April 2010, Issue 21 - Coram CVS Specialty Infusion Services

elebrateLife
For Home TPN and Tube Feeding Patients
Antiemetic Options
Just the Facts...
Gastroparesis, What Do
We Know?
Enteral Feeding
with Gastroparesis
Managing Medication
Shortages
Answering the Call
How to Manage Healthcare
Claims Rejections
April 2010 | Issue 21
A publication of
Contents
April 2010 | Issue 21
4 Antiemetic Options
Patients on TPN may experience nausea and vomiting, but these side effects can be alleviated. There
are many treatment options and antiemetic (anti-nausea) medications available that can help.
9Just the Facts… Gastroparesis, What Do We Know?
Gastroparesis is a complicated syndrome in which the muscles in your stomach don’t
function normally. Learn about its symptoms and how it can be managed.
12 Enteral Feeding with Gastroparesis
A jejunostomy tube (J-tube) can be used to provide adequate nutrition when an
oral diet is not possible or is insufficient. It can also assist in leading a full and active
life by supporting adequate nutrition intake and aiding in nausea control.
14 Celebration of Life Circle Award Winner: Susan Husker
Susan is a testament to a positive outlook and perseverance. The time constraints of
infusing TPN did not stop Susan from maintaining an active lifestyle, volunteering,
or training for her EMT certfication.
15 FYI: How to Manage Healthcare Claims Rejections
Having a healthcare claim rejected does not necessarily mean that it’s the
final verdict. People who fight back often do win. The key is knowing how to
communicate with the insurance company and being persistent.
17 Industry Insights: Managing Medication Shortages
Medication shortages occur at various levels in the healthcare delivery system.
Learn how to better manage a shortage by understanding your options.
19 Answering the Call: Access to information regarding
your billing just got easier…
Coram has helped develop a new informational brochure, Your Guide to the Billing
Process, to help to make access to billing information as easy as possible.
Celebrate Life
The Quarterly Magazine for Home TPN
and Tube Feeding Patients
Celebrate Life Staff
Carlota Bentley, Managing Editor
Karen Hamilton, Clinical Editor
Nancy Geiger Wooten, Design and Layout
Contributing Writers
Brenda Gray, Pharm D
Mark DeLegge, MD
Linda Gravenstein, Consumer Advocate
Karen Hamilton, MS, RD, CNSD
Jennifer L. Shobert, RPh, MBA
Celebrate Life is published quarterly and provided as a free
service to parenteral and enteral consumers. Opinions
expressed by contributing authors and sources are not
necessarily those of the publisher. Information contained in
this magazine is for educational purposes only and is not
intended as a substitute for medical advice.
Do not use this information to diagnose or treat a health
problem or disease without consulting a qualified
physician. Please consult your physician before starting
any course of treatment or supplementation, particularly
if you are currently under medical care. Never disregard
medical advice or delay in seeking it because of
something you have read in this publication.
© 2010 Coram, Inc. All rights reserved. No part of this
publication may be distributed, reprinted or photocopied
without prior written permission of copyright owner. All
service marks, trademarks and trade names presented
or referred to in this magazine are the property of their
respective owners.
We welcome your comments, stories and suggestions.
Please send all correspondence to:
Coram, Inc.
Celebrate Life
555 17th Street, Suite 1500
Denver, CO 80202
20 Small Steps to Big Steps – Informational Teleconference Series
23 Advocacy Corner
2 | Celebrate Life | April 2010, Issue 21
COR09007-0410
A Note from
Our Guest Editor
I feel very honored to be the guest editor for this issue of Celebrate Life.
Coram is passionate about caring for and providing support to nutrition
patients, and taking care to coordinate services with all the health
professionals involved in your care.
Although a pharmacist by training, my official job is to oversee the clinical and business operations at two
of Coram’s branches. The most important aspect of my job is to make sure everyone on Coram’s team is
working to make things as easy and convenient as possible for you. I can assure you that our desire is to
meet your needs, not just fill your prescription. After having worked for nine years in hospitals, developing
TPN formulas, and treating related GI conditions, I recognize that Coram’s nutrition care models that of
the hospital, where pharmacists, dietitians, nurses, and physicians consult to develop the best care plan
for each patient. However, for us the most important individual in the plan of care is you! We are here to
serve you, and our goal is to make you as comfortable and confident with your diagnosis and treatment
as possible. Therefore, your input and decisions are important in designing a care plan that works for you.
We value your input, and encourage you to call us with any questions, concerns, or suggestions.
This is an exciting time of year for nutrition medicine. The American Society for Parenteral and Enteral
Nutrition, or A.S.P.E.N., held their annual Clinical Nutrition Week in February. This meeting is dedicated
to specialized nutrition support research and practice, and is highly regarded by nutrition experts
nationwide. Many clinicians involved in nutrition gathered from around the country to participate
in seminars conducted by the leading experts in nutritional diagnosis, treatment, and care. Coram is a
proud sponsor of the conference, and many Coram staff members attended, bringing new insights in
clinical practice back home to incorporate into your ongoing care. In fact, many of the experts giving
these presentations were from Coram! If you didn’t know already, leading experts in nutrition care work
right here at Coram. Our experts taught clinicians about homecare best practice as well as presenting on
topics such as vitamin D, enteral nutrition, and transitioning patients from hospital to home.
In this issue, you will find information on gastroparesis — what it is, how it happens, and treatment
options. For TPN patients, medication used to treat nausea and vomiting are reviewed. For enteral patients,
J-tube feeding considerations are presented. You will also find tips for understanding and dealing with
medication backorders, reducing stress at mealtimes, and managing healthcare claim rejections. I hope
you find this issue interesting and helpful. Remember, the Coram team is here to help you. Our goal is
to benefit your life through nutrition therapy. Your communication is one of the aspects that makes
us better at providing nutritional care. That means we want to talk with you about your challenges and
successes in nutrition care. We look forward to hearing about your experiences!
