Death rate from prescription pain med overdoses drops in Washington state

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After an eightfold increase in prescription pain medication overdose deaths in the previous 10 years, prescription pain medication-associated deaths in Washington state fell from 512 in 2008 to 407 in 2011, a 23 percent decline, the Washington State Department of Health reported Wednesday.

Here’s more from the Department of Health’s announcement:

Most pain medications that require a prescription contain drugs known as opiates or opioids. These drugs have effects like opium or morphine, and can be addictive.

In addition to morphine, opiates include codeine, oxycodone (brand names OxyContin, Percocet and others), meperidine (Demerol), and hydrocodone (brand names include Vicodin and Lortab).

Prescriptions for these medications have increased dramatically since the late 1990s —misuse and abuse has also increased dramatically.

In the past two years, the Department of Health created new prevention tools to help health care providers and consumers: pain management rules for health care providers and the Prescription Monitoring Program.

“We’re not out of the woods yet,” said State Health Officer Dr. Maxine Hayes. “While it’s encouraging that deaths have dropped, the death rate in 2011 was six times higher than in 1998.

Health care providers play a critical role in prescribing medications and helping patients manage pain safely. Prescription pain medications are powerful drugs and must be handled carefully.”

New pain management rules for health care providers who prescribe pain medication include guidance for using opiate-based medications to manage chronic, non-cancer pain.

These rules encourage practitioners to become better educated for safe and effective use of these drugs. Rules became effective July 1, 2011 for osteopathic physicians and osteopathic physician assistants, advanced registered nurse practitioners, dentists, and podiatrists. They became effective for physicians and physician assistants on January 2, 2012.

The new Prescription Monitoring Program is a secure online database that allows prescribers to see all of the prescriptions for controlled substances that their patients are receiving.

Health care providers were offered access to the system in January 2012. The prescriber can look for duplicate prescriptions, misuse, drug interactions, and other concerns. In less than a year, 22 percent of eligible prescribers had registered to use the system.

Patients taking these medications should keep them in a safe place so others can’t get to them, and never share their medicine with others.Always follow the directions and consult with your doctor or pharmacist if you have questions or concerns. Taking these powerful drugs with alcohol, other prescription or illegal drugs can be dangerous — and deadly.

Unused or expired prescription medications should be disposed of properly. Several drug take-back programs exist across the state, including pharmacies, police and fire departments, and locations are easy to find in your community.

The Good Samaritan Law allows immunity from criminal charges for anyone who is either experiencing an overdose or witnessing one and reports it. Call 9-1-1 to get care as quickly as possible. Our Take as Directed webpage has community resources and publications to help people with this serious issue.

Online resources:

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Quit Smoking Tips from HealthFinder.gov

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Quitting smoking is one of the most important things you can do for your health. The sooner you quit, the sooner your body can begin to heal. You will feel better and have more energy to be active with your family and friends.

Take Action!

Follow these steps to quit:

  1. Call 1-800-QUIT-NOW (1-800-784-8669) for free support and to set up your quit plan.
  2. Talk with your doctor about medicines to help you quit.
  3. Set a quit date within the next 2 weeks.
  4. Make small changes, like:
    • Throw away ashtrays in your home, car, and office so you aren’t tempted to smoke.
    • Make your home and car smoke-free.
    • If you have friends who smoke, ask them not to smoke around you.
  5. Plan for how you will handle challenges like cravings.

Here are some more tips to help you quit.

Write down your reasons to quit.

Make a list of all the reasons you want to quit. For example, your reasons to quit might be to set a healthy example for your kids and to save money. Keep the list with you to remind yourself why quitting is worth it.

Change your routine.

Changing your routine can help you break the smoking habit.

  • Try taking a different route to work.
  • For the first few weeks, avoid activities and places you connect with smoking.
  • Do things and go places where smoking isn’t allowed.
  • Make getting active and eating healthy part of your quit plan. Go for walks and try different foods.

Quitting may be hard, so prepare yourself. 

Remember, the urge to smoke will come and go. Here are some ways to manage cravings:

  • Do something else with your hands, like washing them, taking a shower, or washing the dishes. Try doing crossword or other puzzles.
  • Have healthy snacks ready, like carrots, nuts, apples, or sugar-free gum.
  • Distract yourself with a new activity.
  • If you used to smoke while driving, try something new. Take public transportation or ride with a friend.
  • Take several deep breaths to help you relax.

Take this withdrawal quiz every day to see your progress.

Break the connection between eating and smoking. 
Many people like to smoke when they finish a meal. Here are some ways to break the connection:

  • Get up from the table as soon as you are done eating.
  • Brush your teeth and think about the fresh, clean feeling in your mouth.
  • Try going for a walk after meals.

Deal with stress.

Manage stress by creating peaceful times in your daily schedule. Try relaxation methods like deep breathing or lighting candles.

Check out these tips on dealing with stress as you quit.

Stick with it.

When you stop smoking, you may feel:

  • Irritable
  • Anxious
  • Hungry

You may even have trouble sleeping.

Don’t give up! It takes time to overcome addiction. Check out these tips on staying quit.

Learn from the past. 

Many people try to quit more than once before they succeed. Most people who start smoking again do so within the first 3 months after quitting. If you’ve tried to quit before, think about what worked for you and what didn’t.

Drinking alcohol, depression, and being around other smokers can make it harder to quit. If you are finding it hard to stay quit, talk with your doctor about what medicines might help you. Remember, quitting will make you healthier.

If you’ve tried to quit before, check out this booklet about how to commit to quitting again [PDF – 797 KB].

If you want help, talk with your doctor.

A doctor or nurse may be able to help you quit smoking. The doctor can help you choose the strategies that are likely to work best for you. She can also tell you about medicines to help make quitting easier.

Get more information about the different types of medicines that can help you quit.

What about cost?

You can get free help with quitting by calling 1-800-QUIT-NOW (1-800-784-8669) or by visiting smokefree.gov.

Also, some services to help people quit smoking are covered under the Affordable Care Act, the health care reform law passed in 2010. Depending on your insurance plan, you may be able to get these services at no cost to you.

Check with your insurance provider to find out what’s included in your plan. For information about other services covered by the Affordable Care Act, visit HealthCare.gov.

