Medicare Health Support

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Medicare Health Support

• Success requires a human connection

2
Re-Hospitalization Prevented for Heart Failure
Beneficiary

• On August 2, 2005, the MHS nurse called Ms. P, a
  78 year old beneficiary with heart failure who
  had been discharged from the hospital on July 25.
  Ms. P told the nurse she had been going to the
  ER at least once a month for my heart. The
  nurse asked what medications or prescriptions Ms.
  P was given when she was discharged from the
  hospital on July 25, and the beneficiary said
  none. The nurse asked whether the beneficiary
  had been taking any medications since she left
  the hospital, and Ms. P said no. The MHS nurse
  inquired further, and found out Ms. P was
  experiencing fluid buildup and her ankles had
  become very swollen.
• Ms. P said she had tried to call her doctors
  office but hadnt been able to reach them. While
  talking to the MHS nurse, she became upset and
  started to cry, trying to explain that she
  thought her insurance had been canceled. The
  nurse found out her sister lived with her and
  asked to speak with the sister. When the sister
  got on the phone, she explained that the nurse at
  the hospital had told them the hospital pharmacy
  would send medicines to their home, but that
  hadnt happened.
• The MHS nurse told the sisters she would call the
  doctors office for them. She then phoned the
  cardiologists office and explained the
  situation, emphasizing that it needed to be
  addressed right away since Ms. P had been without
  medication for almost a week and was experiencing
  fluid buildup. The MHS nurse then called the
  beneficiary to let her know she would be hearing
  from her doctor soon. Since that was late in the
  day, the MHS nurse called the physicians office
  again early the next morning. They said the
  prescriptions were ready and Ms. P could come
  pick them up. The MHS nurse notified the
  beneficiary, who then (despite her swollen
  ankles) took the city bus to the doctors office
  and got the prescriptions. When the MHS nurse
  checked on her again that afternoon, she was
  taking the medications.
• Ms. P was very grateful for the nurses help.
  The nurse set another call with her for the next
  week, and she happily made the appointment.
• --Teri Koppelman, RN

3
MHS Nurse Overcomes Language Barrier for 82 Year
Old Immigrant
On August 2 the MHS nurse placed call to Mr. F,
an 82-year-old diabetic beneficiary. His wife
answered the phone and the nurse began explaining
the MHS program. Mrs. F haltingly said that they
do not speak English well and were not interested
in the program. When the nurse inquired what
language they speak, Mrs. F responded Russian.
The nurse explained that we have Russian
translators, and Mrs. F agreed to speak with the
nurse via a translator. The nurse got the
translator on the line and together they spoke to
Mr. F, who agreed to participate in the MHS
program. Mrs. F returned to the phone and
answered our Senior Assessment questions on
behalf of Mr. F. The nurse picked up on the fact
that the couple doesnt have much money and
mentioned how difficult it must be to pay for all
their medications. Mrs. F said they have always
been very independent and self-sufficient and it
was hard to ask for help. The nurse mentioned
that we have social workers in MHS who may be
able to help them find ways to pay for their
medications. Mrs. F again said that her English
is not so good. The nurse told her she could
talk with the social worker via a translator
also, and Mrs. F breathed a sigh of
relief. Mrs. F then said, in broken English and
without a translator, Now I finally know I am in
America. She thanked the MHS nurse multiple
times and asked what the nurses name was. When
the nurse responded Angela, Mrs. F exclaimed,
I knew you were an angel! The nurse later
recounted, That gave me the chills the feeling
you get when you realize you have touched someone
and made a difference. I now know that I can
make a difference in this program. --Angela
Hoffman, RN
4
Hospitalization Prevented for 87 Year Old