Sincerely,
Jennifer L. Shobert, RPh, MBA
Branch Infusion Manager, Coram
3
Antiemetic
Options
By Jennifer L. Shobert, RPh, MBA
Patients on TPN may experience nausea
and vomiting, but these side effects can
be alleviated. There are many treatment
options and antiemetic (anti-nausea)
medications available that can help.
4 | Celebrate Life | April 2010, Issue 21
About Antiemetics
Nausea may be related to a primary disease, a side
effect of medication, or may not be explained by
any other conditions. There are many treatment
options to help provide relief of these symptoms.
Medications that alleviate nausea and vomiting
are called antiemetics.
There are many medications now available to
treat nausea and vomiting. The newer drugs also
have multiple formulations so they can be given
without aggravating a patient’s symptoms. Each
type of antiemetic also has a specific way that it
works in the body. Sometimes you may have to
try a few different antiemetic medications before
you find the one that works best for you.
Antiemetic Administration
A primary consideration for TPN patients is
how the antiemetic is administered. Taking
medication by mouth may not be feasible for
some patients. Others may not have restrictions
on oral intake, but have limited absorption from
their gastrointestinal (GI) tract, and therefore are
not candidates for oral medications. Additionally,
if vomiting is ongoing or caused by oral intake,
medications that are swallowed may not be
retained, leading to ineffective treatment.
There are now many methods of administration
available, and for TPN patients with intravenous
(IV) catheters, injectable medications are also
an option. A list of administration methods and
their medical abbreviations is outlined on page 7.
Choosing an Option
body process. The following information reviews
antiemetic medications, divided by what action
they have, as well as their class. Medications
are assigned to a class when they have similar
properties and chemical structures. The drugs
are listed with the trade or brand name first, then
their generic name in parentheses.
ACTION: Reduction of Gastric Acid
CLASS: Antihistamine (H2 Antagonist)
Histamine, a natural substance in the body, acts
with the H2, or parietal cells, in the stomach to
increase gastric acid secretion. H2 antagonists
(also known as H2 blockers), prevent the activity
of H2 cells, thereby reducing the production of
gastric acid. Decreased gastric acid production
in some patients results in fewer symptoms
of heartburn and reflux. This drug must be
absorbed into the bloodstream before it
becomes active. Regular and consistent use is
required for benefit. Side effects are minimal, but
may include dizziness, headache, constipation,
and diarrhea. This class of medications is
composed of Tagamet® (cimetidine), Pepcid®
(famotidine), Axid® (nizatidine), and Zantac®
(ranitidine).
A note on Tagamet (cimetidine) — Tagamet was
the first drug in this class to be approved. After
widespread use, many drug-drug interactions
were established. Cimetidine has the ability to
either increase or decrease the effects of many
medications, leading to toxicity or limited effect.
Now that all the oral medications in this class are
available without a prescription, cimetidine is not
typically recommended.
Frequently, symptoms of nausea and vomiting
are associated with, or triggered by certain body
processes. An antiemetic can then be chosen
by your physician for its action on the identified
5
ACTION: Reduction of Gastric Acid
CLASS: Proton Pump Inhibitors (PPIs)
Proton pump inhibitors are so named because
they inhibit the pump mechanism that produces
gastric acid in the stomach. Heartburn and reflux
areoftenrelievedthroughtreatmentwithPPIs.Just
as with the H2 blockers, this type of medication
requires absorption into the bloodstream.
Consistent use is required to achieve desirable
results. Manufacturer products in this class
include: Prilosec OTC® (omeprazole), Prevacid®
(lansoprazole), Kapidex™ (dexlansoprazole),
Nexium® (esomeprazole), Protonix® (pantoprazole),
and Aciphex® (rabeprazole). Common side
effects include headache, dizziness, flatulence,
and taste distortion.
ACTION: Reduction of Vomiting Stimulation in the Brain
CLASS: Serotonin Antagonists
(5-HT3 Receptor Antagonists)
This class of medications blocks the action of
serotonin, which reduces stimulation of the
vomiting center in the brain and blocks activity in
the small bowel. Available drugs in this class are
Zofran® (ondansetron), Anzemet® (dolasetron),
and Kytril® (granisetron). Side effects are
minimal, but can include headache, diarrhea,
fatigue, and disruption to normal heart rhythm.
ACTION: Reduction of Vomiting
Stimulation and Gastric Acid
CLASS: Antihistamines (H1 Antagonist)
Histamine activates secretions from the glands
in your mouth and eyes by acting on the H1
cells. This in turn, can trigger increases in gastric
acid secretion in your stomach and make
your symptoms of nausea worse. Histamine
6 | Celebrate Life | April 2010, Issue 21
can also stimulate a vomiting response from
the brain. Administration of an antihistamine
prevents histamine’s normal actions and
results in decreased stimulation of the brain’s
vomiting response, reduced gastric acid,
and leads to dry mouth and eyes. Useful
antihistamines are: Unisom® (doxylamine),
Dramamine® (dimenhydrate), and Benadryl®
(diphenhydramine). Drowsiness, which can be
severe, is the most common side effect. Urinary
retention and rapid heart rate are also known
side effects.
Phenergan® (promethazine) blocks the action
of both histamine and dopamine. In the brain,
histamine and dopamine trigger different
centers to stimulate a vomiting response.
Promethazine is able to work against both
stimuli as well as block histamine and dopamine
activity in the gastrointestinal tract. Side effects
include those reported from antihistamines, as
well as low blood pressure and IV injection site
problems. Extrapyramidal symptoms (Parkinsonlike movements) are related to promethazine use
and require discontinuation of promethazine as
well as treatment of symptoms.