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HMO-like plans may be back on health insurance exchanges

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Shopping cart redBy Julie Appleby
KHN Staff Writer

This story was produced in collaboration with 

It’s back to the future for insurers, which plan to sharply limit the choice of doctors and hospitals in some policies marketed to consumers under the health law, starting next fall.

Such plans, similar to the HMOs of old, fell into disfavor with consumers in the 1980s and 1990s, when they rebelled against a lack of choice.

But limited network plans — which have begun a comeback among employers looking to slow rising premiums — are expected to play a prominent role in new online markets, called exchanges, where individuals and small businesses will shop for coverage starting Oct. 1.

That trend worries consumer advocates, who fear skimpy networks could translate into inadequate care or big bills for those who develop complicated health problems.

Because such policies can offer lower premiums, insurers are betting they will appeal to some consumers, especially younger and healthier people who might see little need for more expensive policies.

Insurers, who are currently designing their plans for next fall, “will start with as tight a network control as they can,” says Ana Gupte, a managed care analyst with Sanford Bernstein.

Plans may also benefit from offering such policies because they are less attractive to those with medical problems, who can no longer be turned away beginning in January 2014.

“Plans will basically say they can minimize their risk by creating narrow networks,” saysJohn Weis, president of Quest Analytics, an Appleton, Wis., firm that analyzes provider networks for insurers.

State or federal regulators, who must review the plans sold in the online markets, are unlikely to permit them to exclude an entire class of doctors, such as cancer or diabetes specialists.  But there might be more subtle ways to discourage consumers with medical problems.

“They might have too few oncologists, or only general oncologists,” for example, says Stephen Finan, senior director of policy with the American Cancer Society Cancer Action Network, an advocacy group in Washington.

Cost Vs. Choice

“Narrow networks may be more than adequate 90 percent of the time,” Finan says, but are “not well-suited to deal with complicated medical conditions and chronic diseases.”

That’s because there may be few or no specialists available for certain complex conditions, so patients may have to seek care outside of the networks.

If the policy doesn’t cover non-network care, they may end up footing the bill themselves. Even if policies allow for outside the network coverage, patients can incur large copays or other costs. “Your (financial) exposure could be high,” Finan says.

The federal health law requires the policies to include a standard set of essential benefits, from emergency room and hospital care to prescription drugs, but the law is less prescriptive about the size of the policies’ networks of participating doctors and hospitals.

In March, the Obama administration issued rules stating that insurers must “maintain a network of a sufficient number and type of providers, including providers that specialize in mental health and substance abuse, to assure that all services will be available without unreasonable delay.”

That fell short of the specific standards sought by some consumer advocates, but pleased other groups that say insurers should have broad discretion to shape their networks to meet regional needs.

The administration noted that “nothing in the final rule limits an exchange’s ability to establish more rigorous standards.”

Shaving Costs

Insurers contend that by limiting network size, they can offer plans with higher quality or more efficient doctors and hospitals, which might slow spending or improve care.

Networks are already part of most health plans. For doctors and hospitals, joining a network brings in business. In exchange, they agree to negotiate their prices with insurers.

Driven by consumer and employer demand for lower-cost plans, insurers are already rolling out narrow network policies that have shaved premiums 10 percent or more.

recent survey by benefit firm Mercer found that 23 percent of large employers offered such plans this year, usually among a choice of plans, up from 14 percent in 2011.

In Massachusetts, insurer Harvard Pilgrim launched its Focus Network in April, touting 10 percent lower premiums. While it includes 50 hospitals and 16,000 physicians, it excludes some of the state’s highest-cost systems.

In California, Blue Shield has a number of SaveNet HMO plans that contract with select doctor and hospital groups, creating networks averaging a little more than half the size of its standard ones.

Next year, for example, one serving Marin and Sonoma counties will offer a network of about 100 primary care doctors and 325 specialists.

Still, narrow network plans are a hard sell to employers, particularly the large ones, which don’t want to hear gripes from workers about limited choice of doctors simply to save 10 percent on premium costs.

But small businesses and individuals buying their own coverage in the online markets might regard that tradeoff differently.  “If my doctor is in the [narrow] network and cheaper, it might work,” says Wall Street analyst Carl McDonald at Citi Research, a division of Citigroup Global Markets.

Competing On Price

To stand out from competitors, some plans may choose to offer the lowest possible rates, and would “narrow their networks” to do so, says Chet Burrell, CEO of insurer CareFirst in Maryland.

He acknowledged that narrow networks could be “a subtle but powerful way” to discourage less-than-healthy applicants. “The question will be what degree of tolerance will a state have to permit narrow networks?”

State rules on what makes an adequate insurance network vary.  Some states, including California, specify that specialists must be available within a certain driving time or distance. Others simply say insurers must have sufficient numbers of providers.  Some states don’t have any requirements.

“State rules are very, very loose,” says Weis at Quest, who says states should consider adopting the rules that now apply to Medicare Advantage, the private market alternative to Medicare.

In that program, the federal government requires networks to include primary care physicians and more than 25 types of specialists, and sets county-level requirements on both the minimum number of doctors required in each category and how far patients might have to travel to see one.

Even though state rules vary, regulators say plans that are too skimpy will be called out by regulators, consumers or both.

“We will look very closely at how plans put their packages together,” says Sandy Praeger, the elected insurance commissioner in Kansas.

“If you have a crummy network, no one will buy the plan,” says consultant Robert Laszewski, a former insurance executive, adding the law also includes programs that financially reward insurers that get a large share of sicker patients and penalize those that get a healthier and more profitable bunch.

Many policies that currently offer a limited network of doctors and hospitals generally allow patients to go to out-of-network providers, with whom they do not have negotiated prices.

But patients who seek such care face significant co-payments, which often start at 30 percent of the bill and can go as high as 50 percent.

It is often hard for consumers to figure out how much they might be charged if they go out of network, says Lynn Quincy, senior policy analyst at Consumers Union, publisher of Consumer Reports magazine.

In addition to meeting separate annual deductibles for out-of-network care, patients can be “balance-billed” by doctors or hospitals for the difference between what the insurer pays them and their total charges.

That doesn’t change under the federal health law, so consumers could be left on the hook for tens of thousands of dollars.