• On Friday afternoon August 19, the MHS nurse
  called Ms. H, an 87 year old beneficiary with
  heart failure and diabetes. Ms. H said she was
  not feeling well that day, but blamed it on the
  high humidity and heat. The MHS nurse became
  concerned as she talked to her further, and
  convinced Ms. H to call her physician and ask to
  see him that day. The physician agreed and she
  went in that afternoon. He examined her and drew
  a blood sample, which showed that her hemoglobin
  count was 25 well below the normal range of 35
  to 40. The physician then ordered an infusion of
  two units of packed blood cells.
• The doctor was grateful Ms. H had come in when
  she did. Since it was a Friday afternoon and her
  blood count was so low, its likely her condition
  would have worsened over the weekend and she
  would have had to be hospitalized by the next
  week had it not been for MHS.
• The MHS nurse called the beneficiary again the
  next week to check on her. Ms. H thanked the
  nurse for her help, and said she would not have
  called her doctor if the nurse hadnt encouraged
  her to do so. Telling the nurse of her
  gratitude, Ms. H added, Its nice to know
  someone really cares.
• --Heather Henry, RN

5
MHS Provides Key Support to 90 Year Old Nursing
Home Resident

• On August 23 the MHS nurse received a frantic
  phone call about 8 p.m. from the daughter of Ms.
  P, a 90 year old diabetic beneficiary in a
  nursing home. Ms. P had agreed to participate in
  MHS on August 17 when the nurse visited her in
  the nursing home and met with her daughter. Her
  daughter mentioned then that her mother had
  developed a bedsore that week, which the daughter
  attributed to the facilitys failure to change
  her mothers position in bed regularly,
  particularly during the night when the daughter
  thought there was insufficient staff at the
  nursing home.
• The daughter was calling the MHS nurse on August
  23 because her mothers condition had worsened
  and the daughter was desperate for advice. She
  had talked to the nursing home administrator
  about the situation that day, but he brought up
  hospice and that upset the daughter.
• The MHS nurse talked with the daughter for about
  30 minutes that night, and gave her a list of
  questions to discuss with the administrator and
  her mothers physician. The MHS nurse also faxed
  a Facility Communication Sheet (form we developed
  for such communications) to the nursing home
  administrator, outlining the daughters concerns.
  The administrator called the MHS nurse when he
  got the fax and was very receptive. He said he
  would meet with the nursing homes Medical
  Director and Ms. Ps attending physician, and
  they would work to resolve the issues.
• The MHS nurse made a follow-up call to Ms. Ps
  daughter on August 26. She said that her mom was
  now being turned every two hours, had a dietary
  consult and change of diet (she had been on a low
  protein diet and needed more protein to recover
  from the bedsore), and was improving. The
  daughter planned to attend the facilitys family
  counsel meeting that night for a further
  discussion of the case.
• The daughter said she believed the MHS nurses
  intervention is what made the difference in the
  nursing homes care for her mother. She
  appreciated the support because she had no one
  else to help her with her mother. The daughter
  thanked the nurse and told her she was truly
  heaven sent.
• --Melissa Jones-Holley, RN

