1. Incontinence & Diabetic Products for the Aging
Choosing the Proper Products and Getting them Paid for by Medicaid and other Insurances
Designed by Paula D. Estridge Director of Corporate Supply Bird and Bear Medical, Inc.
Designed by Paula D. Estridge, Director of Corporate Bird and Bear Medical, Inc.

2. HOW TO TALK COMFORTABLY WITH YOUR INCONTINENCE CLIENTS
You are providing your clients a very valuable service if you can help them live a more full life by managing their incontinence. Here are a few tips to help bring up the conversation in a comfortable way for your clients:
“Bladder Leakage”: Use terms like this to describe incontinence or ask if they wear pads for urine leakage. Incontinence is not a word everyone is familiar with or comfortable using.
They are not alone: Assure your client that incontinence is not a disease but it does impact many people; over 25 million in the U.S. alone.

3. Facts about Bladder Leakage
Affects up to 25 million Americans each year
15% of men over 65 experience bladder leakage
Over 80% of those who are incontinent are women
It is not a disease, it is a symptom with many causes.
Some causes are:
job related activity like heavy lifting
high impact activities
lung disease due to chronic coughing
certain foods/beverages
poor nutrition
constipation
anatomical predisposition
obesity
previous urinary tract or renal problems
loss of pelvic muscle tone
pregnancy & childbirth
menopause
pelvic surgery or trauma
neuromuscular or cognitive impairments
medication side effects and the use of diuretics.

4. There are Six Different Types of Incontinence
Stress Incontinence: Leakage if you laugh, sneeze, or exercise: involuntary loss of a few drops, most common in women, usually occurs with a laugh, cough, sneeze, or exertion. Common causes: Pregnancy & Childbirth, pelvic surgery or trauma, obesity or weak pelvic muscles.
Urge Incontinence: Can’t get to the bathroom on time: awareness of the need to go, frequent, strong & sudden urges but cannot always make it to the bathroom on time. Common causes: Bladder irritants, urinary tract infections, or tumors and stones.

5. 6 Types of Incontinence continued
Reflex Incontinence: Urine loss with no warning. Can not tell they need to go. Common Causes: Stroke, brain tumors, or spinal cord injuries.
Overflow Incontinence: Bladder too full. Leakage when the bladder reaches a level of fullness, often accompanied by dribbling, frequency & urgency of urination increases. Common Causes: Medications, urethral obstruction, neurological conditions, or benign prostatic hyperplasia (BPH). (BPH is a non-malignant enlargement of the prostate gland occurring in men after the age of 50, and sometimes leads to compression of the urethra and obstructions of the flow of urine.)

6. 6 types of Incontinence continued
Functional Incontinence: A barrier when getting to the bathroom. Immobility or cognitive impairment hinders ability to get to the toilet, person may be a fall risk or bathroom may be inaccessible. Common causes: Cognitive impairment, functional disability, psychological impairment, or environmental barriers.
Mixed Incontinence: A combination of two or more types. Symptoms can include a combination of the other types of incontinence.

7. Managing Incontinence
Behavioral Therapy
Diet Modification
Medication
Surgery
Incontinence Products
Behavior Therapy involves understanding your body.
Certain foods act as diuretics and may be removed from the diet.
Certain medications for unrelated issues can trigger incontinence.
All surgery must be considered carefully.
Assess for the proper product needs based on the type of incontinence the client has.
You may create toileting schedules to proactively visit the bathroom
Eliminating one or all of the foods may improve your urine control.
Look into medications that are bladder irritants.
Surgery comes with risks and potential complications.
Patients may need a variety of products. For example, pantyliners or pullups during the day and diapers at night.
Use a diary to create a schedule & discuss with your physician.
Look into foods & beverages that are bladder irritants.
Other medications can help treat bowel/fecal incontinence. Discuss with MD.
Talk to the MD.
For women: Kegal exercises are also sometimes recommended to strengthen the pelvic muscles.

