  Time limits depend on how cold it is.   Call individual inside periodically to warm up. 
•	When possible, individuals who are particularly at risk (e.g. elderly, people with poor circulation, non-ambulatory status) should not go outdoors when bitterly cold. 
•	Use common sense: For example, if there is a cold or frostbite warning issued, do not let the individuals go outside at all.  If they must go out, accompany them and ensure that they continue to wear the protective clothing (such as coat, hat, and gloves) throughout the time that they are outdoors. 
•	 Make sure the individual’s clothing is dry.  Change into dry clothing immediately as wet clothing can make frostbite occur quicker.
•	Change the batteries in all battery operated smoke detectors, carbon monoxide detectors and flashlights.
•	Ensure that the fireplace is inspected and cleaned for winter use.
•	Arrange for the furnace to be inspected and cleaned, and ensure that there is plenty of fuel to begin the winter.  Space heaters should not be utilized as a heating solution. 
•	Make sure that all outside heat ventilation outlets are free from snow and  debris. 
•	All residential locations are required to have at least one Carbon Monoxide detector within 10 feet of bedroom doors. 
•	Continue to ensure that there is adequate staffing, especially during and around holidays, winter storms, and possible illness.
•	Inform all staff of individuals’ holiday plans and routines.

Preparing for a Disaster Emergency

Disasters can happen anytime, anywhere, and sometimes without warning. A winter storm could keep you and those you care for at home for days. A fire, flood, tornado, or any other disaster could stop water, electricity, and telephone services. You could have to leave the home. 
Be prepared for a disaster emergency before it happens. Make a Disaster Supplies Kit. Keep these supplies on hand:
•	Water – a 3-day supply for each household member
•	Food – a 3-day supply for each household member
•	First Aid Kit
•	Essential medications – prescription and over-the-counter     
•	Special equipment and supplies for individuals with special needs
•	Generator, if an individual is dependent on machines using electricity
•	Sanitation supplies (toileting and hygiene)
•	Flashlight with extra batteries
•	AM/FM portable radio with extra batteries
•	Cellular phone with extra battery
•	Cash
•	Extra clothing and bedding
•	Important documents
•	A copy of the Emergency fact Sheet for each individual
•	Important phone numbers
•	Other tools and supplies

Tip: Keep the phone number of an out-of-state or out-of-immediate- area contact person in the Disaster Supplies Kit. Sometimes, it is easier to contact a person in another state or out of the area during a disaster.
For more information on Disaster Planning, contact the Federal Emergency Management Agency (FEMA) at 800-480-2520 or 800-621-3362 (TTY). You can also contact your local American Red Cross Chapter. Many communities have community emergency or disaster teams that work with FEMA and can give people local help.

         

You’re Mother Was Right…Wash your Hands! 

The return of cold and flu season seems the right time to review with everyone the need to wash their hands often, including the hands of the people we support. Besides the flu vaccine, hand-washing is cited as being the single most preventative step you can take to protect yourself from the flu. Recent studies have confirmed that hand washing with soap and water or applying alcohol-based hand rubs between caring for different individuals and throughout the day reduces the transmission of bacteria or viruses (germs) significantly; in some settings as much as 85%!  Below are some facts that you may find very interesting and that may help you, your family and the people with whom you work to stay healthy, especially during flu and cold season.

•	The CDC is recommending the use of alcohol-based hand rubs for people who provide personal care to others because they can address some of the obstacles staff encounter when taking care of people. For example, lack of appropriate hand-washing opportunities when out in the community.  Alcohol-based hand rubs significantly reduce the number of germs on the skin, are fast-acting and cause less skin irritation than many soaps. Allergies are very uncommon. You should rub your hands until they are completely dry.

•	Hand-washing with soap and water is still highly recommended to reduce the spread of germs. Soap breaks down dirt and germs and “traps” them so they can be washed away with water. Use of liquid or foaming soaps in pump bottles is better than bars of soap that can “hold” germs on their surface

•	You should wash your hands for the length of time it takes you to sing “Happy Birthday”. 

•	The use of gloves does not eliminate the need for hand-washing and hand washing does not eliminate the need for gloves. Gloves reduce hand contamination by 70-80%, prevent spreading germs to others and protects everyone from infection. Hand rubs should be used before and after care is provided just as gloves should be changed before and after providing care. 
 
•	Staff should avoid wearing artificial nails and keep natural nails less than ¼” long if they are caring for individuals at high risk for acquiring infections. 
 
•	Just as you encourage people to “cover their nose or mouth” when coughing or sneezing, you should encourage them to wash their hands after doing so as well as frequently throughout the day. 

Remember, the infection you prevent may be your own!

Do I Just Have a Cold or Is It …..THE FLU?!! 