Transderm Scōp® (scopolamine) inhibits the
action of histamine and acetylcholine in both
the brain and the GI tract. The benefit of this
medication is that it comes in a small patch
that can be left on the skin for up to three
days. Scopolamine has the same side effects as
antihistamines, as well as confusion, irregular
heart rate, and elevated eye pressure. This
medication should not be used in patients with
some forms of glaucoma.
continued on page 8
Antiemetic Medications
Action
Reduce
Gastric Acid
Class
Antihistamine,
H2 Antagonist
Reduce Vomiting
Stimulation and
Gastric Acid
Increase
Movement in
the GI tract
Generic Name
Administration
Options*
Generic
Available
Prescription
Only
Can Add
to TPN
Pepcid®
Famotidine
PO, IV
Yes
PO – no
IV – yes
Yes
Zantac®
Ranitidine
PO, IM, IV
Yes
PO – no
IM – no
IV – yes
Yes
Axid®
Nizatidine
PO
Yes
No
---
Prilosec OTC®
Omeprazole
PO
Yes
No
---
Prevacid®
Lansoprazole
PO, IV
No
Yes
No
Kapidex™
Dexlansoprazole
PO
No
Yes
---
Nexium®
Esomeprazole
PO, IV
No
Yes
No
Protonix®
Pantoprazole
PO, IV
No
Yes
No
Aciphex®
Rabeprazole
PO
No
Yes
---
Serotonin
Antagonists
(5-HT3 Receptor
Antagonist)
Zofran®
Ondansetron
PO, ODT, IV, SC
Yes
Yes
No
Anzemet®
Dolasetron
PO, IV
Yes
Yes
No
Kytril®
Granisetron
PO, IV
No
Yes
No
Antihistamines,
H1 Antagonist
Unisom®
Doxylamine
PO
Yes
No
---
Dramamine®
Dimenhydrate
PO, PR
Yes
No
---
Benadryl®
Diphenhydramine
PO, IM, IV
Yes
PO – no
IM – no
IV – yes
No
Phenergan®
Promethazine
PO, PR. IM, IV
Yes
Yes
No
Transderm
Scōp®
Scopolamine
TOP
No
Yes
---
Reglan®
Metoclopramide
PO, IM, IV, SC
Yes
Yes
No
---
Erythromycin
PO, IV
Yes
Yes
No
Proton Pump
Inhibitor
Reduce Vomiting
Stimulation in
the Brain
Brand Name
Prokinetic
*Administration Options
IM = Intramuscular
IV = Intravenous
ODT= Orally disintegrating tablet (see also SL).
PO = Oral
PR = Rectal
SC or SQ = Subcutaneous
SL = Buccal or Sublingual. Dissolves in saliva and is absorbed into the bloodstream through the
membrane under the tongue. Most manufacturers label these tablets as ODT (See ODT).
TOP or TP = Topical. Usually a patch that sticks to the skin. Medication is released from the patch
and absorbed through the skin into the bloodstream.
7
Antiemetic Options (continued from page 6)
ACTION: Increasing Movement
through the GI Tract
CLASS: Prokinetic
Reglan® (metoclopramide) exerts antiemetic
properties through several actions. In the
brain, metoclopramide blocks dopamine and
serotonin. GI movement speed (motility) and
stomach emptying time are also accelerated
without added gastric acid. Extrapyramidal
symptoms also limit the use of this medication.
Erythromycin is an antibiotic that also increases
movement through the GI tract. Lower doses
than needed to treat infections are used.
Erythromycin may cause nausea in some
patients. Other side effects include irregular
heart rate, headache, abdominal pain, cramping,
and diarrhea. Typically, this drug is not used for
long-term treatment. Many medications have
drug interactions with erythromycin, so care
must be taken to screen all current medications
for potential risk.
Conclusion
When it comes to nausea and vomiting, many
patients experience significant discomfort and
disruption to their life. In order to treat these
symptoms when they become uncomfortable,
each patient’s underlying medical conditions
must be considered. Medication treatment
should be tailored to alleviate symptoms,
minimize side effects, prevent aggravating other
conditions, and avoid drug interactions.
If you are experiencing nausea and vomiting, talk
to your physician or Coram pharmacist who can
help you identify the medication that may work
8 | Celebrate Life | April 2010, Issue 21
best for your unique needs. Gaining control of
the symptoms, often through antiemetic use,
offers patients improved quality of life and
avoids nutritional depletion as well as minimizing
physician visits and hospital admissions. t
References
1. Nausea and Vomiting – Acute. DISEASEDEX General Medicine Clinical Review.
Available at: http://www.thomsonhc.com. Accessed January 7, 2010.
2. Flake ZA, Scalley RD, Bailey AG. Practical Selection of Antiemetics. American
Family Physician. 2004; 69:1164-1176.
3. Lacy CF, Armstrong LL, Goldman MP, Lance LL. Lexi-Comp’s Drug Information
Handbook. Hudson, OH: Lexi-Comp; 2008.
4. Micromedex Heathcare Series. Available at http://www.thomsonhc.com.
Accessed January 7, 2010.
5. Facts & Comparisons. Available at http://online.factsandcomparisons.com.
Accessed January 7, 2010.
Just the Facts…
Gastroparesis, What Do We Know?
By Mark H. DeLegge, MD, Coram Medical Director, Professor of Medicine,
Director of Digestive Disease Center, Medical University of South Carolina
Definition
Gastroparesis: a condition in which the muscles in
your stomach don’t function normally, resulting
in delayed or halted stomach emptying, causing
nausea, vomiting, bloating, discomfort, poor diet
tolerance, and weight loss.
Introduction
Gastroparesis is a complicated syndrome. The
bottom line is that there is a problem in which
the stomach takes a long time to empty its
contents. It often occurs in people with diabetes
but can also occur with abdominal inflammation,
scleroderma, vagus nerve damage, and use of
anticholinergic medications.
The vagus nerve, originating in the brain,
controls the movement of food through the
digestive tract. If the vagus nerve is damaged
(say by surgery or a disease) the muscles of the
stomach and intestines do not work normally,
and the movement of food is slowed or stopped.
Diabetes can damage the vagus nerve if blood
glucose levels remain high over a long period
of time. High blood glucose causes changes in
nerves and damages the smaller blood vessels
that carry oxygen and nutrients to the nerves.
These nerves then do not work as well.
The Signs and Symptoms
of Gastroparesis
• Nausea
• Vomiting of undigested food
• Lack of appetite
• Heartburn and regurgitation
• An early feeling of fullness when eating
• Weight loss
• Abdominal pain
Any of these symptoms may be mild, moderate,
or severe. Not all symptoms need to be
present for the patient to have the diagnosis of
gastroparesis.