“There’s no escaping that we’re going to see” insurance policies that include networks both wide and narrow, says Quincy. “That can be OK if there are much better tools to reveal to consumers how adequate those networks are and how much it might cost to go outside of them.”

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This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Blacks missing out on critical early treatment for strokes

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clockBy Joan MacDonald, Contributing Writer
Health Behavior News Service
Research Source: Ethnicity & Disease

Getting to the emergency room within the first few hours of recognizing stroke symptoms can help prevent permanent brain damage, but a recent study in Ethnicity & Disease finds that Blacks are only half as likely as Whites to get timely treatment.

The study found that on average it took 339 minutes for Blacks to visit the emergency room for stroke treatment as opposed to 151 minutes for Whites. Delaying treatment can result in the death of vital brain cells.

“It has been estimated that nearly two million neurons die per minute during a stroke,” said Sheryl Martin-Schild, M.D., Ph.D., the study’s lead author. “Intravenous tissue plasminogen activator (IV tPA) is the only treatment during the acute phase of a stroke, the first 4.5 hours, proven to improve outcome in controlled clinical trials.”

Because IV tPA treatment breaks down the clots that obstruct blood flow inside the brain, delaying treatment within that narrow time frame puts patients at greater risk of permanent neurological damage.

The study, which followed 368 patients with a median age of 65 years, sought to identify racial disparities and the reasons for varying delays between symptom onset and emergency room treatment.

While the study found that Blacks and Whites received the same treatment once they arrived at the emergency room, reasons for the delay were not clear.

Socioeconomic standing did not seem to be a factor. Nor did the study find any bias in the way patients of different races were treated once they arrived in the emergency room.

There was no significant difference in the types of symptoms patients reported, with weakness being the most common symptom.

“Explanations for the delay could be numerous,” said Martin-Schild. They may include delayed symptom recognition, a lack of eagerness to call for help, fear of medical personnel and/or hospitals, social or environmental factors, a lack of local social support and/or longer transit time to hospital.

“Community education is vital in improving recognition of stroke symptoms,” said James McKinney, M.D., associate professor of neurology at Robert Wood Johnson Medical School in New Brunswick, New Jersey. “Unlike a heart attack, stroke is often painless, and many patients wait to see if their symptoms go away.”

McKinney suggests that further research is also needed to investigate the use of 911/EMS services, transport times and stroke center access. “All of these can decrease times from stroke onset to medical evaluation,” added McKinney.

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

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Healthy Monday Tip: Start slow, go steady

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Woman's pink running shoesPhysical activity isn’t just a way to lose weight; it’s an essential step towards a long, vibrant life!

If you haven’t been active in a while, now’s the time to revamp your routine.

Start out with smaller amounts of exercise at lower intensities and gradually progress to moderate-intensity activity to reduce your risk of injury.

This week, work on your fitness routine and don’t worry about how fast, or hard others are exercising around you.

Remember that you’re never too out-of-shape to get active!

 

About the Monday Campaigns:

The Healthy Monday Tips is produced by a national health promotion initiative called the Monday Campaigns.

The thinking behind the initiative derives from two studies done at the Center for a Liveable Future at Johns Hopkins Bloomberg School of Public Health by Jullian Fry and Roni Neff.

In one study, they reviewed the scientific studies that looked at ways to get people to adopt healthy habits.

In that review, they found that one of the most effective ways to keep people on track is simply to remind them from time to time to stick to it.

But when would be the best time send those reminders?

Fry and Neff decided to look at Monday, which many of us consider the start of our week.

To better understand how we thought and felt about Monday, they reviewed the scientific literature as well as cultural references to Monday in movies, songs, books and other forms of art and literature, even video games.

They noted that a number of scientific studies have found that we may suffer more health problems on Monday. For example, a number of studies find that Americans have more heart attacks and strokes on Monday.

There is also evidence that we have more on-the-job injuries on Monday, perhaps because we are not quite back into the swing of things, or are still recovering from our weekend.

Fry and Neff also found that while many of us, facing the return to work, may dread Mondays, Monday is also seen as a day for making a fresh start.

Fry and Neff concluded that Monday might be a good day for promoting healthy habits. Calling attention to the health problems linked to the first day of the work week, such as heart attacks and on-the-job injuries, makes Monday a natural day to highlight the importance of prevention.

And the Monday’s reputation as a day to make a fresh start offers the opportunity to help people to renew their efforts to adopt healthier habits.

Fry and Neff’s findings are put into practice by the Monday Campaigns, which helps individuals and organizations use Monday as a focus for their health promotion efforts, providing free research, literature and artwork, and other support.

To learn more about Healthy Mondays:

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Flu in Washington is now widespread, say state health officials

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The Washington State Department of Health warns that flu activity is now classified as “widespread” Washington, which means people are catching and spreading the flu in most areas of the state.

People die from flu every season in Washington and even healthy people can get very sick with the flu, health officials said.

“Flu is a serious illness that can be fatal, and several Washington residents have died from influenza this season,” said Secretary of Health Mary Selecky. “Taking simple steps to prevent the flu can help people avoid this miserable and potentially dangerous illness. We urge people who haven’t been vaccinated to do it now.”

Washington State Health Officials strongly recommend vaccination :

Everyone six months of age and older is recommended to get a flu vaccine. Vaccination is especially important for people at higher risk, including people 65 years and older, people of any age with certain chronic medical conditions (such as asthma, diabetes, or heart disease), pregnant women, young children, American Indians, and Alaska Natives.

Flu outbreaks in several long-term care facilities around the state are a particular concern, health officials said. Many people who live or receive medical care in long-term care facilities and health care centers are elderly, frail or have chronic health conditions putting them at high risk for influenza and its complications.

Wahington Flu Postcard

State Health Officer Dr. Maxine Hayes has sent a letter to facility managers urging them to encourage employees to get vaccinated to protect clients, patients, and themselves from the flu. Visitors to these facilities should get the flu vaccine and delay visits if they’re sick.

Vaccine for adults is available in most Washington communities, though some providers may run out. Flu often comes on quickly with symptoms that may include fever and chills, cough, sore throat, muscle and body aches, and extreme tiredness.

