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Falling through the cracks
There are some health services not provided free by the Health Ministry, the health funds or companies that seem so obvious and beneficial to individuals and society, it seems incredible they were unavailable until a voluntary organization decided to provide them. Two such services are a drug information center and an information center to reduce red tape for patients and their families.
Eshel, the Joint Distribution Committee’s Association for the Planning and Development of Services for the Aged in Israel, and the Hadassah Medical Organization (HMO) in Jerusalem have since 2008 quietly provided this assistance at no cost to all comers, even though limited resources would make it difficult to meet demand if they were widely publicized and no additional funds were injected into the projects.
Take the case of an elderly woman who almost never left her house because she had been prescribed 13 medications to take a few times a day. Fearful of missing any, she took a pill every 15 minutes – and had no time to do anything else. She finally contacted by phone the Drug Information Center at Hadassah University Medical Center in Ein Kerem and presented her problem. The clinical pharmacist on duty asked detailed questions about her condition and her life and created a chart itemizing all the information and planning when she could take her pills only twice a day without them conflicting with each other or with what she ate. Finally, she was able to live and get out of the house.
Another patient was found to be taking three times the prescribed amount of the blood thinning drug Coumadin and was advised to cut the dosage drastically. Yet another, who suffered from osteoporosis, had difficulty swallowing her pills and decided on her own to pulverize them and take the powder with food. But this medication and many others must be swallowed whole rather than cut or ground up. The woman ended up with a mouth ulcer and a perforation in her gastrointestinal system. This innocent error could have killed her.
The idea for the center came from Prof. Yosef Caraco, chief of Hadassah’s clinical pharmacology unit in the hospital’s internal medicine department who was conscious of his elderly mother’s difficulties in coping with their numerous medications for chronic illnesses. Once, she made an error taking a drug. She was given a generic medication after having used one with a commercial name, and the capsule looked very different.
If she, the parent of a senior clinical pharmacologist, doesn’t know how to take her pills properly, what about the countless other older people whose children were not physicians, Caraco thought.
With financial help from Eshel and professional staff and office facilities from Hadassah, the center was launched.
“Sometimes, just looking at the chart tells you where the problem is,” says Dr. Bruria Raccah, a senior clinical pharmacist who is on the center team, along with Caraco and clinical pharmacologist Dr. Mordechai Muszkat. “Prof. Caraco had a lot of vision about this,” Raccah told The Jerusalem Post in an interview.
The initiative was welcomed from the start by Prof. Shlomo Mor-Yosef, until a few weeks ago director-general of HMO.
“Hadassah should be very proud of this effort,” Caraco said. “There are so many medical problems that can be prevented, so many situations that affect people’s lives and their quality of life. Every year, more than a million people come to our medical centers with a variety of illnesses, diseases and medical problems ranging from simple situations to complex conditions. Many of them are hospitalized, treated and discharged. They leave with a list of instructions, a handful of prescriptions, frequently a need for supportive services and, more often than not, dilemmas they will only realize when they get home.”
Patients are hospitalized, and we fix them up, but what about when they go home?” Raccah continued. “It’s important that they know how to manage. And family doctors who spend six or seven minutes on each patient usually don’t have the time to explain how and when to take medications.”
With all patients, the center’s advice is always followed by a letter with the same information for the family doctor.
“We want to strengthen the patient’s relationship with their family doctor,” Raccah said. “We want to help them improve their lives.”
Around the world, there are many patients who become ill – and even die – because they took too many medications or one conflicted with the others. Even taking a pill with grapefruit juice or milk can interfere with the medication, but physicians and even pharmacists often don’t give proper advice.
The most common questions are, “How often should I take my medications and is it safe to take this combination of pills?” The Center’s staff looks at the assembled data and answers the callers – but they don’t stop there. If there is negative interaction, they recommend alternatives; sometimes they suggest a newer medication or a more specific one, cautioning the patient not to make any changes without consulting their family doctor. There is a recommendation, said Raccah, that the medications of every elderly person with chronic diseases should be checked by an expert every few months to make sure that he is not suffering from needless side effects or getting over- or undertreated.
“When we receive a call from an elderly person, we ask for their medical history and for them to take out all their boxes of pills and read them to us,” Raccah continued.
The drug information service (tel: (02) 677- 8866; fax: (02) 677-8166; e-mail: firstname.lastname@example.org) is meant for the elderly, but anyone is welcome to call. It’s open Sunday though Thursday from 8 a.m.
to 4 p.m., and one can leave a message on an answering machine. Within 48 hours of receipt (on weekdays), a response will be sent.