Managing Your Blood Sugar
If you have diabetes, gastroparesis can make its
management difficult. When food that sits in
the stomach and then finally enters the small
intestine and is absorbed, blood glucose levels
can rise quickly. Or, if the food remains in the
stomach and never enters the small intestine (or
empties in small amounts), blood sugar levels
can fall. Since gastroparesis makes stomach
emptying unpredictable, a person’s blood
glucose levels can be all over the map, from low
to high, and therefore difficult to control.
9
Other Major Causes of Gastroparesis
Besides gastroparesis being brought on by
diabetes, other diseases associated with
gastroparesis include post-viral syndromes,
surgery on the vagus nerve (such as after a
partial gastrectomy), medications (particularly
anticholinergics and narcotics), and smooth
muscle diseases such as scleroderma or
amyloidoisis. Sometimes we do not know the
cause of the gastroparesis — this is referred to
as “idiopathic.”
Diagnosis of Gastroparesis
The diagnosis of gastroparesis may be made by
a number of tests. After taking a patient history
that is consistent with gastroparesis, tests can
be ordered to confirm the diagnosis. These tests
commonly include:
• Gastric-emptying scan: This is the gold
standard for diagnosis. You will eat
food that contains a slightly radioactive
substance that will show up on the scan.
After eating, you will lie under a machine
that detects the radioisotope and shows
an image of the food in the stomach and
how quickly it leaves the stomach. There
are “normal” gastric emptying times to
compare to.
• Barium x-ray: You will drink a liquid called
barium, which coats the inside of the
stomach, making it show up on the x-ray.
Normally, the stomach will be empty of all
food after 12 hours of fasting. If the x-ray
shows food in the stomach, gastroparesis
is likely.
• Upper endoscopy: After giving you a
sedative, the doctor passes a long, thin tube
called an endoscope through the mouth
and guides it down the esophagus into
10 | Celebrate Life | March 2010, Issue 21
the stomach and small intestine. Through
the endoscope, the doctor can look at
the lining of the stomach to check for any
abnormalities that could be causing a
delay in food emptying from the stomach.
With gastroparesis, the doctor often sees
retained food in the stomach.
Medications for Gastroparesis
Several drugs are used to treat gastroparesis.
Your doctor may try a drug or combination of
drugs to find the most effective treatment. The
most common medications include:
• Metoclopramide (Reglan®): This drug
stimulates stomach muscle contractions
to help empty food. It also helps reduce
nausea and vomiting. Metoclopramide
is taken 4 times a day before meals. Side
effects of this drug are fatigue, sleepiness,
depression, anxiety, and the development
of neurological problems, such as “twitches.”
• Erythromycin: This antibiotic also improves
stomach emptying. It works on receptors
of the stomach called “motilin” receptors.
Side effects are nausea, vomiting, and
abdominal cramps.
• Domperidone: This drug is not currently
available in the U.S. but is used elsewhere
in the world to treat gastroparesis. It is a
pro-motility agent like metoclopramide.
Domperidone also helps with nausea.
Diet and Gastroparesis
Changing your eating habits may help control
gastroparesis. Generally this revolves around the
concept of not overfilling your stomach. Try to
eat six small meals a day instead of three large
ones. Sometimes, liquid meals such as over–thecounter nutrient drinks move from the stomach
to the small intestine more easily than solids.
Liquid meals provide all the nutrients found in
solid foods. High fat foods can slow digestion,
and you may be asked to
limit fats in your diet. Some
foods containing poorly
digestible fiber can result
in the formation of a bezoar
(a large mass of undigested
food that clumps together)
in the stomach. A large
bezoar can cause pain or
blockage of the stomach.
Ask your dietitian for tips
on a healthy diet if you
have been diagnosed with gastroparesis or slow
gastric emptying.
Treatment of
gastroparesis
focuses around
diet alterations
and medications
Feeding Tubes
If other approaches do not work, you may need
a feeding tube. The tube, called a jejunostomy
tube (J-tube), is inserted through the skin on
your abdomen into the small intestine. It can
be done via endoscopy by a gastroenterologist,
in the operating room by a surgeon, or with
fluoroscopy by a radiologist. The feeding tube
allows you to put nutrients directly into the small
intestine, bypassing the stomach altogether.
You will receive special liquid food to use with
the tube called enteral nutrition or tube feeding.
A pump is needed to infuse the enteral nutrition
(tube feeding) into your small bowel through
the J-tube. A J-tube can be temporary and may
only be necessary when gastroparesis is severe.
Sometimes, patients will also have a gastrostomy
tube (G-tube). Because of the gastroparesis, food
and medication are not put through this tube.
However, the G-tube can be used to decompress
(drain) the stomach when nausea or vomiting
is occurring to relieve nausea and drain the
stomach contents.
Parenteral Nutrition
Parenteral nutrition refers to delivering nutrients
directly into the bloodstream, bypassing the
digestive system. It is usually recommended
for patients with gastroparesis who cannot be
fed into the stomach or the small intestine. The
doctor places a catheter in a vein, leaving an
opening to the outside, usually on the chest
wall. The doctor places a catheter in a large vein,
leaving an opening to the outside. This catheter
is usually threaded through the chest wall.
Elemental liquid nutrients that have been mixed
together in a sterile environment are infused
through the catheter and directly into the
bloodstream. Careful monitoring of laboratory
values must be done by your physician.
Other Potential Treatments
A gastric pacemaker has been developed to
assist people with gastroparesis. The pacemaker
is a battery-operated, electronic device that
is surgically implanted. It emits mild electrical
pulses that stimulate stomach contractions so
food is moved from the stomach into the small
intestines. Some medical centers have reported
reasonably good results with these devices,
others have not.
A gastroenterologist may use botulinum toxin
(yes, the wrinkle blaster) and inject this into
the pylorus muscle (the valve at the end of
the stomach) during upper endoscopy. You
are asleep for this procedure. By relaxing the
pylorus valve, stomach emptying occurs and the
symptoms of gastroparesis become lessened.