Most people who get the flu will recover in less than two weeks, but some will develop complications (such as pneumonia) as a result of the flu. For some people, these complications can result in hospitalization or death.

The Department of Health urges people at risk for flu complications to contact their health care provider promptly if they develop flu symptoms. Antiviral medication – when taken within the first 48 hours of illness – can reduce the likelihood of severe illness.

For more information on influenza visit the Washington State Department of Health’s Flu News webpage.

King County and Snohomish County are offering free flu vaccination clinics for the uninsured and those who are unable to pay.

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Mental health provisions of Obama’s gun plan focuses on children, teens, and young adults

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By Sarah Varney
KHN Staff Writer

This story was produced in collaboration with NPR

If the National Rifle Association’s plan to curb violence is, in part, arming school employees with guns, President Barack Obama wants to arm them with something quite different: mental health training.

The president’s plan centered largely on training teachers and others who work with children, teens and young adults to recognize mental illness as it’s developing.

“I think this is really putting the focus on children’s mental health as a child issue,” says Dr. Paramjit Joshi, the president-elect of the American Academy of Child & Adolescent Psychiatry. She notes that “about 50 percent of lifetime mental illness starts before the age of 14.”

President Barack Obama signs executive orders initiating 23 separate executive actions after announcing new measures to help prevent gun violence, in the South Court Auditorium of Eisenhower Executive Office Building in Washington, D.C., Jan. 16, 2013. (Official White House Photo by Chuck Kennedy)

President Barack Obama signs executive orders initiating 23 separate executive actions after announcing new measures to help prevent gun violence, in the South Court Auditorium of Eisenhower Executive Office Building in Washington, D.C., Jan. 16, 2013. (Official White House Photo by Chuck Kennedy)

Dr. Joshi says 3 out of 4 people with mental illness develop their condition — including bipolar disorder, depression and schizophrenia — by young adulthood when the intricate structures of the brain are taking shape. But fewer than half receive treatment.

The president has called for a new initiative — which would need congressional approval — that would provide mental health first aid training for teachers and set up a robust referral system for children with mental health and behavioral problems.

President Barack Obama signs a series of executive orders about the administration’s new gun law proposals
Mike Fitzpatrick, executive director of the National Alliance on Mental Illness, says that training is critical: “People say: ‘Oh, we saw the signs,’ but no one knows what the next steps are. And that includes families and caregivers and teachers and resource officers. So to go into the communities and offer training on what to look for, how to spot the signs of mental illness and where do you go to get assistance: This, in many ways, would be a game changer.”

Obama’s proposal also points out that a startling number of children have direct experience with gun violence: 22 percent of 14 to 17 year olds in the U.S. have witnessed a shooting in their lifetime, and the plan calls on Congress to direct some $25 million to help traumatized students.

“People say: ‘Oh, we saw the signs,’ but no one knows what the next steps are . . . “

A separate initiative would aim support at older teens and young adults — ages 16 to 25 — in need of help who can get lost in the tumble of college or a first job.

But mental health experts say that while it’s critical to recognize the first signs of mental illness, it’s just as important that children and their families have health insurance that guarantees them coverage for treatment.

That problem was supposed to be addressed, in part, in 2008 when then-President George W. Bush signed the Mental Health Parity and Addiction Equity Act.

GunIt requires employers with more than 50 workers to offer mental health coverage that is on par with medical benefits.

But writing the regulations has proved difficult: There has been disagreement, for example, over a lifetime cap on the number of therapy visits for people with depression.

In the meantime, advocates say that people with mental illness have languished under temporary rules that have barred patients from a full range of mental health services.

That’s set to change now. One of the executive actions the president signed yesterday included a vow to issue final rules sometime next month.

Chuck Ingoglia of the National Council for Community Behavioral Healthcare says the rules will apply to nearly every type of insurance, from state Medicaid programs to employer coverage to individual health plans sold under the Affordable Care Act.

Among the so-called “essential benefits” will be mental health care.  “We’re hoping a final rule on parity will make it very clear about the scope of services that are offered. … The whole intent of the parity law was that if you need mental health and addiction services, that it should be available to you.”

Those rules won’t require congressional approval, but much of the president’s plan to improve mental health services – and his other gun-related proposals – will hinge on support from House Republicans, who vociferously oppose the administration’s health policies, especially implementing and funding the 2010 federal health law.

Still, the NRA and a number of Republicans have said they support addressing the nation’s fractured mental health system, and advocates for the mentally ill say they anticipate far less political resistance.

The total package of mental health proposals in the president’s plan total some $155 million in federal spending. And the modest scale, those advocates say, might just be something everyone can agree on.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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3-D model of the flu virus      Credit: Dan Higgins/CDC

King County to offer free flu vaccination clinics for people without insurance or unable to pay

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Public Health – Seattle & King County is offering free flu vaccination clinics to make flu vaccine more widely available to people without health insurance or who are unable to pay. Here’s the announcement.

Free flu vaccination clinics

People without health insurance can get best protection against flu

Along with the rest of the nation, King County is experiencing widespread flu, with more people sick and requiring medical care early in the flu season compared to recent years.

Public Health – Seattle & King County is offering free flu vaccination clinics to make flu vaccine more widely available to people without health insurance or who are unable to pay.

Flu vaccine (shots and nasal spray) is also available at many healthcare provider offices and pharmacies for those who have insurance or are able to pay for vaccination.

Visit http://flushot.healthmap.org to find locations.

“The flu will likely continue to circulate for many weeks, so getting flu vaccine now can still provide protection for the rest of the flu season,” said Dr. Jeff Duchin, Chief of Communicable Disease Epidemiology & Immunization at Public Health. “Flu vaccine is especially important for pregnant women, people in contact with infants who are too young to vaccinate, and also to people with health conditions that put them at greater risk for severe illness and hospitalization.”

Flu vaccine offers the single best protection against the flu. Health experts recommend flu vaccine for all people 6 months and older, especially for pregnant women and people who have long-term health problems, like diabetes, asthma, and heart or lung problems.

Anyone who lives with or cares for an infant younger than 6 months should also get vaccinated to protect the infant from getting flu.