8. Choosing the right product
Types of Products
Information on Product
Stress
Urge
Overflow
Functional
Reflex
Bladder Control Pads (pantyliners, pads or male guards)
Available in a variety of sizes and absorbencies
Individually wrapped for discretion and convenience X
Belted Shields (belted undergarments or open sided belted pads)
One size fits most
Reusable elastic straps
Reinforced buttonholes
Protective Underwear
(pullups, DPU, briefs, overnight pants)
SIZED BY HIP SIZE
Pull on & off like regular underwear
Available in a variety of sizes, styles & absorbencies
Adult Briefs
(diapers)
SIZED BY WAIST SIZE
Ideal for heavy & fecal incontinence protection
Available in a variety of sizes & absorbencies
Underpads
(Chux, bed pads)
Placed under client in bed/chair
Protects when leakage may occur

9. Food & Beverages that affect Incontinence
Common Bladder Irritants
Alcoholic Beverages: beer, wine, liquor in any form are dehydrating
Carbonated Beverages
Soft Drinks with Caffeine
Coffee (Caffeine stimulates the bladder.)
Tea
Honey
Sugar
Artificial Sweetener
Corn Syrup
Chocolate
Tomatoes (these are acidic)
Citrus Fruits & Juices
Helpful Foods & Beverages
Fiber: Found in oat bran, applesauce, prune juice, and in the form of additives, can improve bowel habits and help ease constipation which can lead to incontinence.
Grape, cranberry, cherry and apple juice are thirst-quenchers that usually are not irritating.
Water: the best beverage of choice.
Important Note on Liquids
Many people who have bladder control issues reduce the amount of liquids they drink thinking that will help. This only causes more concentrated urine (dark yellow, strong smelling). This can irritate the bladder and increase the potential for a urinary tract infection and more incontinence.

10. Medications that affect Incontinence
Effect
Bladder Symptoms
Diuretics (water pills): Hydrodiuril (HCTZ), Lasix (furosemide), Maxzide (HCTZ-triamterene)
More urine is produced
Frequency, urgency, increased amount of urine output
Sedatives, muscle relaxants: Valium (diazepam), Librium (chlordiazepoxide), Ativan (lorazepam)
Sedation and drowsiness
Possible lack of appreciation of bladder events
Antihistamine: Benadryl (diphenhydramine)
Antipsychotics/Antidepressants: Elavil (amtriptyline), Prolixin (fluphenazine), Haldo (haloperidol), Prozac (fluoxetine HCl)
Calcium channel blockers: Calan (verapamil), Procardia (nifedipine), Cardizem (diltiazem)
Retention of urine because the bladder is relaxed or bladder outlet resistance is increased
Difficulty in starting the urinary stream, straining to void, voiding with a weak stream, leaking in between urinations, frequency, urinary retention
Anticholinergics: Oxybutynin, tolterodine tartrate, trospium chloride
Possible difficulty in passing urine due to relaxation of bladder muscle
Possible decrease in bladder emptying; rarely urinary retention, overflow incontinence
Alpha adrenergic agonist: Entex, Sudafed (pseudoephedrine)
Increases the resistance of the bladder outlet muscle
Urinary retention, difficulty in starting the urinary stream, straining to void, voiding with a weak stream, leaking between urinations, frequency

11. Medications that affect continued
Effect
Bladder Symptoms
Over-the-counter cold remedies: Nyquil, Theraflu, Alka Seltzer Plus Cold Relief, Afrin, long-acting nose drops
Retention of urine (Either because the bladder is relaxed or the strength of the bladder outlet muscle is increased, depending on the particular medication)
Urinary retention, difficulty in starting the urinary stream, straining to void, voiding with a weak stream, leaking between urinations, frequency
Alpha adrenergic antangonist: Hytrin (terazosin), Cardura (doxazosin), Flomax (tamsulosin)
Relaxes the bladder outlet muscle
Leaking when coughing, sneezing, laughing, exercising, etc.
DDAVP (desmopressin acetate)
Decreases urine output made by the kidneys
Possible decrease in blood levels of salts. Decreased urine production.

12. Troubleshooting Guide for Products
Leakage:
Is the client in the proper product?
Is the client in the proper size for their height and weight. Briefs too large will leak and sag.
Is the product making contact with the body? It should be a snug fit.
For briefs, are the bottom tabs angled up to cup the buttocks?
For briefs, are the top tabs angled at a downward angle for a snug fit at the waist?
Are barrier creams being used? Overuse may diminish the wicking action.
Has the product been “doubled-up” in an effort to maximize absorbency? Products are designed to be used as a single product. Pads inserted into the brief will hinder the absorbency process and may cause leakage. (Unless a diaper doubler, designed for an extra layer in the brief for more absorbency. These are just made of the fluff, no lining at all.
Skin Irritation:
Is the skin “scalded” at the mid-thigh area? Product may not be close enough to the body. Postion product close to the body for a snug fit.
Is the skin blistered at the upper thigh? Elastics may be positioned incorrectly. Leg elastics should rest on the natural creases of the groin.
Other potential causes of skin irritation: Infrequent absorbent product changes, inadequate skin care of pericare, and lack of repositioning.