The toxin is injected into the pyloric sphincter.
The effect of relaxing the pylorus can last from
weeks to months.
continued on page 22
11
Enteral Feeding
with Gastroparesis
By Karen Hamilton, MS, RD, CNSD and Mark DeLegge, MD
A jejunostomy feeding tube (J-tube) is placed
into the small intestine (jejunum), while
a gastrostomy tube (G-tube) is placed in the
stomach. Either can be used to provide adequate
nutrition when an oral diet is not possible or is
insufficient. When the stomach is not working
properly, such as in the case of gastroparesis, or
when a large portion of the stomach is missing,
such as after a partial or total stomach resection,
a jejunostomy tube placement is the preferred
route for feeding.
There are two types of percutaneous (through the
skin) jejunostomy tube placement techniques.
The first is percutaneous gastrojejunostomy.
Percutaneous gastrojejunostomy tube placement
entails the placement of a feeding tube
through the stomach and duodenum, ending
in the jejunum (the middle portion of the small
bowel). This method combines the simplicity of
gastric access with the benefits of direct small
bowel tube feedings. This tube system may
12 | Celebrate Life | April 2010, Issue 21
G-tube
Duodenum
Jejunum
Large
intestine
(colon)
Stomach
Small intestine
(small bowel)
This illustration shows the placement of a G-tube.
have an opening in the stomach (for stomach
decompression) and in the small intestine (for
feeding), or only one opening into the small
intestine (for feeding only).
The two opening (also called two port) G-J
tube system is often used in patients who have
gastroparesis as it helps reduce bloating and
nausea by allowing venting of stomach contents.
The G-J tube stays anchored in the stomach
because there is a balloon or a plastic bumper
at the end of the tube inside the stomach
(also called an internal bolster). There is also
a plastic disc around the tube outside of the
person’s body that keeps the tube from sliding
in and out of the opening (external bolster or
external bumper). The disc should be placed
gently against the abdominal wall skin with
approximately the width of a half dollar coin
between the bottom of the disc and the skin.
In contrast, percutaneous jejunostomy requires
the placement of a feeding tube directly into
the small bowel (there is no gastric component
of this tube). This method is technically more
difficult than percutaneous gastrojejunostomy
and is associated with a slightly higher risk of
complications during placement. Jejunostomy
feeding tubes may also be placed during an open
abdominal surgical procedure (in the operating
room). If you only have a jejunostomy feeding
tube and not a gastrojejunostomy tube, you
and your doctor may decide to put in a separate
gastrostomy tube for stomach venting.
Your physician or homecare clinician will teach
you how to best care for your skin and your
G-J or jejunal tube insertion site to reduce the
possibility of infection and skin breakdown.
Table 1 shows a few considerations that should
to be made to help you achieve the best possible
experience with your G-J or jejunal tube.
Having a G-J feeding tube can assist you or
your loved one in leading a full and active life,
by supporting adequate nutrition intake and
aiding in nausea control. Having a G-J tube does
not necessarily prevent you from taking liquids,
solids, or medications by mouth if your physician
approves, and it can alleviate the burden of
trying to meet your nutrition needs orally when
your stomach is just not working well. t
Improving Your G-J or Jejunal Tube Experience
Consideration
Rationale
Do not rotate the G-J or
jejunal tube
May cause tube kinking and
displacement
Flush the tube only with
warm, clean tap water
Soda, juice, or other beverages
can damage the tube or lead
to tube clogging
Discuss which medications
can be given via the jejunal
tube with your physician or
pharmacist
Certain medication forms
are not compatible with the
tubing or cannot be absorbed
efficiently when given directly
into the jejunum
Protect the tube from
dislodgement
Secure the G-J tube by taping
the tube under your shirt or
cover it with stretchy gauze. If
the tube is placed in an infant,
tape the child’s diaper over
the tube.
Check site daily
If red or sore, or if green or
white drainage is present, it
may be a sign of skin infection
Monitor for tube feeding
tolerance
If vomiting occurs, or if your
stomach is bloated, the J-tube
may have become displaced
Keep a record of tube type,
tube diameter (French size),
and balloon volume. Your
physician or healthcare
provider can give you this
information.
This information is essential
if your tube needs to be
replaced
Check tube position daily
If the tube markings indicate
that the tube has extended
outside of the body further
than it should or has retracted
further into the stomach
or jejunum, re-positioning
by your physician may be
necessary
Avoid using creams, powders,
or sprays near the tube site
Products that have not been
prescribed for use with the G-J
tube may damage the tube or
degrade it
Table 1
13
Celebration of Life Circle Award
Susan Husker
Susan Husker started home parenteral nutrition (TPN) in June of
2007 after a surgery resulted in short bowel syndrome. Due to high
fluid requirements, she infused two bags (over 6 liters) of TPN over a
total of 19 hours every day!
This time constraint did not keep Susan at home,
however. She maintained an active lifestyle and
a positive attitude which still continues today.
Susan volunteers at her church and also at the
local high school covering study hall, working in
the office, and coaching high school volleyball!
Susan had to quit her job as an EMT when she
became ill. However, she never gave up hope
that she would one day return to her job, and
worked hard to keep her EMT license current. To
do this, Susan attended online classes, completed
tests and written exams, renewed her CPR
certification, and participated in a two-day (16
hour) practical exam. During one of the practical
sessions, Susan was required to demonstrate
her ability to extricate an accident victim from
a car. She recruited her daughter to hold her TPN
backpack while she performed these practical
competencies.
Early this spring, Susan was evaluated for a small
bowel transplant. Initially she was informed
she was not a candidate because of other
health concerns. Further testing ensued and
revealed that these did not pose an issue, so the
transplant workup began. During the workup,
the medical team discovered 39 inches of small
bowel remaining in her lower abdomen. She
14 | Celebrate Life | April 2010, Issue 21
also had an intact
terminal portion of
her ileum, or small
bowel, along with
a full colon. She
underwent surgery
to reconnect her
bowel. To date, the
surgery has been a
success, and Susan has been fully weaned from
TPN as of September, 2009! Her goal is to return
to work this summer.
