Healthways MHS Stories

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Published on May 2, 2008

Author: Nathaniel

Source: authorstream.com

Medicare Health Support:  Medicare Health Support Success requires a human connection… Re-Hospitalization Prevented for Heart Failure Beneficiary :  Re-Hospitalization Prevented for Heart Failure Beneficiary On August 2, 2005, the MHS nurse called Ms. P, a 78 year old beneficiary with heart failure who had been discharged from the hospital on July 25. Ms. P told the nurse she had been “going to the ER at least once a month for my heart.” The nurse asked what medications or prescriptions Ms. P was given when she was discharged from the hospital on July 25, and the beneficiary said none. The nurse asked whether the beneficiary had been taking any medications since she left the hospital, and Ms. P said no. The MHS nurse inquired further, and found out Ms. P was experiencing fluid buildup and her ankles had become very swollen. Ms. P said she had tried to call her doctor’s office but hadn’t been able to reach them. While talking to the MHS nurse, she became upset and started to cry, trying to explain that she thought her insurance had been canceled. The nurse found out her sister lived with her and asked to speak with the sister. When the sister got on the phone, she explained that the nurse at the hospital had told them the hospital pharmacy would send medicines to their home, but that hadn’t happened. The MHS nurse told the sisters she would call the doctor’s office for them. She then phoned the cardiologist’s office and explained the situation, emphasizing that it needed to be addressed right away since Ms. P had been without medication for almost a week and was experiencing fluid buildup. The MHS nurse then called the beneficiary to let her know she would be hearing from her doctor soon. Since that was late in the day, the MHS nurse called the physician’s office again early the next morning. They said the prescriptions were ready and Ms. P could come pick them up. The MHS nurse notified the beneficiary, who then (despite her swollen ankles) took the city bus to the doctor’s office and got the prescriptions. When the MHS nurse checked on her again that afternoon, she was taking the medications. Ms. P was very grateful for the nurse’s help. The nurse set another call with her for the next week, and she happily made the appointment. --Teri Koppelman, RN MHS Nurse Overcomes Language Barrier for 82 Year Old Immigrant:  MHS Nurse Overcomes Language Barrier for 82 Year Old Immigrant On August 2 the MHS nurse placed call to Mr. F, an 82-year-old diabetic beneficiary. His wife answered the phone and the nurse began explaining the MHS program. Mrs. F haltingly said that they do not speak English well and were not interested in the program. When the nurse inquired what language they speak, Mrs. F responded “Russian.” The nurse explained that we have Russian translators, and Mrs. F agreed to speak with the nurse via a translator. The nurse got the translator on the line and together they spoke to Mr. F, who agreed to participate in the MHS program. Mrs. F returned to the phone and answered our Senior Assessment questions on behalf of Mr. F. The nurse picked up on the fact that the couple doesn’t have much money and mentioned how difficult it must be to pay for all their medications. Mrs. F said they have always been very independent and self-sufficient and it was hard to ask for help. The nurse mentioned that we have social workers in MHS who may be able to help them find ways to pay for their medications. Mrs. F again said that her English is not so good. The nurse told her she could talk with the social worker via a translator also, and Mrs. F breathed a sigh of relief. Mrs. F then said, in broken English and without a translator, “Now I finally know I am in America.” She thanked the MHS nurse multiple times and asked what the nurse’s name was. When the nurse responded “Angela,” Mrs. F exclaimed, “I knew you were an angel!” The nurse later recounted, “That gave me the chills – the feeling you get when you realize you have touched someone and made a difference. I now know that I can make a difference in this program.” --Angela Hoffman, RN Hospitalization Prevented for 87 Year Old:  Hospitalization Prevented for 87 Year Old On Friday afternoon August 19, the MHS nurse called Ms. H, an 87 year old beneficiary with heart failure and diabetes. Ms. H said she was not feeling well that day, but blamed it on the high humidity and heat. The MHS nurse became concerned as she talked to her further, and convinced Ms. H to call her physician and ask to see him that day. The physician agreed and she went in that afternoon. He examined her and drew a blood sample, which showed that her hemoglobin count was 25 – well below the normal range of 35 to 40. The physician then ordered an infusion of two units of packed blood cells. The doctor was grateful Ms. H had come in when she did. Since it was a Friday afternoon and her blood count was so low, it’s likely her condition would have worsened over the weekend