William Leahy, MDand The Editors of Hartman Publishing

at HomeCaregiving

Caregiving at Home

William Leahy, MDand The Editors of Hartman Publishing

Albuquerque, NM

Copyright Information

© 2006 by Hartman Publishing Inc. and William Leahy, MD8529 Indian School Road NEAlbuquerque NM 87112(505) 291-1274web: www.hartmanonline.come-mail: orders@hartmanonline.com

All rights reserved. No part of this book may be reproduced, in any form or by any means, without permission in writing from the publisher.

ISBN 1-888343-90-7

Notice to the ReadersThough the guidelines and procedures contained in this text are based on consultations with healthcare professionals, they should not be considered absolute recommendations.

The publisher, authors, and editors cannot accept any responsibility for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the contents of the book. The publisher does not warrant or guarantee any of the products described herein or perform any analysis in connection with any of the product information contained herein.

Even properly performed, not every procedure is safe and appropriate for everyone. Before performing any care procedure listed in this text, consult a physician to learn which procedures are appropriate for your loved one. Ask for a healthcare professional to demonstrate the correct way to do the procedure and adapt these procedures for your loved one’s condition.

Internet addresses and telephone numbers listed in this book were correct at press time.

Gender UsageThis textbook utilizes the pronouns “he,” “his,” “she,” and “hers” interchangeably to denote family caregivers and their loved ones.

CreditsManaging EditorSusan Alvare

Development EditorsJennifer Plane HartmanSuzanne Wegner

Cover and Interior DesignerKirsten Browne

Page LayoutThaddeus Castillo

IllustrationThaddeus Castillo

PhotographyArt Clifton/Dick Ruddy/Susana Marks

ProofreaderKristin Calderon

SalesGailynn Garberding/Debbie Rinker

Customer ServiceYvonne Gillam/Kim Williams

AcknowledgmentsWilliam Leahy, MD became involved with home health aide education both out of an interest in the care his patients received and to give direction and meaning to the lives of young people in his community. After teaching the home health aide program at Bladensburg High School in suburban Maryland, he undertook the project of writing a better book. All royalties from sales of this book fund a foundation formed to support young people studying healthcare careers.

Since 1994 Hartman Publishing has developed educational material for frontline healthcare workers. Nurses are the lifeblood of frontline care, and they have guided each step we’ve taken. A sincere thank you to the wonderful nurses who have contributed to the material drawn on for this project:

Jetta Fuzy, RN, MS; Julie Grafe, RN, BSN; Betty Wolfe, RN; Susan Cutro, RN; BSN, Anna Blum, RN, MS; Linda Westerman, RN, MN; Delores Pederson, BSN; Charles A. Illian, RN, BSN, CIC; Kathlene Benson, BSN, RN, C