Susan is a testament to a positive outlook and
perseverance. She is a Celebration of Life Circle
Award winner from October 2009, and continues
to inspire her clinicians, friends, and family. t
The Celebration of Life Circle Award recognizes
nutrition consumers and caregivers for their
commitment towards living an independent and
full life.
To nominate someone you know for the
Celebration of Life Circle Award, please send an
email to [email protected].
Information
By Karen Hamilton, MS, RD, LD, CNSD
How to Manage
Healthcare Claims Rejections
Chances are, if you are lucky enough to have health insurance, you will eventually have a claim
rejected. Many people accept the verdict, even if the decision appears arbitrary, because the
thought of taking on the health insurance bureaucracy seems too difficult, and winning seems
like such a long-shot.
People who fight back often do win. The key
is knowing how to communicate with the
insurance company and being persistent.
Remember, an ounce of prevention is worth a
pound of cure, so before receiving medical care,
make your health provider familiar with your
plan. Always use your medical identification
card when you receive treatment. If your plan
requires pre-certification prior to treatment
or certain medications, follow your plan’s
pre-certification guidelines. Your physician and/
or healthcare provider may also be able to assist
you by providing additional materials or prior
authorization requests in order to substantiate
your claim. This way, you are less likely to receive
a denial.
If you do receive a denial, it doesn’t matter what
type of insurer you have or whether they agree
to pay only part or none of a claim; the steps to
success are the same. It is up to you to gather the
information and make a case. Here are some tips
to improve your success:
Know Your Rights
Check your rights under your healthcare plan
and under state law. If you receive your insurance
through an employer, call the human resources
15
(HR) department to get
a copy of your policy.
Read it carefully since it
will tell you exactly what
is covered and how
the insurer wants you
to communicate with
them to challenge your
health plan’s decision.
People who fight back often do win.
Following their rules and
Knowing how to communicate with
review process will help
the insurance company and being
expedite your challenge.
persistent are key.
If the language is too
confusing, ask your HR person to help you
understand it or contact the insurer directly and
speak with their customer relations staff.
Contact Your Health Plan Insurer
Make sure you have all of your paperwork
together and in a logical order before you call
your health plan. Be prepared to be able to
state your case clearly and succinctly — you
will have a greater chance at convincing them
that your claim is valid. Every denial form will
have a contact telephone number. In some
cases, you may receive a favorable result after
one call. In other cases, this may be the first of
many conversations. Keep track of all of your
conversations with the insurer. Write down the
dates, the name of the person you spoke with,
and the highlights of your conversations; create
a file for all of your documentation.
File an Appeal
If you feel like you’re not getting the results you
want from a phone call, file a written appeal
with your health plan. You can also request
from the insurer a copy of your entire claim file
which should contain the specific reason for
your claim denial. Create your letter taking into
16 | Celebrate Life | April 2010, Issue 21
consideration the plan’s criteria for acceptance
and attach any supporting information. For
example, if the claim was denied because the
treatment was deemed “unnecessary”, include
in your appeal letter any documentation that
shows that other treatments have failed and a
letter from your doctor as to why you needed
the treatment. Also, make sure you file the
appeal within your plan’s designated time limit.
After you submit your written appeal, follow
up if a decision has not been made within 15 to
30 days. Be sure to retain a copy of the appeal
for your records. Confirm that the appeal was
received and then ask about the status. If the
claim denial was upheld, you can re-submit with
new information. If the denial continues to be
upheld, ask for a one-time exception or consider
filing an insurance complaint with your state’s
Insurance Commissioner.
Get Support
Depending upon your diagnosis and condition,
there may be an advocacy organization devoted
to your disease or therapy. You can tap into these
resources to help create a stronger letter of
appeal or obtain information that “experimental”
treatments in patients with similar issues have
been successful and are medically accepted.
You can find some of these resources online at
WeNourish.com/consumers/links.aspx.
In about 50 percent of appeal cases, the consumer
prevails and is able to obtain coverage. Know
your rights, and with a little persistence, you may
successfully appeal your denied claims. t
Industry
Insights
By Brenda Gray, Pharm D
Managing Medication Shortages
“Hello, Mr. Smith? This is the pharmacy. Due to a manufacturer shortage, I’m unable to provide you with
all of your requested medication.” Many long-term consumers will experience this situation at some
point in their lives. Hopefully, this is followed by a discussion about an alternative plan. Unfortunately,
sometimes there are a lot of unanswered questions: How long will this last? What alternatives are there?
What happens if I miss a dose? What can I do?
Medication shortages occur at various levels in
the healthcare delivery system. This can be an
alarming experience for the provider and for the
patient. Understanding the shortages, exploring
the options, and making informed decisions can
help these shortages to be less stressful.
Reasons for a Medication Shortage
The shortage could be at the local level. These
“out of stock” situations are usually limited
and are quickly resolved. Planning ahead and
ordering before you run out of a given medication
can avoid missing doses. Although doses are
not available at the local level, sometimes
medications can be obtained from another
provider, or the prescriber may approve a missed
dose or two as inconsequential. Coram is able to
use a national network of infusion pharmacies
across the country to limit the interruption in
patient care from these types of shortages.
Shortages on a national or manufacturer level
are much harder to manage. These shortages
include unavailability of source products,
problems in the manufacturing process or
distribution system, and quality concerns.
Depending on the root cause of the shortage,
these can be long-term problems.
Shortages in source products can be caused
by many situations. A product made from a
natural source can be affected by environmental
conditions, predators, viruses, or other such
uncontrollable sources. Synthetic products can
be impacted in many ways as well including
economic and political factors. A company
making a product used in the manufacture of
the medication may go out of business or decide
not to produce the item. Imported items may
not be allowed.
Problems in the manufacturing process can
include a mechanical breakdown at the facility
that produces the product or a component of
the product. Depending on the cause of the
breakdown, repairs can be extensive. Once
17
completed, there may be delays in the time to
produce additional product and for inspections
of the final product. Many times, there is not
another facility that can readily make the product
while the repairs are completed. If the product
is made elsewhere, there may be regulatory or
shipping delays in making it available.