and she would have had to be hospitalized by the next week – had it not been for MHS. The MHS nurse called the beneficiary again the next week to check on her. Ms. H thanked the nurse for her help, and said she would not have called her doctor if the nurse hadn’t encouraged her to do so. Telling the nurse of her gratitude, Ms. H added, “It’s nice to know someone really cares.” --Heather Henry, RN MHS Provides Key Support to 90 Year Old Nursing Home Resident:  MHS Provides Key Support to 90 Year Old Nursing Home Resident On August 23 the MHS nurse received a frantic phone call about 8 p.m. from the daughter of Ms. P, a 90 year old diabetic beneficiary in a nursing home. Ms. P had agreed to participate in MHS on August 17 when the nurse visited her in the nursing home and met with her daughter. Her daughter mentioned then that her mother had developed a bedsore that week, which the daughter attributed to the facility’s failure to change her mother’s position in bed regularly, particularly during the night when the daughter thought there was insufficient staff at the nursing home. The daughter was calling the MHS nurse on August 23 because her mother’s condition had worsened and the daughter was desperate for advice. She had talked to the nursing home administrator about the situation that day, but he brought up hospice and that upset the daughter. The MHS nurse talked with the daughter for about 30 minutes that night, and gave her a list of questions to discuss with the administrator and her mother’s physician. The MHS nurse also faxed a Facility Communication Sheet (form we developed for such communications) to the nursing home administrator, outlining the daughter’s concerns. The administrator called the MHS nurse when he got the fax and was very receptive. He said he would meet with the nursing home’s Medical Director and Ms. P’s attending physician, and they would work to resolve the issues. The MHS nurse made a follow-up call to Ms. P’s daughter on August 26. She said that her mom was now being turned every two hours, had a dietary consult and change of diet (she had been on a low protein diet and needed more protein to recover from the bedsore), and was improving. The daughter planned to attend the facility’s family counsel meeting that night for a further discussion of the case. The daughter said she believed the MHS nurse’s intervention is what made the difference in the nursing home’s care for her mother. She appreciated the support because she had no one else to help her with her mother. The daughter thanked the nurse and told her she was “truly heaven sent.” --Melissa Jones-Holley, RN Despondent Beneficiary’s Life Turned Around through MHS:  Despondent Beneficiary’s Life Turned Around through MHS In September when the MHS nurse first spoke to Mrs. Y, a 78 year old beneficiary with diabetes, she said she was very sad and didn’t see any reason to go on living. She lives in an apartment in the basement of her daughter’s home, but said she hadn’t seen her daughter for more than two weeks and was feeling isolated. Moreover, her right shoulder was very painful from a torn rotator cuff. An orthopedist had told her a while ago she needed surgery to have it repaired, but she had delayed making a decision and that orthopedist had retired. Recently the pain had increased and she had gone to see a new orthopedist, but that visit went badly. When the new orthopedist examined her, he squeezed her shoulder, which made her flinch. She said he then became belligerent and insisted “I have to touch you.” He also refused to look at her MRI results and ordered new x-rays. After he examined the new x-rays, he said her shoulder didn’t look so bad and he didn’t think she needed surgery. Mrs. Y felt the orthopedist hadn’t listened to her, and she became despondent. As she drove away from his office, she ran through a red light in the hopes of being killed. During the MHS nurse’s call with Mrs. Y, the nurse discussed depression and how a chemical imbalance can affect our perception of the world. Mrs. Y agreed to see her primary physician about how she was feeling, and the physician started her on an anti-depressant. The MHS nurse re-contacted Mrs. Y after she’d been on the medication for about a week, and Mrs. Y said she was beginning to feel better. Her daughter had brought Mrs. Y’s new great granddaughter to see her that day, and she had enjoyed that very much. The MHS nurse gave Mrs. Y the phone number for the Department of Aging in her county and encouraged her to contact them about activities that could interest her. Mrs. Y called them, and when she mentioned her interest in writing, they connected her with a writers group that meets regularly. When the MHS nurse next spoke with Mrs. Y on October 26, she was cheerful and engaging in life again. She has an appointment at a pain clinic to help manage the pain in her shoulder, and an appointment with another orthopedist. She is now optimistic about her future -- and very grateful to Medicare Health Support. --Linda Smith, RN Physician and Beneficiary Grateful for MHS Discovery of Duplicate