6
Despondent Beneficiarys Life Turned Around
through MHS

• In September when the MHS nurse first spoke to
  Mrs. Y, a 78 year old beneficiary with diabetes,
  she said she was very sad and didnt see any
  reason to go on living. She lives in an
  apartment in the basement of her daughters home,
  but said she hadnt seen her daughter for more
  than two weeks and was feeling isolated.
  Moreover, her right shoulder was very painful
  from a torn rotator cuff. An orthopedist had
  told her a while ago she needed surgery to have
  it repaired, but she had delayed making a
  decision and that orthopedist had retired.
• Recently the pain had increased and she had gone
  to see a new orthopedist, but that visit went
  badly. When the new orthopedist examined her, he
  squeezed her shoulder, which made her flinch.
  She said he then became belligerent and insisted
  I have to touch you. He also refused to look
  at her MRI results and ordered new x-rays. After
  he examined the new x-rays, he said her shoulder
  didnt look so bad and he didnt think she needed
  surgery. Mrs. Y felt the orthopedist hadnt
  listened to her, and she became despondent. As
  she drove away from his office, she ran through a
  red light in the hopes of being killed.
• During the MHS nurses call with Mrs. Y, the
  nurse discussed depression and how a chemical
  imbalance can affect our perception of the world.
  Mrs. Y agreed to see her primary physician about
  how she was feeling, and the physician started
  her on an anti-depressant.
• The MHS nurse re-contacted Mrs. Y after shed
  been on the medication for about a week, and Mrs.
  Y said she was beginning to feel better. Her
  daughter had brought Mrs. Ys new great
  granddaughter to see her that day, and she had
  enjoyed that very much.
• The MHS nurse gave Mrs. Y the phone number for
  the Department of Aging in her county and
  encouraged her to contact them about activities
  that could interest her. Mrs. Y called them, and
  when she mentioned her interest in writing, they
  connected her with a writers group that meets
  regularly.
• When the MHS nurse next spoke with Mrs. Y on
  October 26, she was cheerful and engaging in life
  again. She has an appointment at a pain clinic
  to help manage the pain in her shoulder, and an
  appointment with another orthopedist. She is now
  optimistic about her future -- and very grateful
  to Medicare Health Support.
• --Linda Smith, RN

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Physician and Beneficiary Grateful for MHS
Discovery of Duplicate Medication

• On October 4 the MHS nurse called Mr. M, a 69
  year old beneficiary with heart failure and
  diabetes. She reviewed all his medications with
  him, and discovered that he was taking a double
  dose of hypertension medication (Metoprolol
  Tartrate). He had two containers of the
  medicine, each of which had been prescribed by a
  different doctor. Every day he took the
  prescribed dose from each container in other
  words, a double dose.
• The MHS nurse discussed with Mr. M that his
  physician may not want him taking doses from both
  containers, and neither of the two physicians may
  know that the other prescribed the same medicine.
  She explained the potential for adverse side
  effects and complications, and the possibility
  that those could result in hospitalization.
• The MHS nurse stressed that Mr. M needed to
  contact his primary physician right away and get
  very clear instructions on how to take the
  medicine. Mr. M said he had an appointment with
  his physician the next week and asked if it could
  wait until then. The nurse said no, it really
  shouldnt wait that long. Mr. M asked if the MHS
  nurse would explain all of that to his wife, and
  the nurse did so. The wife said she would call
  the physician that day, and go with her husband
  to see the doctor to hear all that he said. Both
  Mr. and Mrs. M were very appreciative of the
  nurses discovery of the duplicate medication.
  The wife said she would call the MHS nurse back
  the next week to let her know what happened.
• A few days later the MHS nurse got a call from
  Mr. Ms physician. He said Mr. and Mrs. M had
  just been in to see him and told him about the
  situation. The physician had been totally
  unaware that another physician had prescribed
  hypertension medication also and Mr. M. had been
  taking a double dose. During the office visit,
  the physician carefully reviewed all of Mr. Ms
  medications with him and his wife, and instructed
  them on the correct way to take all his
  medications.
• When the physician spoke with the MHS nurse, he
  thanked her for discovering the duplicate
  medication and averting a potentially serious
  medical problem. He also wanted to know Who are
  you and what is this program? The nurse
  explained Medicare Health Support and our staff
  of nurses, social workers and dieticians. The
  physician was very pleased to know there is such
  a program. He noted this patient needs a lot of
  help, and thanked the nurse for all her
  assistance.
• --Lillian Romanek, RN