Flu season is upon us (November through April) and everyone should be alert to early signs and symptoms of the disease. But how do you know if it’s the flu or just a cold (rhinovirus)? Here are some clues:

If you have the flu…

•	You have a fever (sometimes as high as 102+) Know a person’s normal body temperature. A change in their normal temperature by as little as 2 degrees is significant and should be reported to their Health Care Provider or the agency nurse immediately.
•	You have a headache 
•	You are very tired (can even be extreme)
•	You have a dry cough (that may progress to a productive cough) 
•	You may have a sore throat
•	You have nasal congestion
•	You have severe body aches
•	It probably came on quite suddenly (some people can even tell you the moment they felt ill) 
•	You will be very ill for several days and take up to several weeks to recover fully
•	You are unable to go about your daily routine

If you have a cold…..

•	You probably don’t have a fever (and if you do it is very low grade)
•	You have a runny nose
•	You may have a loose productive cough
•	You may have a headache from coughing
•	You are able to continue your daily routine
•	You feel a little “under the weather” for a few days 
•	The symptoms probably came on gradually over several days

Uh oh, I have the flu. Now what do I do?
•	The flu is very contagious so stay home! 
•	Rest
•	Drink plenty of liquids
•	Wash your hands often!
•	Avoid alcohol and tobacco
•	Take medication to treat the symptoms (like acetaminophen for the aches and pains and cough syrup for the cough)
•	Never give aspirin to a child or teenager who has the flu! (it can cause serious neurological damage)
•	See your physician if you are not improving after several days.

Well…how contagious is it? 
•	A person can spread the flu starting one day before they feel sick
•	Adults can continue to pass the flu virus to others for another 3-7 days after symptoms start (children can pass it on for longer than 7 days)
•	Symptoms start 1-4 days after the virus enters the body

•	Some people can be infected with the virus but have no symptoms. They can still pass the virus on to others though. 
•	( I don’t know how you are supposed to spot these people)

How did I get it?
•	The flu is spread when a person who has the flu coughs, sneezes or speaks and sends flu virus into the air and other people inhale the virus
•	The virus enters the nose, throat, lungs of a person and begins to multiply, causing flu symptoms. 
•	Flu may, less often be spread when a person touches a surface that has flu virus on it -a door handle for instance- and then touches his or her nose or mouth.

How do I prevent the flu?
•	This is a very simple answer: Get a flu shot!  While it is best to get one before the end of November, it is never too late.. 

Information about where flu shots are being offered in your area can be found by going to: www.Masspro.org.

Warning Signs That a Person 
is Having Swallowing Difficulty				

Individuals served by DDS have a higher incidence of aspiration pneumonias and choking. This is usually caused by an issue they have with swallowing that may be due to a physical or medical problem or may be a side effect of a medication. If such a problem is noticed it must be brought to the attention of the Health care provider. 

Some of the signs and symptoms of difficulty swallowing listed below can occur during or after meals.

o	Gurgle/wet voice quality

o	Weight loss for unknown reason / malnutrition

o	Frequent respiratory infections

o	Dehydration

o	Aspiration pneumonia

o	Low-grade temperature or spiking a temperature 30 minutes to 1 hour  after meal

o	Prolonged change in appetite

o	GERD (Regurgitating food/vomiting/gagging/rumination) 

o	Coughing or excessive throat clearing during meals or after meal

o	Food remaining in the mouth after eating/swallowing (pocketing)

o	Audible and/or multiple swallows on a single mouthful of food or   liquid

o	Incidents requiring the use of the Heimlich Maneuver

o	Impulsive behavior during meals ~ overstuffing food in the mouth or stealing food or guzzling liquids

o	Food or liquids coming out of the nose

o	Initially very hungry but quickly becomes disinterested in eating

General Rules for Safe Dining

•	Check for upright posture, close to table.  Provide lap trays or other supportive equipment as needed.
•	Provide needed adapted dining equipment as specified by dining plan.
•	Never offer a tablespoon for eating non-finger foods.  Use of tablespoons can result in putting too much food in the mouth at once. 
•	Serve small to moderate amounts of food at a time as per individual need to discourage overfilling of utensil and the mouth at one time. This will also decrease spillage and increase dignity when dining. 
•	Serve small amounts of a beverage at a time.  Encourage sips throughout the meal to help with safe swallowing.  Allow for a drink at the end of the meal for clearing of mouth and throat.  “Guzzling” beverages is an unsafe behavior.
•	A fork provided for cut-up finger foods may promote a safer eating pace as needed.
•	Avoid dumping food into one pile on the plate, e.g. pasta, chips, fruit, cereal bar. Separate food or offer separately.
•	Follow individual protocols to the letter as these have been devised for the purpose of keeping the individual safe while dining as well as to promote nutrition, dignity, and independence.
•	Request assistance from familiar staff if you are not sure or do not understand a dining program.  Do not guess as you may be putting someone at risk
•	Report any suspected eating, chewing or swallowing problem to your supervisor.
•	Offer the individual their glasses, hearing aids or dentures prior to dining.
•	Try to reduce chaos and distractions in the environment.  Eating should be fun, relaxing and pleasurable.  Turn down the television, play soft music and reduce clutter.
•	THERE IS NO SUBSTITUTE FOR CLOSE SUPERVISION DURING DINING!