The free flu vaccination clinics will be held at Public Health Centers at the following locations and times:

4400 37th Ave S, Seattle, 206-296-4650
Saturday, Jan. 19, 10 a.m.-2 p.m.
Thursday, Jan. 24 and Thursday, Jan. 31, 3-7 p.m.
14350 SE Eastgate Way, Bellevue, 206-296-4920
Saturday, Jan. 19, 10 a.m.—2 p.m.
Wednesday, Jan. 23 and Wednesday, Jan. 30, 3-7 p.m.
33431 13th Place S, Federal Way, 206-296-8410
Saturday, Jan. 19, 10 a.m.-2 p.m.
Saturday, Jan. 26, 10 a.m.-2 p.m.
10501 Meridian Ave N, Seattle, 206-296-4765
Saturday, January 19, 10 a.m.-2 p.m.
Tuesday, Jan. 22 and Tuesday, Jan. 29, 3-7 p.m.

The vaccinations will be given to people who do not have insurance or cannot afford to pay for vaccination otherwise. No other vaccinations will be offered at the time of the clinics.

You will be able to get flu shots or nasal spray vaccines, and preservative-free, gelatin-free, and latex-free vaccines will be available.

For more information, visit www.kingcounty.gov/health/flu

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Air quality improves but burn ban remains in effect

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Photo: Sanja Gjenero

Photo: Sanja Gjenero

Air quality in King, Pierce, and Snohomish counties has improved but the the Puget Sound Clean Air Agency says a “stage 1″ burn ban remains in effect,

“Air pollution levels throughout the region have dropped, likely due to clouds and warmer temperatures,” said Dr. Phil Swartzendruber, agency forecaster. “The drop in pollution could also be due to the help of our communities following the burn ban.”

Earlier in the week, the agency had imposed the stricter stage 2 ban, but the improving air quality led officials to lower the ban to stage 1.

During a Stage 1 burn ban:

  • No burning is allowed in fireplaces or uncertified wood stoves.
  • Residents should rely instead on their home’s other, cleaner source of heat (such as their furnace or electric baseboard heaters) for a few days until air quality improves, the public health risk diminishes and the ban is cancelled.
  • No outdoor fires are allowed. This includes recreational fires such as bonfires, campfires and the use of fire pits and chimneys..
  • Burn ban violations are subject to a $1,000 penalty.

It is OK to use natural gas, propane, pellet and EPA-certified wood stoves or inserts during a Stage 1 burn ban.

The Washington State Department of Health recommends that people who are sensitive to air pollution limit time spent outdoors, especially when exercising.

Air pollution can trigger asthma attacks, cause difficulty breathing, and make lung and heart problems worse. Air pollution is especially harmful to people with lung and heart problems, people with diabetes, children, and older adults (over age 65).

For more information:

Photo courtesy of Sanja Gjenero

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Health law offers dental coverage guarantee for some children

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Child having teeth examined at dentistsBy Michelle Andrews

Tooth decay is the most common chronic health problem in children. By the time they enter kindergarten, more than a quarter of kids have decay in their baby teeth.

The problem worsens with age, and nearly 68 percent of people age 16 to 19 have decay in their permanent teeth, according to the Centers for Disease Control and Prevention.

Starting in 2014, the Affordable Care Act requires that individual and small-group health plans sold both on the state-based health insurance exchanges and outside them on the private market cover pediatric dental services. However, plans that have grandfathered status under the law are not required to offer this coverage.

The requirement also doesn’t apply to health plans offered by large companies, although they are much more likely to offer dental benefits than small firms.

Eighty-nine percent of firms with 200 or more workers offered dental benefits in 2012, compared with 53 percent of smaller firms, according to the Kaiser Family Foundation’s annual survey of employers health plans. (Kaiser Health News is an independent project of KFF.).

The changes in the health law apply specifically to children who get coverage through private plans. Dental services are already part of the benefit package for children covered by Medicaid, the state-federal health program for low-income people.

But many eligible kids aren’t enrolled, and even if they are, their parents often run into hurdles finding dentists who speak their language and are willing to accept Medicaid payments.

The health law encourages states to expand Medicaid coverage for adults, which advocates say will have the added benefit of probably bringing more children into the system. Despite the challenges, advocates say they anticipate that many low-income children will gain dental coverage.

Dental health advocates say they’re pleased that pediatric dental services (along with other pediatric care) were included among the 10 “essential health benefits” that new health plans must cover in the exchanges and the small-group and individual markets under the law.

When it comes to health care, “oftentimes the mouth is separated from the body,” says David Jordan, dental access project director at Community Catalyst, a consumer health-care advocacy organization in Boston.

Poor oral health care can have a significant impact on overall health, causing pain and weight loss, missed school days and reduced self-esteem, say experts.

Still, some advocates are concerned that the new benefits may not be sufficiently comprehensive or affordable.

Specific coverage requirements will be determined by each state within guidelines set by the federal Department of Health and Human Services.

HHS guidance to date suggests that medically necessary orthodontia — to correct a problem with chewing, for example — may be required in addition to preventive and restorative care.

Dental coverage may be embedded in a medical plan that’s sold on the exchanges or offered on a stand-alone basis.

In private dental plans, preventive care such as teeth cleanings, topical fluoride and sealants are typically covered at 100 percent, but such other services as fillings, crowns and root canals require patients to pay up to half the cost, and coverage maxes out at about $1,500 a year.

Under the health-care law, pediatric dental health coverage sold on the exchanges cannot have annual or lifetime limits on coverage.

But families who buy dental coverage on an exchange may be subject to an annual out-of-pocket cost-sharing limit of up to $1,000 for dental care. A rule proposed by HHS suggests there be a “reasonable” annual limit. The National Association of Dental Plans has proposed $1,000. Experts expect that the final rule, when issued, will clarify the amount.

“That would be on top of whatever out-of-pocket limit people are already facing [for medical coverage],” says Colin Reusch, senior policy analyst at the Children’s Dental Health Project, who co-authored a recent report on the health law’s pediatric dental benefit. “We see that as being in conflict with what the law intends.”

Evelyn Ireland, executive director of the National Association of Dental Plans, says families who need expensive dental care such as braces may fare better in dental plans sold on the exchanges than in the plans many employers currently offer.