8
Blind Beneficiary and Physician Grateful for MHS
Help

• In October the MHS nurse called Mr. F, a 65 year
  old diabetic beneficiary who is blind and lives
  independently in a senior home. He sounded very
  weak and sick when he answered the phone. He
  said hed had his first chemotherapy treatment
  that week and had been vomiting for four days.
  He hadnt been given any medication to manage the
  nausea and side effects from the chemotherapy.
  The MHS nurse could tell he was very dehydrated
  and might soon need hospitalization.
• Mr. F said he had no one to help him and didnt
  know what to do. The MHS nurse told him she
  would help him, and Mr. F said he was very glad
  to know there was someone to help.
• The nurse called Mr. Fs oncologist to inform him
  of the patients status. The oncologist said Mr.
  F should come into his office right away to be
  evaluated. Mr. F was transported to the
  physicians office, where he was treated for
  dehydration and prescribed anti-nausea
  medication. The physician was very grateful for
  the MHS assistance, as was Mr. F.
• The MHS nurse also contacted the Adult Evaluation
  and Review Services for that county (a public
  agency that provides home health services), and a
  registered nurse visited him the next day to
  evaluate his needs. She is working on obtaining
  a waiver to help him pay for his medications, and
  evaluating the safety of his current living
  arrangements.
• When the MHS nurse called again on October 27,
  Mr. F had had his second chemotherapy treatment
  but was taking his anti-nausea medication and had
  not had any nausea or vomiting. He was very
  grateful for MHS and the assistance he received.
• --Linda Smith, RN

9
350 Pound Nursing Home Resident Motivated to
Improve Health

• The MHS nurses first visit to Mr. T was
  challenging. A 51 year old beneficiary with
  heart failure and diabetes, Mr. T weighs more
  than 350 pounds, has a tracheotomy, and lives in
  a nursing home. When the MHS nurse arrived, he
  was reluctant to speak with her and seemed
  depressed and down in the dumps. After the
  nurse explained the Medicare Health Support
  program and how it could help him, he agreed to
  talk with her.
• Mr. T said he had refused to get flu or pneumonia
  vaccinations in the past (I dont like shots),
  did not exercise, and had no advanced directives.
  The nurse explained why it made sense to be
  vaccinated for flu and pneumonia, especially
  since he has a tracheotomy, and discussed the
  benefits of exercise and advanced directives.
  She also asked if she could contact Mr. Ts
  sister, who serves as his healthcare power of
  attorney. Mr. T agreed, and the nurse later
  talked at length with his sister.
• When the MHS nurse returned for her second visit,
  Mr. T looked much better and reported that he
  had done everything she asked on the first visit.
  He had gotten flu and pneumonia shots, was
  walking daily, and had filled out the Five Wishes
  advanced directives document she left with him.
  He and the MHS nurse then met with the nursing
  homes social worker to review his advanced
  directives, and Mr. T gave a copy to his
  physician.
• The MHS nurse was very encouraged by Mr. Ts
  receptivity. We have a lot more to work on, but
  this was a fantastic start!
• --Melissa Jones-Holley, RN

10
MHS Helps Beneficiary Get Needed Medications
after Heart Attack

• On November 9 the MHS nurse made a regular care
  call to Mr. R, a 65 year beneficiary with
  diabetes. When she asked how things were going
  since they last talked, he said Not so well. I
  had a heart attack on Friday. He had spent the
  last four days in the hospital and had just been
  discharged. When the nurse inquired further, she
  found out he didnt have three of the medications
  his cardiologist had prescribed at discharge.
  Mr. R told her, I dont know if I can afford
  them at the pharmacy. The VA usually provides
  all my medications, but it takes about two weeks
  to get them since they come in the mail. He was
  upset and said he didnt know where to turn.
  Moreover, he didnt have time to seek help then
  because he was due for a radiation treatment and
  had to drive 30 minutes to get there.
• While the beneficiary went to his radiation
  appointment, the MHS nurse worked on getting him
  the medications. She contacted the cardiologist
  who treated him in the hospital and the VA
  hospital. The cardiologists office provided the
  medications he needed for the short term, and the
  VA mailed his longer term supply. Were it not
  for the MHS nurses quick action, Mr. R could
  well have had to be re-hospitalized.
• --Margaret Frost, RN