Table of Procedures 6

1 Thinking About Home Care 11

2 Communication 22

3 Caring for Yourself 34

4 Setting Up Your Home, Safety and Body Mechanics 43

5 Preventing Infection in the Home 57

6 Normal and Abnormal Signs of Aging 72

7 Meeting Special Needs and Conditions 83

Arthritis

Cancer 85

87

84

Ostomies

Diabetes 89

Cerebral Vascular Accident (Stroke) 93

Hypertension (High Blood Pressure) 97

Coronary Artery Disease 97

Myocardial Infarction (Heart Attack) 98

Congestive Heart Failure 99

Dementia 100

Alzheimer’s Disease 100

Chronic Obstructive Pulmonary Disease 110

Hip or Knee Replacement 111

Table of Contents

8 Death, Dying and Hospice Care 116

9 Providing Personal Care 125

10 Transfers and Ambulation 153

11 Basic Healthcare Skills 169

12 Healthy Eating and Hydration 203

13 Emergency Care 221

14 Medications 233

Forms 247

Index 255

Washing hands 61

Putting on gloves 62

Taking off gloves 63

Putting on a gown 63

Putting on a mask and goggles 64

Caring for an ostomy 88

Helping a person transfer to the bathtub 129

Helping a person who can walk to take a shower or tub bath 130

Assisting with a bed bath 131

Shampooing hair 134

Giving a back rub 135

Combing or brushing hair 136

Providing fi ngernail care 137

Providing foot care 138

Helping someone shave 139

Assisting with oral care 141

Performing oral care on an unconscious person 142

Flossing teeth 142

Assisting with denture care 143

Reinserting dentures 144

Assisting in using a bedpan 145

Assisting in using a urinal 147

Assisting with use of the toilet or a portable commode 148

Making an occupied bed 150

Making an unoccupied bed 151

Assisting a person to a dangling position 154

Helping someone sit up using the arm lock 155

Helping someone stand up 155

Using a transfer belt to assist with ambulation 157

Assisting with walking for a person who uses a cane, walker, or crutches 157

Table of Procedures

WarningEven properly performed, not every procedure is safe and appropriate for everyone. Performed incorrectly, they can cause injury to your loved one or yourself. And, some procedures can be dangerous for persons with certain conditions. Before performing any procedure, consult your physician to learn which procedures are appropriate for your loved one. Ask for a healthcare professional to demonstrate the correct way to do the procedure and how to adapt these procedures for your loved one’s condition.

Helping someone move from a bed to a chair 159

Helping someone transfer using a slide board 159

Transferring someone using a mechanical lift 160

Turning someone in bed 163

Moving someone up in bed 164

Logrolling a person 165

Taking and recording an oral temperature 172

Taking and recording a rectal temperature 174

Taking and recording an axillary temperature 175

Taking and recording a tympanic temperature 176

Taking and recording apical pulse 177

Taking and recording radial pulse and counting and recording respirations 177

Taking and recording blood pressure (two-step method) 179

Providing catheter care 182

Emptying the catheter drainage bag 183

Collecting a sputum specimen 186

Collecting a routine urine specimen 187

Collecting a clean catch (mid-stream) urine specimen 187

Collecting a 24-hour urine specimen 188

Collecting a stool specimen 189

Changing a dry dressing using non-sterile technique 190

Applying warm compresses 191

Administering warm soaks 192

Using a hot water bottle 192

Assisting with a sitz bath 193

Applying ice packs 193

Applying cold compresses 194

Applying anti-embolic hose 194

Assisting with passive range of motion exercises 196

Assisting with deep breathing exercises 201

Measuring and recording intake and output 212

Assisting someone with eating 219

Heimlich maneuver for the conscious person 224

Shock 225

Heart attack 225

Bleeding 226

Poisoning 227

Burns 227

Seizures 228

Fainting 229

Nosebleed 229

Helping someone who has fallen 230

Since 1994 our textbooks have helped train home health aidesand nursing assistants. Soon thereafter, family caregivers calledlooking for the same help in understanding the basics of caregiving.Caregiving at Home is the result of these requests.

Caregiving is amazingly rewarding and important work.At times, it is also exhausting and frustrating.

This book provides a foundation of knowledge to best coordinatea loved one’s care and provide the hands-on assistance he or sherequires. A section that covers 13 of the most common diseasesand conditions among the elderly is included.

Much of the material in this book was originally developed to train certified home health aides and nursing assistants; thus,many of the photographs show uniformed professionals providing care. This information has been used in thousands of successfultraining programs; it is regularly reviewed and updated to meet the latest medical standards.

Each chapter offers a few “First Steps” to help get you started.

Care guidelines are included for over 33 typical problems,including prompts to report subtle changes to a professional caregiver.

Seventy-two procedures help prepare you for hands-on tasks like bathingand other activities of daily living.

Concise lists of resources can help provide answers you need.We’ve limited our resources sections to the most trusted, established,reliable sources to help you quickly find good information.

Tools for organizing medications, holding family meetings,and coordinating care.

A primer on aging—what’s normal and what’s not.