Bowel Obstruction

A bowel obstruction can be an extremely serious and dangerous condition. If not treated promptly it can cause death within a few hours. A bowel obstruction is any blockage in the bowel that prevents bowel contents from passing through.

What are some of the risk factors?
•	Abdominal surgery may cause scar tissue to develop that can contribute to blockage
•	Cancer or tumors can be increase the risk 
•	Congenital abnormalities (problems at birth) of the bowel
•	A history of constipation
•	Poor dietary habits (food and fluid): Adequate fluids are needed to prevent the body from reabsorbing fluid from the bowel which, in turn, causes the stool to be hard. Adequate roughage is needed to stimulate muscle activity in the bowel to push the stool along.
•	Lack of adequate exercise due to physical restrictions: An air-fluid lock can collect in the bowel loops and the smooth muscle of the bowel may be too weak to push the fluid along. Exercise helps strengthen those muscles.
•	Medications can cause constipation as a side effect.

How can I prevent it?
•	Know the person’s medical history. If they have a history of any of the above risk factors, closely monitor them for signs and symptoms of obstruction.
•	Consult with the person’s Health Care Provider to determine if an exercise regimen is indicated and support the person in following it.
•	Ensure that the person gets adequate fluids. Everyone should consume at least eight 8-ounce glasses of non-caffeine beverages per day. More in warm weather.
•	Consult with the person’s Health Care Provider or dietician regarding the amount of fiber or roughage that should be included in their diet.
•	Monitor for constipation. If the person cannot reliably self-monitor or self-report or if more than one person is responsible for the care of the person, it is highly recommended that a monitoring and documentation system be in place to consistently provide a record of the person’s bowel habits that can be shared with the Health Care Provider. 

What are the symptoms of bowel obstruction?
•	Lack of appetite
•	Severe, sharp, intermittent abdominal cramping or pain
•	Vomiting. It may be frequent, sudden in onset, abundant, foul in odor.
•	Lack of stool (bowel movement)
•	Dehydration ( may be due to vomiting) Signs of this may include intense thirst, drowsiness, general malaise, achiness, parched tongue, sunken eyes, fever)
•	Abdominal distention or bloating

What do I do if I see any of these signs and symptoms?
•	Notify the person’s Health Care Provider
•	If the symptoms are serious or the individual looks extremely ill, call 911 
•	Inform whoever may be treating the person of their bowel habits, risk factors and last bowel movement. 

An X-ray is needed to identify the level of obstruction and its cause and therefore the mode of treatment. Care providers need to provide accurate, timely information to health care practitioners in order to assure prompt and effective intervention.

Constipation

 The body gets rid of waste through bowel movements. Every person has a pattern that is normal for him or her, whether the person moves his or her bowels once a day or every three days.  The bowel movements should be soft, formed and it should not hurt or cause bleeding.    
If a person has a bowel movement (stool) less often than usual, then they may become constipated.  Constipation occurs when too much water is absorbed from the stool in the intestine and the stool becomes hard and dry.  Constipation can often be prevented by increased fluid and fiber intake.

Symptoms of Constipation:
•	Less frequent bowel movements (fewer than usual pattern)
•	Stools that are hard, dry, difficult to pass
•	Grunting or straining during bowel movements
•	Swollen belly
•	Belly tenderness
•	Increased gas, either flatus or burping
•	Decreased appetite 
•	Small amounts of liquid stool (liquid stool leaking around hard stool)

What causes constipation?
•	Decreased fluid intake 
•	Some medications, especially antipsychotics, muscle relaxants or pain medications
•	Drug toxicity
•	Decreased physical activity like walking
•	Neuromuscular disease, such as cerebral palsy
•	Physical deformities that affect the intestine
•	Lack of enough fiber in the diet
•	Changes in toileting routines
•	Stress
•	Pain when eliminating – may be caused by hemorrhoids, skin irritations
•	Obstruction in the intestine

What Should You Do?
Call 911 if the person appears:
•	Gravely ill
•	Gray in color
•	In severe pain 
•	Has large amounts of blood in their stools

In other situations:
•	Consult your nurse or health care consultant
•	If the individual is sick, call the health care provider
•	If the person is constipated, increase fluid, dietary fiber and exercise
•	Check their bowel pattern over the past few days.  If the person has only had small movements over the past few days, they may need a laxative (stool softener). Consult their health care provider or their routine orders for laxatives
•	Notify your health care provider if there are no results from laxatives
•	Notify your nurse/health care consultant/health care provider if the person is constipated more than twice per month.
•	Tell other care takers what you know and see
•	Write down what you see