11
MHS Helps 83 Year Old Artist Resume Painting

• When the MHS nurse first called Ms. F, an 83 year
  beneficiary with heart failure, she learned the
  beneficiary was an artist who loved to paint.
  Ms. F had been unable to paint for some time,
  though, because of pain and stiffness in her arm
  caused by a 2004 stroke. Those conditions also
  hampered her activities of daily living and made
  it difficult for her to function independently.
• The MHS nurse called the beneficiarys physician
  to suggest physical therapy, as well as a home
  care nurse to administer laboratory tests related
  to Ms. Fs use of the anticoagulant Coumadin.
  Ms. F hadnt been tested for a while because her
  debilitated condition prevented her from getting
  out to a test facility.
• The physicians office followed up right away on
  the MHS nurses request and initiated physical
  therapy and home care services that week. That
  made Ms. F very happy because the therapy enabled
  her to resume painting and greatly improved her
  quality of life.
• --Stephanie Jackson, RN

12
Couple Thankful for Just in Time Advance Care
Planning

• In November when the MHS nurse talked to Mrs. K,
  an 82 year old beneficiary with heart failure and
  diabetes, she had stopped going to her primary
  physician several months before because she
  didnt like or trust him, and had stopped taking
  any medications for her diseases. While
  discussing the need for her to see a doctor
  regularly and take her medications, the nurse
  asked if Mrs. K had talked to her family about
  advanced directives. Mrs. K said she was afraid
  of lingering on machines and wanted to go as fast
  as possible. The MHS nurse encouraged her to
  read and fill out the Five Wishes booklet we had
  sent, and suggested she talk to her husband and
  children about her preferences.
• A few weeks later, Mrs. K informed the MHS nurse
  that she had filled out her Five Wishes. She
  also tried to talk to her husband and children
  about her wishes, but they didnt want to discuss
  it at that time. In addition, she saw a new
  primary physician on December 6 and gave him her
  advanced directives.
• On December 12 when the MHS nurse called again,
  Mrs. Ks husband answered and informed her that
  Mrs. K had had a massive heart attack and passed
  away. He said she woke him about 3 a.m. and told
  him she had chest pain. She then reminded him of
  the Five Wishes and said she did not want
  machines or feeding tubes. When the ambulance
  came to get her, her husband gave them the Five
  Wishes. Mrs. K died on the way to the hospital.
• When the MHS nurse spoke to her husband on
  December 12, he thanked her for all that Medicare
  Health Support had done, and said he did not know
  until she filled out the Five Wishes that she did
  not want to linger on machines. He said he will
  tell his friends about us, and hopes the Medicare
  Health Support program will be expanded so he can
  join.
• --Debbie Cheeves, RN

13
Physicians Office Glad for MHS Patient Support

• On December 2, MHS Provider Support Manager Cindy
  Friend made an introductory visit to a
  physicians office and met with the office
  manager. She gave the office manager a brief
  overview of MHS, and explained the home
  monitoring services that are available for some
  MHS participants. As she talked, the office
  manager looked over the list of the physicians
  MHS patients. Suddenly the office manager
  interrupted to point out a particular patient.
• As the office manager explained, this was an 82
  year old heart failure patient the doctor had
  recently referred to a cardiologist since three
  of the patients heart vessels were almost
  completely blocked. The cardiologist was
  unwilling to operate, however, because of the
  patients co-morbidities and weakened condition.
  The patient had a return visit with the physician
  scheduled soon, and the physician was
  uncomfortable that he had nothing to offer this
  patient.
• The office manager was enthusiastic the physician
  could now offer the patient home monitoring
  through MHS. That would enable the doctor to
  monitor the patient more closely, and would
  provide reassurance to the patient. The office
  manager was grateful that they now have
  something to offer this patient. She concluded,
  Medicare Health Support will be a true asset to
  the health care industry by helping physicians
  address needs, such as this, with their elderly
  Medicare patients.
• --Cindy Friend, RN