“We do a little advertising,” said Raccah, “and have handled some 3,000 queries so far.
We can deal with an average of six a day, but if more people call, we do our best to help them.”
A few years ago, the State Comptroller’s report looked into the issue of medication advice for the elderly and, finding that many people went without, recommended the Eshel-Hadassah service as a model.
The Drug Information Service would love to get additional funds from other sources, but it has to be careful that pharmaceutical companies’ logos do not insist that their logos appear on information material, she said. Certainly, the four public health funds should contribute because it is in their interest that their members get the right medication and are not over- or under-dosed, as they would have to pay for their treatment and hospitalization.
The center conducted a survey following up some of the patients they had helped by phone, and a large number said they had changed the way they were taken pills, including dosages, and took different or fewer drugs than previously after confirming the center’s advice with their family doctors.
Appearing at a pharmacology conference in Texas recently, members of the team were told by participants that they were very impressed by the Jerusalem model.
The second free public service provided to the elderly (and others) by Eshel and HMO is Kivunim (Directions), the Patients’ Information Center on the Ein Kerem campus, with a smaller branch on the Mount Scopus campus.
Kivunim is funded by HMO, Eshel and the Mashov Fund (Feedback Fund), a private charity funded by Florence Galkin in the US.
It is supervised by Rita Abramov, head of Hadassah’s social work department, and run by Alma Fridlender, a social worker with a master’s degree in public health who has worked at Hadassah for 11 years. The day-today queries are handled by some 40 volunteers who undergo a special training session before they begin.
Many patients fall between the cracks. For example, a 35-year-old-man with emotional problems was denied services by the National Insurance Institute, which imposed a heavy fine on him for not keeping an appointment. Fortunately, his father turned to Kivunim for help, and the center staff immediately responded and went right to the top. They contacted NII management and persuaded them to cancel the fine; they also arranged for the man to receive the social welfare services he deserved.
Staffed by members of Hadassah’s department of social work services, the center runs thanks to well-trained volunteers. Kivunim was conceived to provide patients with a centralized source of information and assistance, with offices at both Hadassah-Ein Kerem and Hadassah-Mt. Scopus. The Ein Kerem center operates weekdays 9 a.m. to 5 p.m. and can be called at (02) 677-7011 or emailed at kivunim@hadassah. org.il. The Mount Scopus center is open on Mondays, Tuesdays and Thursdays, and the phone number is (02) 584-4025.
“Many people are not aware of their rights and entitlements within the health care system – and don’t even know how to find out about them,” said Fridlender. Red tape such as that encountered by the young man with emotional difficulties often leave them without the help they need.
Sometimes patients are referred by hospital personnel – nurses, physicians or social workers. Sometimes patients and families initiate contact themselves; others come from faraway places in desperation. All who don’t phone or fax in their problem come to a comfortable and welcoming place where staff members conduct personal interviews, assess their needs, advise them of their rights and help them access the available services.
Working with a specially designed resource data base, they provide information about the broad spectrum of community resources, such as home healthcare providers, nursing homes and rehabilitation centers. Follow-up is important: Two weeks after the initial visit, the volunteers contact the patients to find out how they are coping at home and check whether they are receiving the services and benefits that they are entitled to by law.
“It is very satisfying work,” said Elad Greenberg, one of the volunteers who is a board member at Kupat Holim Meuhedet but retired from work at a number of important positions. “I receive a lot more than I give. We deal with rights of patients, not drug information, and advise patients on NII, the income tax authorities, the health funds, voluntary organizations and other institutions.
“The NII, for example, regards us as real partner and invites us to seminars; so do the various ministries, the authorities that deal with foreign workers and the disabled and even municipalities and local authorities.
But about half of the problems deal with the NII alone or together with other offices.”
“There are social workers in all the hospital departments, but they can’t reach all who need help. They don’t give service, for example, to the many who come for treatment at outpatient clinics,” said Abramov. “We set up the free service after the Health Ministry years ago recommended to hospitals to provide information to patients in a coordinated way so they can take advantage of their entitlements. At Kivunim, all the information is coordinated under one roof. Russianand Arabic-speaking volunteers are also available.”
The computer in the office has all needed NII forms that can be printed out without patients having to go to those offices in person or download them from websites.
“They fill them out themselves but with our help and advice,” said Fridlender.
“People suddenly go from being healthy to ill, and they are confused. They don’t know how to manage,” added Abramov.
“If applicants for help have properly filled in forms, a lot of the red tape is cut because there is nothing missing in the paperwork.”
Fridlender concluded that Kivunim can easily serve as a model for around the country and that she and colleagues would be happy to advise them.