13. Troubleshooting Guide continued
Absorbency:
Is the client in the proper product?
Is the client using the proper sized brief? A product too large will leak because of sagging.
Is the product making contact with the perineal area? Fit should be snug.
Odor:
Is the client receiving thorough pericare after each incontinence episode?
Are soiled products being rolled up and secured before disposal? It is recommended wrapping used items in plastic shopping bags or plastic gloves before disposing. Also, make sure you are using a trash receptacle with a secure lid.
Medicaid is the only insurance that will cover incontinence products. They pay $ a month from date delivered!!!!
Wipes ARE NOT a covered item!!!!

14. Diabetic Products based on the diagnosis
INSULIN DEPENDENT
6 boxes of strips MAXIMUM PER QUARTER (300 STRIPS TOTAL) and 3 boxes of lancets.
This is for supply up to 3 times a day testing (TID) ****You only give them the quantity of strips and lancets needed per the prescription on file, not automatically 300 strips****
NON-INSULIN DEPENDENT 2 boxes of strips MAXIMUM PER QUARTER (100 STRIPS TOTAL) and 1 box of lancets. This is for supply up to 1 time a day testing
INFORMATION BASED ON MEDICARE GUIDELINES & STANDARDS

15. Medical Documentation Required
Medical documentation is required every 6 months
Prescription from physician with testing frequency and diagnosis
Physician notes documenting the testing frequency, reason for testing frequency,
follow- up notes pertaining strictly to the diagnosis requiring the diabetic testing and treatment.

16. Types of Glucometers Covered and the Requirements
Standard Glucometer: (E0607)
Patient must meet all the following criteria:
Diagnosed with and treated for Diabetes (ICD-9 codes )
Monitor and related supplies must be ordered by the physician treating the diabetes
Patient or caregiver must have completed training on the use of the equipment
Patient is capable of using the test results to control their glucose levels
The device is designed for home use
Special Feature Monitors (for the visually challenged) E2100: visually impaired or E2101: manual dexterity impaired)
All the above basic criteria are met AND
The treating physician certifies severe visual impairment (20/200 or worse in both eyes) (for E2100 or E2101)
Specific visual acuity is documented (for E2100 or E2101)
Treating physician certifies the patient’s severe impairment of manual dexterity (Physician’s narrative statement must be on file) (for E2101 only-is not dependent upon a visual impairment)

17. Covered Accessories and Supplies
Covered Supplies
Blood glucose test strips (A4253) 1 unit=50 strips
Lancets (A4259) 1 unit=100 lancets
Glucose control solutions (A4256)
Spring powered lancing device (A4258)
Non-Covered Supplies
Alcohol or peroxide (A4244, A4245)
Betadine or phisoHex (A4245, A4247)
Urine reagent strips or tablets (A4250)
Home glucose disposable monitor (A9275)
Continuous glucose monitor
Reflective colorimeter devices

18. Not Medically Necessary
Laser skin piercing device (E0620)
Replacement lens shield cartridges (A4257)

19. Normal Utilization Guidelines
Patients not treated with insulin injections:
100 test strips, 100 lancets every 3 months
Patients being treated with insulin:
100 test strips and 100 lancets every month. Medicare, the only insurance that does; allows supplies shipped for a 3 month period at time. That would be 300 test strips and 300 lancets a quarter (every three months).

20. Guidelines for Excess Utilization
Patients who exceed normal guidelines must meet all the following criteria:
All basic criteria 1 through 5 are met (on the Standard Glucometer page)
Supplier maintains order in the patient’s record
Patient’s supply on hand is nearly exhausted
Treating physician ordered a frequency of testing that exceeds utilization guidelines (documented with specific reason in medical record required)
Treating physician has seen the patient and evaluated their diabetes control within six (6) months of prior to any order for quantities that exceed the normal utilization guidelines
Must be documented in the physician’s medical records
Additional physician visits are not required
There is documentation that frequency of testing matches physician’s order
A copy of the patient’s testing log, or
A statement in the physician’s medical record indicating the log was reviewed and how often testing was done
New documentation required every six (6) months

21. Documentation Requirements
A detailed written order is required prior to billing for the product; which has to include:
Patient’s name
All items to be dispensed (details)
Options or additional features needed by the patient
Specific frequency of testing
Treating physician’s signature and date
Start date if different from the signature date
***Note: If the physician’s order only lists frequency of testing as PRN or “as needed”, it is not medically necessary…you must get a set frequency.***
A new written order is required when:
There is a change in the frequency of testing
There is a change in supplier for the glucose monitor and/or supplies