Problems can occur at the distribution level
for the medication. These include short-term
issues such as weather delays affecting shipping,
or larger scale problems such as destruction
of a warehouse or interruption of a shipping
channel by some type of crisis. In these cases,
the medication may be available but unable to
be distributed.
Lastly, and most commonly, shortages can result
from a quality issue, such as packaging problems,
contaminations, or tampering concerns. This
was the case of a recent multivitamin shortage
where a two-chambered vial was found to have
leaks. Although this type of problem may be
found in only a few packages, large scale recalls
may be needed to ensure safety.
Managing Shortages
When a product shortage occurs, what is Coram’s
process for assuring that our patients can get
the medications they need? First, we explore
the reason behind the shortage: Is this a limited
or large scale problem? Has the cause of the
shortage been identified? Is there a timeline
for the resolution? If this timeline is beyond
current inventory, then further questions must
be considered. Coram immediately evaluates
the issues to determine the best and quickest
course of action for their patients.
Other considerations include, “What are the
alternatives for therapy?” Often, an alternative
product may be available that is acceptable
for use in the short-term. During the recent
multivitamin shortage, many patients were able
to be readily switched to an alternative vitamin
product. For those in whom this was not ideal,
a different version of the product was able to
be used. Coram worked with the manufacturer
to identify another version of the product
packaging, making this an option for some
patients. Coram’s purchasing team works with
manufacturers to see if alternative products
can be acquired and made available to our
patients. Our purchasing team also monitors the
marketplace for potential shortage situations.
Recently, many TPN patients were impacted by a
lipid emulsion shortage. Fortunately, this was not
the Coram preferred product, but we monitored
our product availability for potential shortages
due to increased demand during this time.
Sometimes the alternative product may not be
available in the United States. In these cases,
Coram may not be able to assist a patient in
acquiring the product. And, due to limited
information on these unapproved FDA
products, Coram also cannot advise their use
or support combination with any product we
provide. However, Coram will work with the
patient to make sure any product they obtain
is considered and evaluated in making therapy
decisions (such as reviewing for potential drug
interactions and adverse events). It is important
to make sure your pharmacist knows of any
alternative products you may be obtaining.
For some products, there are no alternatives and
the patient must discuss with their prescriber
the impact on the individual therapy plan. If the
product is available at all, there may be restrictions
under which circumstances the product may
be used or which dose conservation measures
continued on page 22
18 | Celebrate Life | April 2010, Issue 21
Answering the Call
Access to information regarding your billing just got easier…
Long-term TPN consumers often become healthcare billing experts by experience and
necessity. The ins and outs of medical reimbursement are challenging for most patients and
their families, and it is important to have the right support and resources to turn to when you
have questions.
At an event held during the 2009 Oley Foundation conference,
we were given a challenge by our long-term consumers — to
make access to information regarding billing as easy as possible
for each patient. Answering that call are Coram’s Patient Financial
Services Representatives who have helped to develop a new tollfree number available for billing inquiries to connect you directly
to your Patient Financial Services Representative, along with a new
informational brochure, “Your Guide to the Billing Process”, which
will be made available to all Coram patients over the next few
months.
How Can I Assist in Receiving
the Benefits I Deserve?
New informational brochure,
Your Guide to the Billing Process
You can help ensure that the billing process is accurate and timely, and that you receive the benefits
you deserve from your insurance company by doing the following:
• Review and sign required consents and releases
• Provide Coram with a copy (both front and back) of your insurance card — initially and when your
insurance changes
• Notify Coram immediately if there are changes in your
reimbursement eligibility
• Review and keep copies of the “Explanation of Benefits”
provided to you from your insurance company
• Be familiar with your insurance policy, including your
responsibility for co-payments and charges which your
insurance considers to be “Non-Covered” or “Patient
Responsibility”
• Let Coram know of any problems or dissatisfactions
with billing. We are here to help! t
19
Small Steps to Big Steps
2010 Informational Teleconference Series
Join other nutrition consumers for this free teleconference
series — it’s a great way to learn about key topics for nutrition
consumers from leading clinical and advocacy experts, all from
the comfort of your home!
We have an exciting lineup for 2010! Look out for the following
teleconferences. By popular demand, we are now archiving past
presentations on our consumer resource website, WeNourish.com. To
listen to a recorded presentation, or to find upcoming teleconference
topics and times, please visit WeNourish.com/consumers/events.aspx.
joining a call
•All calls begin at
4pm PST | 7pm EST
•Call toll-free:
866.418.5399
•Entry Code:
3036728726
January: Taking Control of Your Pain
A Q&A on controlling your pain and related symptoms
Featured Speakers:
Mark DeLegge, MD, Medical Director
Betsy Rothley, RN, MSN, FNP, BC, Sr. Marketing Manager,
Pain & Palliative Services
Listen to our January teleconference online at WeNourish.com/consumers/events.aspx
March: Enhancing the Patient Experience
Leveraging both technology and direct consumer feedback to enhance the patient experience
Featured Speakers:
Carlota Bentley, Sr. Director, TPN Center of Excellence
Jill Ashcraft, VP, Customer Service
Listen to our March teleconference online at WeNourish.com/consumers/events.aspx
20 | Celebrate Life | March 2010, Issue 21
Tuesday, May 18:
Great Escapes – Travel for Home Nutrition Consumers
A review of available resources and tips from our Nutrition Consumer Advocate
with helpful insight from the Transportation Security Administration
Featured Speakers:
Linda Gravenstein, Consumer Advocate
TSA Guest Representative
4pm PST | 7pm EST
Toll-free: 866.418.5399 Entry Code: 3036728726
MISSED a call?
If you’ve missed a call,
don’t worry! You can
still listen to it online
at WeNourish.com/
consumers/events.aspx.