14
Beneficiary and Physician Grateful for Prevented
Hospitalization

• On December 6 the MHS nurse spoke to Ms. J, a
  beneficiary with heart failure, diabetes, chronic
  obstructive pulmonary disease, and a history of
  frequent hospitalizations. She was having some
  shortness of breath and coughing up green phlegm.
  The nurse discussed with her that was
  symptomatic of an infection, and with her
  history, it was important to contact her primary
  physician. Ms. J was resistant at first and
  fearful she would be hospitalized again, but she
  promised to call her doctor. She got in touch
  with him that day, and he gave her a prescription
  for an antibiotic. When the MHS nurse spoke with
  Ms. J again later that week, she was improved and
  glad she had contacted her doctor.
• On December 12 Ms. J called the MHS nurse to say
  she had gotten worse. The nurse encouraged her
  to go see her doctor again, which she did that
  day. He found she had a lung infection and put
  her on another antibiotic and prednisone. The
  physician said, I dont know who youre talking
  to, but Im impressed.
• Ms. J feels she would have been hospitalized if
  it werent for Medicare Health Support. She said
  she is grateful for our calls, and loves Medicare
  and the Medicare Health Support program.
• --Margot Levin, RN

15
MHS Nurse Saves Life of Diabetic Beneficiary

• On January 5 the MHS nurse received a call from
  Ms. B, a beneficiary she had not been able to
  reach since late November. During the November
  call, Ms. B reported she had fallen and suffered
  knee damage, but did not want to go to the
  doctor. Concerned about Ms. Bs condition, the
  MHS nurse phoned her daughter to ask if the
  mother could come stay with her for a while, and
  the daughter agreed.
• Ms. B was calling back in January to tell the MHS
  nurse what had happened and to thank her for
  saving her life. Two days after the November
  call, Ms. B suddenly collapsed at her daughters
  home. She had not been testing her blood sugar,
  and developed acute renal failure. Her daughter
  summoned an ambulance and she was rushed to the
  hospital. She was in a coma in the ICU for
  nearly a week, but had slowly recovered and just
  been discharged.
• Ms. B was calling to tell the MHS nurse that, If
  you hadnt urged me to call my doctor and go to
  my daughters house, I would have slipped into a
  coma at home -- and probably died. You saved my
  life!
• Charlotte Stritehoff, RN

16
Beneficiary Gains Peace of Mind from Advance
Care Planning

• While talking to Ms. W, an 80 year old
  beneficiary with heart failure and diabetes, the
  MHS nurse asked if she had received the Five
  Wishes booklet on advance care planning we sent.
  Ms. W said she had received and read it. Because
  she and her husband had been very sick recently,
  it had gotten her thinking about what she wanted.
  She remembered the MHS nurse saying that when
  her mother filled out her advanced directives and
  pre-paid her funeral expenses, it had been a gift
  the nurse still thanked her for, and it helped
  the family so much when her mothers condition
  worsened.
• Ms. W said she had tried to talk to her children
  and husband about the subject, but they didnt
  want to hear about it. So she filled out the
  Five Wishes and gave a copy to her children and
  all her doctors, as well as all the hospitals
  where she might be taken. She then went to the
  funeral home and pre-paid her funeral expenses.
• Her husband sat in the car while she did that and
  refused to come in. After thinking a week about
  her husbands refusal to discuss his advanced
  directives and funeral, she filled out advanced
  directives for him and pre-paid his funeral
  expenses.
• She now feels peace and comfort knowing that the
  future is taken care of and everyone knows what
  she wants. She thanked Medicare Health Support
  for sending the Five Wishes and getting her
  thinking about all of this.
• --Debbie Cheeves, RN