Here’s how it works:First StepsGUIDELINES

Resources

located onthe side ofevery pagemake findinginformationsimple.

Color tabs

Providing foot care

Aging

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11Thinking About Home CareCaring for a family member or loved one in your home can be both challenging and rewarding. This

chapter explores these challenges and rewards so you can make informed decisions about caring for a

family member at home.

For the person receiving care, the benefits of being in a home environment are significant:

• Most of us feel more comfortable in a private residence than we would in an institutional setting,

even if the home in question is not our own.

• Being surrounded by family or other loved ones can combat loneliness (Fig. 1-1).

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• Greater independence may be possible in the home (Fig. 1-2).

• Family caregivers provide cost savings.

There are benefits for thecaregiver as well, especiallythe satisfaction of allowing aspouse, parent, or otherloved one to recuperate orlive out her life in comfort,with dignity and companionship.

Of course, there are difficul-ties to be faced. For the per-son receiving care, any movewill require adjustment. Anychange in health status will

entail changes in relationships with those providing care. Itmay be difficult for someone to accept help or feel dependentupon a spouse or child when he is used to caring for himself.

For the caregiver, the challenges of providing care in the homeare significant:

• Work and family schedules must be modified to allow forcaregiving.

• Additional emotional and physical energy must be avail-able.

• The home must be adapted to be safe and practical foryour loved one’s needs, as well as others in the home.

• Family dynamics will be altered by the change in the household.

• Financial issues will arise (Fig. 1-3).

• Leisure time will be reduced or eliminated.

Fig. 1-2. Living in a home environ-ment may allow your loved one moreindependence than is possible in a facility. Fig. 1-3. Caring for someone in the home can cause financial difficulties.

Fig. 1-1. Being surrounded by family can help your loved one combat loneliness.

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Only you can evaluate thechallenges and benefits ofhome care for your particularsituation. The considerationslisted above provide a start-ing point for your thoughts.It is a good idea to writedown the potential positiveand negative impacts, yourconcerns, and your hopesabout providing home care.Consider sharing yourthoughts with a person youtrust who can help you weighthe pros and cons to make agood decision.

AvailableSupportWhen you are caring for someone in your home, you cannotand should not expect to do everything yourself. There aremany sources of support available to you, from adult daycareservices for the elderly or disabled to personal grooming orhousecleaning services provided by agencies or individuals(Fig. 1-4). Most of these will be listed in the phone book. Manykinds of volunteer help may be available in your community aswell, such as church groups, relatives, or friends. Try to accepthelp when it is offered, and solicit help when it seems to beavailable. You will be a better caregiver if you take advantage ofoutside support.

First StepsWrite down the pros and cons of caring for your loved one inyour home. Try to separate your emotions from practical con-siderations as you do this.

Check with your employer about possible benefits for familycaregivers. The Family and Medical Leave Act may provide un-paid time off for caregiving. Visit www.benefitscheckup.org todetermine what kind of financial benefits your loved one is eli-gible to receive. Created by the National Council on the Aging(NCOA) this free, easy-to-use website helps older Americansdetermine their eligibility for a wide range of public assistanceprograms. It compares the information you give with eligibilityrequirements for Social Security, Medicaid, food stamps,weatherization, in-home services, pharmacy programs, andstate programs. A printable report of programs and enrollmentinformation is available.

Find out as much as you can about your loved one’s specialneeds and abilities and how they will affect daily life for youand other members of the household.

Locate resources in your area that will be able to help you as acaregiver. A good resource to check with is the Eldercare Loca-tor at www.eldercare.gov, 1-800-677-1116.

Here are some options to explore for finding help in your community:

Area Agency on Aging: This is a great place to start, as theywill have details about all of the services that follow. Services

Fig. 1-4. There are many agencies,both paid and volunteer, which canprovide assistance for home caregivers.

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may include information andreferrals regarding health in-surance, transportation, mealdelivery services, and home-maker services. To find AreaAgencies on Aging across thecountry, call the Eldercare Lo-cator at 1-800-677-1116.