Tuesday, July 20:
You are Not Alone
Support Mechanisms for Long-term TPN Consumers
Featured Speakers:
Lillian Harvey-Banchik, MD
Karen Hamilton, MS, RD, LD, CNSD, Strategic Manager, Nutrition
Tuesday, September 21:
Focus on Transplant
A Q&A on the issues and benefits surrounding solid organ transplant
Featured Speakers:
Carol Ireton-Jones , PhD, RD, CNSD, Consulting Director, Nutrition
Robbyn Kindle, RD
Tuesday, November 16:
Probiotics — What You Need to Know
Featured Speaker:
Melinda Parker, MS, RD, CNSD, Clinical Director, Nutrition
21
Industry Insights: Managing Medication Shortages
should be taken. Coram’s clinical teams work
to provide as much information as possible to
patients and providers on the options available.
When this type of situation developed with an
enzyme this summer, Coram worked with the
manufacturer and prescribers to keep patients
informed, provided available information, and
worked with the physicians to help monitor the
patients during the shortage. Unfortunately in
these situations, doses can be missed and the
outcomes are often unknown or undesirable.
Manufacturers work with the FDA and research
groups during these types of shortages to give
the patients as many options as possible and
limit the impact on the patients’ health.
Some shortages can develop into product
discontinuations. In these cases, Coram’s
purchasing team immediately notifies our
clinical teams to assist patients and prescribers
in making alternative plans. Occasionally, this is
simply a product switch; however, sometimes,
the entire therapy has to be reassessed.
The Consumer’s Role
What can you, as the consumer, do during a
shortage? First, make sure to use caution to limit
waste when a product is in limited supply by
carefully following provided dose conservation
instructions. Second, if an alternative therapy
must be used, it is important to follow the
directions for use and report any changes to
your health status to your pharmacist and
prescriber immediately. If using a product from
another source, make sure all of your healthcare
providers are aware of this. When the shortage
resolves, work with your pharmacy regarding
any resumption directions.
Communication and planning are the keys
to managing any shortage. Medication
shortages are inevitable. Working with
patients and prescribers to manage inventories,
communicating the status of medications,
monitoring health status, and making informed
decisions on the alternatives can make these
experiences less of a healthcare crisis. t
Just the Facts… Gastroparesis, What Do We Know?
The antidepressant mirtazapine has also proven
effective in the treatment of gastroparesis
unresponsive to conventional treatment. This
is due to its antiemetic and appetite stimulant
properties. Mirtazapine acts on the same
serotonin receptor (5-HT3) as the popular
antiemetic ondansetron (Zofran®).
Conclusion
Gastroparesis has a variety of causes and
can result in common symptoms of nausea,
22 | Celebrate Life | April 2010, Issue 21
(continued from page 18)
(continued from page 11)
vomiting and weight loss. Diagnosis is made by
obtaining a comprehensive clinical history and
a confirmatory test, usually a gastric emptying
exam. Treatment focuses around diet alterations
and medications (pro-motility agents). Some
people will ultimately receive a jejunal feeding
tube or parenteral nutrition when the symptoms
are severe and resulting in weight loss. t
Corner
By Linda Gravenstein, Consumer Advocate
“May I take your order, please?”
These six simple words can be very stressful to
HPEN consumers who have oral dietary
restrictions or diet intolerances, and for those
who cannot eat but still enjoy the camaraderie
that is shared with friends at a meal. Dining out
at a restaurant or at a dinner party can be
socially rewarding and, with advice from fellow
consumers, it can be relatively stress-free.
For a successful restaurant experience, one
consumer shared her favorite tip — look at the
menu online before meeting your party. This will
allow you the time and freedom to select what
you can tolerate. This also gives you the
opportunity to call the restaurant for any
clarification on ingredients without bringing
attention to your special requirements. If the
menu is not online, a quick call and a short
conversation with the chef can also be helpful.
Two friends that are both on HPEN suggested
that sharing an entrée can save waste and be a
fun way to dine with a friend that has the same
likes and tolerances.
When one consumer was asked how he reduces
his stress when dining with non-TPN consumers,
he joked, “What stress? I just a have a cocktail!” Of
course, as with anyone on a restricted diet, check
with your physician or home nutrition support
team dietitian if you have any questions.
Another consumer told me that she chooses
something off the menu that would be good as
a leftover. Then, you can enjoy your meal twice
when you ask for a to-go container!
Last but not least is to carry a restaurant card
from the Oley Foundation. This card is a discreet
way to let your server know you have special
dietary needs. You may request these cards by
contacting the Oley Foundation at 800.776.6539
or online at www.oley.org/restcards.html. I also
have a supply of meal cards I can share with you;
feel free to call me toll-free at 866.446.6373 or
email me at [email protected].
As always, I encourage all of you to share with
me your tips on dealing with any stressful
situation and, with your permission, I will include
them in a future edition to help inspire other
HPEN consumers. t
I have a serio
us digestive di
sorder which
limits my abili
ty to eat. Mos
t of my nutritio
infused throug
n is
h a tube or IV
catheter.
Please allow
me to order a
smaller portion
share a plate
or order from
,
the children’s
menu.
Thank you fo
r your consid
eration,
Oley Founda
tion Member.
The Oley Foundation’s Restaurant Card
Consumer Contacts
Celebrate Life Magazine
877.WeNourish (877.936.6874)
To submit stories, comments, and
suggestions for Celebrate Life, email:
[email protected]
To speak to a TPN or tube feeding
representative
WeNourish.com
• General information about the Nourish
•
•
•
•
•
•
Nutrition Support Program™
Educational tutorials,
videos, and downloadable
patient education tools
Consumer events and
teleconferences
Consumer blog
Online archive of the
Celebrate Life magazine
Consumer resource links
Local Coram branch maps
and information
Nourish Advocacy Line
To reach a dedicated consumer advocate, call:
Toll-free 866.446.6373
Informational
Teleconference Series
To view a schedule of upcoming teleconference
topics and times, visit:
WeNourish.com/consumers/events.aspx
elebrateLife
For Home TPN and Tube Feeding Patients
555 17th Street, Suite 1500, Denver, CO 80202
© 2010 Coram, Inc. • Celebrate LIfe is a publication of Coram, Inc.