Medication:  Physician and Beneficiary Grateful for MHS Discovery of Duplicate Medication On October 4 the MHS nurse called Mr. M, a 69 year old beneficiary with heart failure and diabetes. She reviewed all his medications with him, and discovered that he was taking a double dose of hypertension medication (Metoprolol Tartrate). He had two containers of the medicine, each of which had been prescribed by a different doctor. Every day he took the prescribed dose from each container – in other words, a double dose. The MHS nurse discussed with Mr. M that his physician may not want him taking doses from both containers, and neither of the two physicians may know that the other prescribed the same medicine. She explained the potential for adverse side effects and complications, and the possibility that those could result in hospitalization. The MHS nurse stressed that Mr. M needed to contact his primary physician right away and get very clear instructions on how to take the medicine. Mr. M said he had an appointment with his physician the next week and asked if it could wait until then. The nurse said no, it really shouldn’t wait that long. Mr. M asked if the MHS nurse would explain all of that to his wife, and the nurse did so. The wife said she would call the physician that day, and go with her husband to see the doctor to hear all that he said. Both Mr. and Mrs. M were very appreciative of the nurse’s discovery of the duplicate medication. The wife said she would call the MHS nurse back the next week to let her know what happened. A few days later the MHS nurse got a call from Mr. M’s physician. He said Mr. and Mrs. M had just been in to see him and told him about the situation. The physician had been totally unaware that another physician had prescribed hypertension medication also and Mr. M. had been taking a double dose. During the office visit, the physician carefully reviewed all of Mr. M’s medications with him and his wife, and instructed them on the correct way to take all his medications. When the physician spoke with the MHS nurse, he thanked her for discovering the duplicate medication and averting a potentially serious medical problem. He also wanted to know “Who are you and what is this program?” The nurse explained Medicare Health Support and our staff of nurses, social workers and dieticians. The physician was very pleased to know there is such a program. He noted “this patient needs a lot of help,” and thanked the nurse for all her assistance. --Lillian Romanek, RN Blind Beneficiary and Physician Grateful for MHS Help:  Blind Beneficiary and Physician Grateful for MHS Help In October the MHS nurse called Mr. F, a 65 year old diabetic beneficiary who is blind and lives independently in a senior home. He sounded very weak and sick when he answered the phone. He said he’d had his first chemotherapy treatment that week and had been vomiting for four days. He hadn’t been given any medication to manage the nausea and side effects from the chemotherapy. The MHS nurse could tell he was very dehydrated and might soon need hospitalization. Mr. F said he had no one to help him and didn’t know what to do. The MHS nurse told him she would help him, and Mr. F said he was very glad to know there was someone to help. The nurse called Mr. F’s oncologist to inform him of the patient’s status. The oncologist said Mr. F should come into his office right away to be evaluated. Mr. F was transported to the physician’s office, where he was treated for dehydration and prescribed anti-nausea medication. The physician was very grateful for the MHS assistance, as was Mr. F. The MHS nurse also contacted the Adult Evaluation and Review Services for that county (a public agency that provides home health services), and a registered nurse visited him the next day to evaluate his needs. She is working on obtaining a waiver to help him pay for his medications, and evaluating the safety of his current living arrangements. When the MHS nurse called again on October 27, Mr. F had had his second chemotherapy treatment but was taking his anti-nausea medication and had not had any nausea or vomiting. He was very grateful for MHS and the assistance he received. --Linda Smith, RN 350 Pound Nursing Home Resident Motivated to Improve Health:  350 Pound Nursing Home Resident Motivated to Improve Health The MHS nurse’s first visit to Mr. T was challenging. A 51 year old beneficiary with heart failure and diabetes, Mr. T weighs more than 350 pounds, has a tracheotomy, and lives in a nursing home. When the MHS nurse arrived, he was reluctant to speak with her and seemed depressed and “down in the dumps.” After the nurse explained the Medicare Health Support program and how it could help him, he agreed to talk with her. Mr. T said he had refused to get flu or pneumonia vaccinations in the past (“I don’t like shots”), did not exercise, and had no advanced directives. The nurse explained why it made sense to be vaccinated for flu and pneumonia, especially since he has a tracheotomy, and discussed the benefits of exercise and advanced directives. She also