Nationwide, medically necessary orthodontia costs roughly $6,500 per person, Ireland says. Currently, if a private dental plan covers orthodontia, the benefit typically covers 50 percent of the cost, up to a lifetime limit of $1,000 or $1,500. “So it ends up basically being a down payment,” she says.

Assuming braces are a covered benefit, the family of a child with dental coverage through an exchange might have to pay the maximum out-of-pocket limit — $1,000, perhaps — and owe nothing more that year for the child’s dental care. But any other expenses would be covered, since plans can’t have dollar limits on coverage.

That unlimited coverage will probably add to the premium for pediatric dental coverage, however.

Ireland’s group asked the benefits consultant firm Milliman to estimate how much pediatric dental premiums might change if the coverage provisions of the law were incorporated.

Milliman estimated that premiums currently range from $21 to $25 per child per month, depending on whether a plan covers orthodontia services, among other things. After incorporating the health law’s requirements, Milliman projected that premiums would probably rise to $34 a month, Ireland says.

“That’s a nine-dollar-to-13-dollar-a-month jump, which is a pretty significant increase for a family,” she says.

Please send comments or ideas for future topics for the Insuring Your Health column toquestions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Sign for an emergency room.

Emergency departments are on the frontline of the flu

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By Jenny Gold
KHN Staff Writer

This story was produced in collaboration with NPR

Dr. Bill Frohna stands in the crowded emergency room of Medstar Washington Hospital Center in D.C. (Photo by Jenny Gold/KHN).

Dr. Bill Frohna stands in the crowded emergency room of Medstar Washington Hospital Center in D.C. (Photo by Jenny Gold/KHN).

Monday is usually the busiest day of the week in the ER. “Now instead of having a Monday peak,” said Dr. Bill Frohna, who runs the emergency department at MedStar Washington Hospital Center in Washington, D.C., “it’s seven days a week of a Monday.”

Though it is still too soon to say whether this is a historically bad flu season or just a bad flu season, one thing is clear: Emergency rooms around the country are filled with a feverish throng that is much larger than last year. Washington Hospital Center had just 20 patients test positive for flu all of last year’s season. This season, as of Monday, there were already 179 cases positive for flu.

Maria McCoy is one of those patients. She had been miserable for more than a week with nausea, vomiting, and other symptoms. She’d had her flu shot, so she didn’t think it could be the flu. But she kept getting worse.

“I called 911. They brought me straight here,” said McCoy, 52, speaking on Thursday from a hospital bed in the ER, where she was, indeed, diagnosed with the flu. “It’s really miserable.”

McCoy has plenty of company in her misery.

“We started to see a lot of activity in the South and in the Southeast in in the middle of November and toward the end of November—which was about a month earlier than what we normally see,” said Tom Skinner, a spokesman with the US Centers for Disease Control and Prevention . “And since that time, activity really has picked up across the country to where most states are seeing either moderate to severe activity.”

Listen to the story

Click on the link to listen to the NPR story: Flu Wave Stresses Out Hospitals

An infectious disease warning sign is posted on a curtain isolating flu patient Maria McCoy, 52, in the emergency room of Medstar Washington Hospital Center in D.C. (Photo by Jenny Gold/KHN).

According to the CDC, more than 112 million Americans have gotten a flu shot this season. Thevaccine is about 60 percent effective, which is a decent percentage for a flu vaccine. But that meanssome people who get the shot, like McCoy, will still get the flu.

This year’s strain of the flu, H3N2, is particularly virulent, Frohna said. He compared the surge in patients to other years.

“Usually there’s a week or two ramp up, a peak, and then a week or two downturn,” Frohna said. “So far, we’ve been basically on a ramp up for about five weeks, and I’m not sure if we’ve seen the peak yet.”

According to Frohna, more patients are being admitted to the hospital because their symptoms are so serious.

Flu 176

An infectious disease warning sign is posted on a curtain isolating flu patient Maria McCoy, 52, in the emergency room of Medstar Washington Hospital Center in D.C. (Photo by Jenny Gold/KHN).

“We’ve got patients wearing masks, we’ve got providers wearing masks to protect themselves and each other from the flu,” said Frohna.

To deal with it, he’s opened a half-dozen extra hospital beds, made sure patients with flu-like symptoms are isolated as quickly as possible and ordered extra supplies like IV poles. He’s also beefed up staffing of doctors and nurses.

Dr. Andrew Sama, president of the American College of Emergency Physicians, says this is exactly the sort of situation that ERs train for.

“There are emergency preparedness plans that occur in every hospital,” said Sama, whose organization is a trade group for emergency department doctors. “Even with all the excellent planning, you become constrained because of space and technology and personnel.”

In Allentown, Pennsylvania, one hospital had to put up a tent outside the ER to manage all the patients. New York state and the city of Boston have declared public health emergencies.

In Washington D.C., Frohna is eyeing the calendar and hoping that things start getting better soon.

“With inauguration coming, I’d just be tickled pink if the flu was on the downturn when a million visitors come to town,” he said. “It’s causing me to lose sleep already.”

This item was updated correct the number of flu cases seen at Washington Hospital Center this flu season. The correct figure is 179 cases as of Monday.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Flu outbreak spreads to Washington state — what parents can do

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This article first appeared on Seattle Children’s blog On the Pulse.

child wincing while be given a shot injection

Flu cases in Washington state are already at higher-than-average levels, and experts say we have yet to hit the flu season’s peak.In the last few weeks, health officials have reported a spike in influenza activity.

Seattle Children’s is seeing an increase in emergency department visits for flu symptoms.In the past week, 62 infants, kids and teens tested positive for flu, which is three times more than the number of cases seen in the first week of December.

Across the United States, 47 states are reporting widespread influenza activity, and at least 18 children have died from the flu this season, according to the Centers for Disease Control and Prevention.

In Washington state, at least six people have died, including a 12-year-old boy.

It’s not too late to get vaccinated against the flu, a contagious virus that infects the nose, throat and lungs, and can cause fever, cough, sore throat, muscle aches, fatigue, vomiting and diarrhea.

Yearly flu vaccines prevent 70 to 90 percent of the flu in children and adults, as Doug Opel, MD, MPH, general pediatrician at Seattle Children’s, explained in a recent blog post. This year’s flu vaccine contains the most common flu viruses currently circulating.