17
You saved my life!MHS Nurse Discovers Ten-Fold
Medication Overdose

• On January 15, Martin Luther King Day, the MHS
  nurse had a care call with Ms. A, a 72 year old
  beneficiary with heart failure and diabetes. The
  beneficiary had just been discharged from the
  hospital the day before, and had been given
  discharge and medication instructions by a
  hospital nurse.
• The MHS nurse went over Ms. As medications, and
  she reported taking four and a half 25 mg tablets
  (112.5 mg total) of Coreg that morning per the
  discharge instructions. Knowing that was a large
  overdose, the MHS nurse asked if she could call
  the beneficiarys pharmacist to check the
  prescription. The beneficiary agreed and the
  nurse called the pharmacist, who said the
  prescription was for 12.5 mg not 112.5 mg. The
  MHS nurse tried to call the beneficiarys
  cardiologist and primary physician to report the
  problem, but both offices were closed for the
  holiday. The nurse then called the hospital
  emergency room, which instructed her to call the
  Poison Control Center. The Poison Control Center
  said there was nothing the beneficiary could do
  herself to counteract the overdose, and she
  should immediately be taken to the hospital.
• The MHS nurse called 911 and an ambulance was
  dispatched. The nurse cautioned Ms. A to not get
  up or walk around as she waited for the ambulance
  (since she could have blacked out). The nurse
  also called the beneficiarys daughter (who lived
  a few minutes away) to inform her of what was
  happening, and ask that she come unlock the house
  for the paramedics and accompany her mother to
  the hospital. When the paramedics arrived, they
  confirmed that the handwritten hospital discharge
  instructions cited the wrong dosage. They took
  the beneficiary to the hospital, where she stayed
  for eight hours for treatment and monitoring.
• The MHS nurse called the beneficiary the next
  morning to see how she was doing. Ms. A told the
  nurse, You saved my life I know you saved my
  life! She repeatedly thanked the MHS nurse, and
  readily agreed to begin our home monitoring
  program.
• --Amy Taylor, RN
• Coreg is a medication that reduces blood
  pressure. That large an overdose could have
  caused a heart attack or stopped the
  beneficiarys heart. It was fortunate the MHS
  nurse spoke to Ms. A only an hour after she took
  the medication since it takes about eight hours
  for the medication to reach full effect. In
  addition, the beneficiary was planning to take
  the same dose again that night per the discharge
  instructions.

18
85 Year Old Beneficiary Hand Delivers Medication
List to MHS

• On January 19 an MHS nurse spoke with Mr. S, an
  85 year old beneficiary with diabetes. She
  reviewed his medications, but Mr. S was somewhat
  confused about which ones he should be taking
  currently. He agreed with the nurse to go over
  that with his physician on his next visit, and
  let us know his current medications on our next
  call.
• A few days later, the MHS office was surprised
  when Mr. S showed up at our doorstep with his
  list of current medications. He had just been to
  see his doctor and gone over his medications as
  wed instructed. He wanted to report that to us
  right away, so drove more than 25 miles to hand
  deliver the medication list.
• The MHS staff thanked Mr. S for his prompt
  follow-up, but urged him not to make the drive
  again for his own safety, and to call us on our
  toll-free line whenever he needs to talk with us.
  His quick and conscientious actions show his
  appreciation for Medicare Health Support and
  dedication to improving his health.

19
Beneficiarys Leg Saved through MHS Efforts

• In December when the MHS nurse called Ms. S, a 67
  year old beneficiary with heart failure and
  diabetes, Ms. S reported that she had lower leg
  wounds that had been worsening over the last
  several weeks. She didnt have a physician she
  liked, so the MHS nurse guided her through
  selecting a new primary physician through the
  doctor referral service at her local hospital.
  The nurse then made several calls to the new
  physician and faxed information to expedite her
  care.
• When Ms. S went to see the new physician, he
  immediately referred her to a dermatologist --
  who she said made all the difference in the
  world to me. Through his care her wounds began
  to heal, and by late January when the MHS nurse
  talked to Ms. S, they were almost completely
  healed.
• Ms. S believes the MHS nurses efforts saved my
  leg. She is very grateful to MHS, and expresses
  renewed commitment to self-management of her
  diabetes and health.
• --Debbie Dellinger, RN