Senior centers or communitycenters may offer caregiversupport groups, adult day-care or respite care.

Meals on Wheels is a mealdelivery service for home-bound people (Fig. 1-5).

Hospitals or nursing homes may offer caregiver supportgroups or adult daycare or respite care.

The Alzheimer’s Association, The American Cancer Society, orother disease-specific organizations may offer support groupsor other services.

County Health Nurse: Local or county departments of health orhuman services sometimes offer eldercare programs.

Hospices provide services for patients who have fewer than sixmonth to live.

Home health agencies offer personal and home health serv-ices, such as help with bathing, dressing, feeding and mealpreparation on an hourly fee basis. Clients with Medicare whoare homebound may qualify for reimbursement of some homehealth expenses (Fig. 1-6).

Faith-based groups, includ-ing churches, temples, orother groups, may offer vol-unteers to visit homeboundpatients, provide respite care,drive patients to appoint-ments, prepare meals or per-form household tasks.Contact large congregationsin your neighborhood andask about their social min-istries, neighborhood out-reach, or eldercare programs.

Accepting HelpSometimes caregivers feel it is simpler to do everything them-selves than to accept or solicit help from others. It may indeedbe simpler, but it will also be more tiring. No one can do every-thing that is required of a caregiver in the home without ac-cepting some help. To preserve your physical, mental, andemotional health, you must give yourself a break and find waysto share the duties of caregiving.

If your loved one resists accepting care from anyone but you,you may have to be creative to get a break for yourself. Perhapsyou can let someone else do the cooking, cleaning, and shop-ping while you provide personal care such as bathing anddressing (Fig. 1-7). Somehow you will need to find relief foryourself if you are to continue as a loving, reliable caregiver.

Often friends and neighbors offer to help but do not knowwhat to do. Help them to help you. Give them specific ideas of

Fig. 1-5. Meals on Wheels is a mealdelivery service for people who cannotleave home.

Fig. 1-6. People who are eligible forMedicare may qualify for some reim-bursement of home care expenses.

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things they can do for you oryour loved one. The listbelow includes specific waysothers can help you. Tailorthe list to your specific situa-tion; add other things neededand keep it available forfriends and neighbors whowant to help.

1. Sit with my loved one soI can run an errand, takea nap, read a book, go toa movie, or take a walk toclear my head.

2. Help with errands thatwe need done, for exam-ple, doing the groceryshopping.

3. Prepare a meal and bringit over in dishes that donot need to be returned.Things that can be frozenare always good, as theyprovide flexibility.

4. Offer to take my lovedone out as appropriate(Fig. 1-8). Be prepared towalk slowly or push thewheelchair. If you canfind a meeting, program

or concert that might be appropriate and of interest, invitehim there.

5. Write down the times you are available and what you areprepared to do so I can call you. For example: Thursdayevenings and Saturday afternoons I can run errands, sitwith your loved one, or bring over dinners.

6. Take my car to get the oil changed and fill it with gas. Runit through the car wash to give us a real treat.

7. Offer to bring over your own cleaning supplies and clean aroom or two or mop the kitchen floor.

8. Ask if there is laundry to be done and do it. Visit with uswhile the loads wash and dry.

9. Bring over something special to interest my loved one:family photos or videos, a musical instrument you can play,or a simple craft project to do together (Fig. 1-9).

10. Take me out, if I can get away, for a meal, a movie, a mas-sage, or just some time away from the responsibilities athome.

11. Offer to mow the lawn,balance the checkbook,fill out insurance forms,shop for gifts, pay bills,answer correspondence,or do anything else I can-not find the time or en-ergy to do.

12. Be positive! Tell me I’mdoing a good job. Give us

Fig. 1-7. Even if your loved oneprefers to have care only from you,there are plenty of opportunities forothers to help out around the home.

Fig. 1-9. Ask friends to bring overpleasant things to share with yourloved one.