Getting the flu vaccine is especially important for children with cancer, lung or heart disease, and diabetes, but the flu can be serious even in children who are otherwise healthy. All caregivers and family members over the age of six months should receive a flu shot each year.

Use the HealthMap Vaccine Finder to search for locations offering the flu vaccine.

5 tips to prevent the spread of flu

Tony Woodward, MD, MBA, medical director of the division of emergency medicine at Seattle Children’s, encourages parents to follow some simple steps to help keep the flu from spreading:

  1. Wash hands – yours and your kids’ – frequently with soap and water. Adults and older children can use alcohol-based hand sanitizers for disinfecting between hand washes.
  2. If your child is sick, keep them home from school or day care for at least one day after they no longer have a fever. If you’re sick, stay home from work.
  3. Use tissue or the crook of your elbow to cover your mouth when coughing or sneezing. Throw used tissues away in a covered trash bin.
  4. Remind kids to avoid touching their eyes, nose or mouth, and to keep their hands away from their face.
  5. Avoid sharing personal items like spoons and towels, and clean shared spaces often.

Where to go for help

In most cases, children do not need emergency care for flu symptoms, unless they are under 2 years old, at high risk because of underlying or ongoing medical issues, or experiencing difficulty breathing or other life-threatening symptoms.

For a stable child with a fever and flu symptoms, Woodward recommends that parents contact their doctor before coming to the emergency department or urgent care clinic.

On evenings and weekends, parents in the Puget Sound region can take kids to one of Seattle Children’s urgent care clinics in Bellevue, Mill Creek and Seattle, which are open from 5 to 10:30 p.m. on weekdays and from 11 a.m. to 8:30 p.m. on weekends and holidays.

For tips on when to visit urgent care and when to go to the emergency department, parents can review this checklist or watch a video.

Related posts:

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Healthy Monday Tip: Suds up for food safety

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healthy red cherry tomatoes with green stalkWashing fruits and vegetables before eating them reduces the risk of foodborne illness.

If fruits and veggies have a ridged or uneven skin, use a scrub brush to remove dirt from the grooves.

Remember, even produce with inedible skin should still be washed as a first step.

This week, get into the habit of washing all produce thoroughly before serving.

Be sure to start with clean hands and a sanitary work station.

 

About the Monday Campaigns:

The Healthy Monday Tips is produced by a national health promotion initiative called the Monday Campaigns.

The thinking behind the initiative derives from two studies done at the Center for a Liveable Future at Johns Hopkins Bloomberg School of Public Health by Jullian Fry and Roni Neff.

In one study, they reviewed the scientific studies that looked at ways to get people to adopt healthy habits.

In that review, they found that one of the most effective ways to keep people on track is simply to remind them from time to time to stick to it.

But when would be the best time send those reminders?

Fry and Neff decided to look at Monday, which many of us consider the start of our week.

To better understand how we thought and felt about Monday, they reviewed the scientific literature as well as cultural references to Monday in movies, songs, books and other forms of art and literature, even video games.

They noted that a number of scientific studies have found that we may suffer more health problems on Monday. For example, a number of studies find that Americans have more heart attacks and strokes on Monday.

There is also evidence that we have more on-the-job injuries on Monday, perhaps because we are not quite back into the swing of things, or are still recovering from our weekend.

Fry and Neff also found that while many of us, facing the return to work, may dread Mondays, Monday is also seen as a day for making a fresh start.

Fry and Neff concluded that Monday might be a good day for promoting healthy habits. Calling attention to the health problems linked to the first day of the work week, such as heart attacks and on-the-job injuries, makes Monday a natural day to highlight the importance of prevention.

And the Monday’s reputation as a day to make a fresh start offers the opportunity to help people to renew their efforts to adopt healthier habits.

Fry and Neff’s findings are put into practice by the Monday Campaigns, which helps individuals and organizations use Monday as a focus for their health promotion efforts, providing free research, literature and artwork, and other support.

To learn more about Healthy Mondays:

 

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Matrix

The ‘Matrix’ meets medicine: surveillance swoops into health care

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By Michael L. Millenson

Michael L. Millenson is a Highland Park, Illinois-based consultant, a visiting scholar at the Kellogg School of Management and the author of Demanding Medical Excellence: Doctors and Accountability in the Information Age.

Matrix

In an inconspicuous control room at the Sioux Falls, S.D., headquarters of the Evangelical Lutheran Good Samaritan Society, nurses keep round-the-clock watch on motion and humidity sensors in the living rooms, bedrooms and bathrooms of elderly men and women in five states.

The seniors — a handful in their own homes and the rest in assisted living facilities owned by Good Samaritan — are part of one of the most comprehensive remote health monitoring efforts anywhere.

Using sophisticated sensors, computerized pattern recognition and human responders, Good Samaritan hopes to show it can detect and head off health threats to the elderly and thereby accomplish two important goals.

Whether this costly technology will ultimately prove clinically or economically effective remains uncertain.

The first is saving money on medical costs.

The second is helping seniors feel secure enough to “age in place” at home or avoid moving from assisted living to a skilled nursing facility.

Whether this costly technology will ultimately prove clinically or economically effective remains uncertain. So, too, is whether a benign health care purpose can help overcome the unsettling “Big Brother” overtones for some potential users.

What is clear, however, is that health care is joining a national trend toward greater surveillance of everyday life.

For example, more than 70 U.S. cities now use ShotSpotter sensors to pick up the sound of gunfire and alert authorities even before 9-1-1 is dialed. Auto insurers are hooking up sensors to a car’s computer system to monitor driving habits and, with the driver’s permission, calculate premiums accordingly.

Even some farmers are equipping cow collars with monitors allowing automated milking systems to track the cow’s milk production, amount of feed eaten and even how long it chews its cud. If the system detects a problem, it can call the farmer on his phone.

What benefits bovines might also help humans, albeit with appropriate modifications. Good Samaritan is the nation’s largest nonprofit provider of senior services, operating more than 240 facilities in 24 states.

Working with the University of Minnesota, the system recruited 1,600 seniors in North Dakota, South Dakota, Minnesota, Nebraska and Iowa to test the impact on cost, quality of care and senior independence of a comprehensive set of monitoring tools.