asked if she could contact Mr. T’s sister, who serves as his healthcare power of attorney. Mr. T agreed, and the nurse later talked at length with his sister. When the MHS nurse returned for her second visit, Mr. T looked much better – and reported that he had done everything she asked on the first visit. He had gotten flu and pneumonia shots, was walking daily, and had filled out the Five Wishes advanced directives document she left with him. He and the MHS nurse then met with the nursing home’s social worker to review his advanced directives, and Mr. T gave a copy to his physician. The MHS nurse was very encouraged by Mr. T’s receptivity. “We have a lot more to work on, but this was a fantastic start!” --Melissa Jones-Holley, RN MHS Helps Beneficiary Get Needed Medications after Heart Attack:  MHS Helps Beneficiary Get Needed Medications after Heart Attack On November 9 the MHS nurse made a regular care call to Mr. R, a 65 year beneficiary with diabetes. When she asked how things were going since they last talked, he said “Not so well. I had a heart attack on Friday.” He had spent the last four days in the hospital and had just been discharged. When the nurse inquired further, she found out he didn’t have three of the medications his cardiologist had prescribed at discharge. Mr. R told her, “I don’t know if I can afford them at the pharmacy. The VA usually provides all my medications, but it takes about two weeks to get them since they come in the mail.” He was upset and said he didn’t know where to turn. Moreover, he didn’t have time to seek help then because he was due for a radiation treatment and had to drive 30 minutes to get there. While the beneficiary went to his radiation appointment, the MHS nurse worked on getting him the medications. She contacted the cardiologist who treated him in the hospital and the VA hospital. The cardiologist’s office provided the medications he needed for the short term, and the VA mailed his longer term supply. Were it not for the MHS nurse’s quick action, Mr. R could well have had to be re-hospitalized. --Margaret Frost, RN MHS Helps 83 Year Old Artist Resume Painting:  MHS Helps 83 Year Old Artist Resume Painting When the MHS nurse first called Ms. F, an 83 year beneficiary with heart failure, she learned the beneficiary was an artist who loved to paint. Ms. F had been unable to paint for some time, though, because of pain and stiffness in her arm caused by a 2004 stroke. Those conditions also hampered her activities of daily living and made it difficult for her to function independently. The MHS nurse called the beneficiary’s physician to suggest physical therapy, as well as a home care nurse to administer laboratory tests related to Ms. F’s use of the anticoagulant Coumadin. Ms. F hadn’t been tested for a while because her debilitated condition prevented her from getting out to a test facility. The physician’s office followed up right away on the MHS nurse’s request and initiated physical therapy and home care services that week. That made Ms. F very happy because the therapy enabled her to resume painting and greatly improved her quality of life. --Stephanie Jackson, RN Couple Thankful for Just in Time Advance Care Planning :  Couple Thankful for Just in Time Advance Care Planning In November when the MHS nurse talked to Mrs. K, an 82 year old beneficiary with heart failure and diabetes, she had stopped going to her primary physician several months before because she didn’t like or trust him, and had stopped taking any medications for her diseases. While discussing the need for her to see a doctor regularly and take her medications, the nurse asked if Mrs. K had talked to her family about advanced directives. Mrs. K said she was afraid of lingering on machines and wanted to go as fast as possible. The MHS nurse encouraged her to read and fill out the Five Wishes booklet we had sent, and suggested she talk to her husband and children about her preferences. A few weeks later, Mrs. K informed the MHS nurse that she had filled out her Five Wishes. She also tried to talk to her husband and children about her wishes, but they didn’t want to discuss it at that time. In addition, she saw a new primary physician on December 6 and gave him her advanced directives. On December 12 when the MHS nurse called again, Mrs. K’s husband answered and informed her that Mrs. K had had a massive heart attack and passed away. He said she woke him about 3 a.m. and told him she had chest pain. She then reminded him of the Five Wishes and said she did not want machines or feeding tubes. When the ambulance came to get her, her husband gave them the Five Wishes. Mrs. K died on the way to the hospital. When the MHS nurse spoke to her husband on December 12, he thanked her for all that Medicare Health Support had done, and said he did not know until she filled out the Five Wishes that she did not want to linger on machines. He said he will tell his friends about us, and hopes the Medicare Health Support program will be expanded so he can join. --Debbie Cheeves, RN Physician’s Office Glad for MHS Patient Support :  Physician’s Office Glad for MHS Patient Support On December 2, MHS Provider Support Manager Cindy Friend made an introductory visit to a physician’s office and met with the office manager. She gave the office manager a brief overview of MHS, and explained the home monitoring services that are available for some MHS participants. As she talked, the office manager looked over the list of the physician’s MHS patients. Suddenly the office manager interrupted to point out a particular patient. As the office manager explained, this was an 82 year old heart failure patient the doctor had recently referred to a cardiologist since three of the patient’s heart vessels were almost completely blocked. The cardiologist was unwilling to operate, however, because of the patient’s co-morbidities and weakened condition. The patient had a return visit with the physician scheduled soon, and the physician was uncomfortable that he had “nothing to offer this patient.” The office manager was enthusiastic the physician could now offer the patient home monitoring through MHS. That would enable the doctor to monitor the patient more closely, and would provide reassurance to the patient. The office manager was grateful that they “now have something to offer this patient.” She concluded, “Medicare Health Support will be a true asset to the health care industry by helping physicians address needs, such as this, with their elderly Medicare patients.” --Cindy Friend, RN Beneficiary and Physician Grateful for Prevented Hospitalization:  Beneficiary and Physician Grateful for Prevented Hospitalization On December 6 the MHS nurse spoke to Ms. J, a beneficiary with heart failure, diabetes, chronic obstructive pulmonary disease, and a history of frequent hospitalizations. She was having some shortness of breath and coughing up green phlegm. The nurse discussed with her that was symptomatic of an infection, and with her history, it was important to contact her primary physician. Ms. J was resistant at first and fearful she would be hospitalized again, but she promised to call her doctor. She got in touch with him that day, and he gave her a prescription for an antibiotic. When the MHS nurse spoke with Ms. J again later that week, she was improved and glad she had contacted her doctor. On December 12 Ms. J called the MHS nurse to say she had gotten worse. The nurse encouraged her to go see her doctor again, which she did that day. He found she had a lung infection and put her on another antibiotic and prednisone. The physician said, “I don’t know who you’re talking to, but I’m impressed.” Ms. J feels she would have been hospitalized if it weren’t for Medicare Health Support. She said she is grateful for our calls, and loves Medicare and the Medicare Health Support program. --Margot Levin, RN MHS Nurse Saves Life of Diabetic Beneficiary :  MHS Nurse Saves Life of Diabetic Beneficiary On January 5 the MHS nurse received a call from Ms. B, a beneficiary she had not been able to reach since late November. During the November call, Ms. B reported she had fallen and suffered knee damage, but did not want to go to the doctor. Concerned about Ms. B’s condition, the MHS nurse phoned her daughter to ask if the mother could come stay with her for a while, and the daughter agreed. Ms. B was calling back in January to tell the MHS nurse what had happened – and to thank her for saving her life. Two days after the November call, Ms. B suddenly collapsed at her daughter’s home. She had not been testing her blood sugar, and developed acute renal failure. Her daughter summoned an ambulance and she was rushed to the hospital. She was in a coma in the ICU for nearly a week, but had slowly recovered and just been discharged. Ms. B was calling to tell the MHS nurse that, “If you hadn’t urged me to call my doctor and go to my daughter’s house, I would have slipped into a coma at home -- and probably died. You saved my life!” Charlotte Stritehoff, RN Beneficiary Gains Peace of Mind from Advance Care Planning :  Beneficiary Gains Peace of Mind from Advance Care Planning While talking to Ms. W, an 80 year old beneficiary with heart failure and diabetes, the MHS nurse asked if she had received the Five Wishes booklet on advance care planning we sent. Ms. W said she had received and read it. Because she and her husband had been very sick recently, it had gotten her thinking about what she wanted. She remembered the MHS nurse saying that when her mother filled out her advanced directives and pre-paid her funeral expenses, it had been a gift the nurse still thanked her for, and it helped the family so much when her mother’s condition worsened. Ms. W said she had tried to talk to her children and husband about the subject, but they didn’t want to hear about it. So she filled out the Five Wishes and gave a copy to her children and all her doctors, as well as all the hospitals where she might be taken. She then went to the funeral home and pre-paid her funeral expenses. Her husband sat in the car while she did that and refused to come in. After thinking a week about her husband’s refusal