With an $8.1 million grant from the Leona M. and Harry B. Helmsley Charitable Trust, the LivingWell@Home study began collecting data at 40 of its assisted living facilities in January 2011, and will stop at the end of June 2013.

LivingWell@Home comprises three technologies. First, sensors from WellAware Systems are distributed throughout the living space. (The company stresses that no cameras or microphones are involved.)

“Unless you gather, integrate and interpret that data in a meaningful way to the client and to their formal and informal caregivers, a sensor hanging on a wall isn’t going to help anyone.”

When a senior is sleeping a motion sensor records how often he or she moves in bed. Showering, toileting and other activities of daily living are also analyzed by WellAware algorithms and scrutinized by nurses for changes that might signal health problems.

The second piece is a medical alert button from Philips Lifeline that includes an auto-alert function designed to detect a fall and call for help even if the user is incapacitated.

Lastly, remote monitoring is provided by the telehealth unit of Honeywell through a clock radio-sized console in each apartment. It turns on each morning and prompts seniors to strap on a special blood pressure cuff, step on a special scale and transmit that and other information back to the monitors in Sioux Falls.

Jacci Nickell, who is Good Samaritan’s vice president of development and operation delivery systems, emphasizes that the technology is just a tool.

“Unless you gather, integrate and interpret that data in a meaningful way to the client and to their formal and informal caregivers, a sensor hanging on a wall isn’t going to help anyone,” she says. “It’s what you do with that data, and how you optimize wellbeing.”

Good Samaritan isn’t waiting for the study results to be finalized to roll out the LivingWell@Home service, in which the system has a financial stake, as an option in all its assisted living facilities. It’s also putting parts of the technology into some skilled nursing facilities and even into seniors’ own homes.

The organization’s website tells the story of an elderly woman who agreed to have the sensors installed in the South Dakota farmhouse where she lived alone.

Not long afterwards, the sensors detected a change in her toileting that prompted a call from a nurse. In response, the woman sought out her doctor, who discovered a bladder infection.

“Maybe it was God talking to me,” says 83-year-old Carol Tipton in a website video, seemingly near tears.

“We think the use of the technology can reduce the need for physical visits and will save expense and time,” Nickell says. Still, the high-tech security blanket doesn’t come cheap.

The technology costs $500 to $750 per month per person at home and about $175 a month for residents in Good Samaritan assisted living facilities that already have a personal emergency response button service.

By comparison, notes Mary Cain, managing director of consulting firm HC3, conventional disease management costs well under $100 per month per patient.

“It’s a very small percent of the population that’s going to benefit from [the Good Samaritan] level of monitoring,” Cain says. “How many will you monitor, and who is paying?”

A similar cautionary note comes from a spokeswoman for United Healthcare, the nation’s largest health plan. United already covers devices such as those used to detect abnormal heart rhythms or measure blood sugar.

But “health insurers typically rely on guidance from the clinical community in making coverage decisions,” says the spokeswoman, and with sensors and similar technology “it’s too early to do so at this time.”

Privacy also remains a concern. Some critics may detect overtones of a 1983 song by The Police that warns, “Every breath you take, every move you make, we’ll be watching you.”

As Christine Sublett, a health privacy and security consultant, put it: “Individuals should have the right to know exactly what information is being transmitted and that appropriate controls are in place.” Good Samaritan says it takes appropriate precautions, but the research study may not provide a rigorous test of protection against hackers.

Nor has Good Samaritan or its vendors yet encountered patients demanding their own data feed, as has happened to makers of defibrillator monitors and similar technologies.

BodyMedia

BodyMedia monitor

Still, other companies are jumping into this market. For instance, StealthHealth offers a radar beam to provide in-home monitoring of vital signs, activities of daily living and falls. The company suggests its equipment be placed inconspicuously behind a picture frame.

And GrandCare Systems offers to collect data from motion, temperature, door, chair and bed sensors, in addition to pill box sensors for monitoring medication use and caller ID information to keep an eye out for telephone scams.

Choices are also proliferating for consumers willing to pay out of pocket for detailed quantification of their diet, exercise and sleep patterns. In just one example, BodyMedia sells wearable sensors said to gather 5,000 data points a minute on skin temperature, heat flux and galvanic skin response. The company says its aim is to provide users with a personalized assessment of health issues such as stress, fatigue and depression.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Flu viruses

Snohomish county offers two no-cost whooping cough & flu vaccination clinics, Jan. 18 & 26

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Uninsured and low-income adults can take advantage of two shot clinics for flu and whooping cough at handy locations in Everett, Wash. Both clinics are free and open to the public.

Low-income and uninsured adults only – first come, first served

  • The first clinic will be held from 10 a.m. to noon on Friday, Jan. 18 during the WorkSource Community Resource Fair at Everett Station, 3201 Smith Ave., Everett, Wash.
  • The second clinic will run from 2 to 6 p.m. on Saturday, Jan. 26 at Comcast Arena, 2000 Hewitt Ave., Everett, Wash. This clinic is sponsored by the South Everett-Mukilteo Rotary Club and coincides with a free skating event for the public in the main ice rink

The Snohomish Health District will provide 200 doses of adult flu vaccine and 200 doses of adult whooping cough vaccine, also called Tdap, at the WorkSource event; and 300 doses of each at the Comcast clinic.

Washing hands, covering your coughs, and staying home when you are sick are effective ways to reduce spreading and getting diseases. The best way to prevent illness is vaccination.

The flu season in Snohomish County is proving to be more severe than usual. Three adults in our county have died from flu complications in the past several weeks.

Getting a current flu shot is the best way to protect yourself and others. Everyone 6 months and older should get a shot every year, since the flu vaccine changes to match the most common illnesses.

Vaccination is also the best protection against whooping cough. Whooping cough, also known as pertussis, is no longer at epidemic levels in Snohomish County, but cases of it are still being confirmed and it can still be deadly to babies.

All adults who have not had a whooping cough booster shot should get one. It is especially important that all pregnant women and people – including teens – who are around newborns get the booster shot to protect the infant.

Download vaccine information sheets and consent forms in English and Spanish at www.snohd.org.

Visit www.flu.gov for more information about flu, and www.doh.wa.gov for statewide updates.

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