to discuss his advanced directives and funeral, she filled out advanced directives for him and pre-paid his funeral expenses. She now feels peace and comfort knowing that the future is taken care of and everyone knows what she wants. She thanked Medicare Health Support for sending the Five Wishes and getting her thinking about all of this. --Debbie Cheeves, RN “You saved my life!” MHS Nurse Discovers Ten-Fold Medication Overdose :  “You saved my life!” MHS Nurse Discovers Ten-Fold Medication Overdose On January 15, Martin Luther King Day, the MHS nurse had a care call with Ms. A, a 72 year old beneficiary with heart failure and diabetes. The beneficiary had just been discharged from the hospital the day before, and had been given discharge and medication instructions by a hospital nurse. The MHS nurse went over Ms. A’s medications, and she reported taking four and a half 25 mg tablets (112.5 mg total) of Coreg that morning per the discharge instructions. Knowing that was a large overdose*, the MHS nurse asked if she could call the beneficiary’s pharmacist to check the prescription. The beneficiary agreed and the nurse called the pharmacist, who said the prescription was for 12.5 mg – not 112.5 mg. The MHS nurse tried to call the beneficiary’s cardiologist and primary physician to report the problem, but both offices were closed for the holiday. The nurse then called the hospital emergency room, which instructed her to call the Poison Control Center. The Poison Control Center said there was nothing the beneficiary could do herself to counteract the overdose, and she should immediately be taken to the hospital. The MHS nurse called 911 and an ambulance was dispatched. The nurse cautioned Ms. A to not get up or walk around as she waited for the ambulance (since she could have blacked out). The nurse also called the beneficiary’s daughter (who lived a few minutes away) to inform her of what was happening, and ask that she come unlock the house for the paramedics and accompany her mother to the hospital. When the paramedics arrived, they confirmed that the handwritten hospital discharge instructions cited the wrong dosage. They took the beneficiary to the hospital, where she stayed for eight hours for treatment and monitoring. The MHS nurse called the beneficiary the next morning to see how she was doing. Ms. A told the nurse, “You saved my life – I know you saved my life!” She repeatedly thanked the MHS nurse, and readily agreed to begin our home monitoring program. --Amy Taylor, RN * Coreg is a medication that reduces blood pressure. That large an overdose could have caused a heart attack or stopped the beneficiary’s heart. It was fortunate the MHS nurse spoke to Ms. A only an hour after she took the medication since it takes about eight hours for the medication to reach full effect. In addition, the beneficiary was planning to take the same dose again that night per the discharge instructions. 85 Year Old Beneficiary Hand Delivers Medication List to MHS :  85 Year Old Beneficiary Hand Delivers Medication List to MHS On January 19 an MHS nurse spoke with Mr. S, an 85 year old beneficiary with diabetes. She reviewed his medications, but Mr. S was somewhat confused about which ones he should be taking currently. He agreed with the nurse to go over that with his physician on his next visit, and let us know his current medications on our next call. A few days later, the MHS office was surprised when Mr. S showed up at our doorstep with his list of current medications. He had just been to see his doctor and gone over his medications as we’d instructed. He wanted to report that to us right away, so drove more than 25 miles to hand deliver the medication list. The MHS staff thanked Mr. S for his prompt follow-up, but urged him not to make the drive again for his own safety, and to call us on our toll-free line whenever he needs to talk with us. His quick and conscientious actions show his appreciation for Medicare Health Support and dedication to improving his health. Beneficiary’s Leg Saved through MHS Efforts :  Beneficiary’s Leg Saved through MHS Efforts In December when the MHS nurse called Ms. S, a 67 year old beneficiary with heart failure and diabetes, Ms. S reported that she had lower leg wounds that had been worsening over the last several weeks. She didn’t have a physician she liked, so the MHS nurse guided her through selecting a new primary physician through the doctor referral service at her local hospital. The nurse then made several calls to the new physician and faxed information to expedite her care. When Ms. S went to see the new physician, he immediately referred her to a dermatologist -- who she said “made all the difference in the world to me.” Through his care her wounds began to heal, and by late January when the MHS nurse talked to Ms. S, they were almost completely healed. Ms. S believes the MHS nurse’s efforts “saved my leg.” She is very grateful to MHS, and expresses renewed commitment to self-management of her diabetes and health. --Debbie Dellinger, RN

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