Fig. 1-8. If appropriate, ask a friend orfamily member to take your loved oneout.

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hugs if that feels right. Bring silly jokes to share. You neverknow what can lift spirits.

13. Be sensitive. Listen to what my words and my body lan-guage are telling you. Offer to come back another time ifthings seem strained.

If you have access to the Internet, there are several websites in-tended for caregivers that may be of interest to you (Fig. 1-10).Phone numbers are included so you can call for information ifyou do not have Internet access. More agencies and websitesare located at the end of the chapter in the “Resources” section.

Family Caregiver Alliancewww.caregiver.org800-445-8106

National Family Caregiver Associationwww.thefamilycaregiver.org

800-896-3650Membership in this organization is free for any family caregiver.

Alternatives to Home CareAs you think about providing home care, it is helpful to knowwhat other options exist. Your ability to provide care maychange with personal circumstances, or your loved one’s needsmay change, necessitating a change in living and care arrange-ments. For example, many families caring for a person withdementia find there is a point where it is no longer physicallysafe to keep the person at home; wandering, aggression, andphysical outbursts may require the person to be moved to a fa-cility designed for those suffering from dementia. If you havefound the best possible way to meet your loved one’s needs, aswell as the needs of your family, then you have succeeded as acaregiver, whether the solution is care in the home or care in afacility.

Adult Daycare

Adult daycare is given at a facility during daytime work hours.Generally, adult daycare cares for people who need some helpbut are not seriously ill or disabled. Adult daycare centers givedifferent levels of care. Adult daycare can also provide a breakfor spouses and family members.

Semi-Independent Living Arrangements

Retirement homes, senior apartments, homes for the elderly,and condominium communities are designed for people whoFig. 1-10. The Internet is a good source of information for caregivers.

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can manage with some assistance. These arrangements maybe appealing if you or your loved one wants more privacy orspace than is available in your home. Group activities may alsobe available. These living accommodations are usually not de-signed for the frail elderly or those needing daily assistancewith bathing, dressing, and eating.

Assisted Living Facilities

This growing category usually describes a group of apartmentswhere meals and housekeeping are included in the rent.Twenty-four-hour emergency medical help may be available;for an additional fee, assistance can be arranged for everythingfrom bathing to dressing to trips to the doctor. The regulationsgoverning these facilities vary widely from state to state, so thelevel of care provided must be determined on an individualbasis. These facilities can be expensive and are usually not cov-ered by insurance or Medicare.

Continuing Care Retirement Facilities

These providers offer a lifetime contract for care in exchangefor a substantial entrance fee plus monthly fees that depend onthe care required. For example, a person may enter at age 65able to live independently in an apartment. Later he moves toan assisted living unit with meals provided until he finallyneeds skilled nursing care in a specialized unit.

Nursing Homes or Skilled Nursing Facilities

These facilities provide daily care, ranging from help withdressing, bathing, and eating to medication monitoring, oxy-

gen therapy, IV therapy, orskilled nursing care. Thesefacilities provide long-termcare and assist those withchronic conditions (Fig. 1-11).

Specialized Facilitiesfor Dementia

Some nursing homes and as-sisted living facilities havespecialized wings or separatebuildings dedicated to thehousing and care of peoplewith dementia. These are se-cure facilities which mayallow residents to wander without leaving the safety of the fa-cility. These facilities have staff and programs that are specifi-cally geared to meeting the needs of residents with dementia.

There may also be other options in your community to helpcare for the elderly or infirm. Keep your mind open to variousoptions so that as your loved one’s needs change, you are pre-pared to adapt your arrangement as necessary.

Financial and Legal Issues Managing the finances of a person who is ill or dying is com-plicated. The regulations governing Medicare and Medicaidand the benefits from Social Security or from private insurerschange often and vary with individual situations. Thus it is dif-

Fig. 1-11. Nursing homes offer 24-hour skilled care for people with a va-riety of needs.

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ficult to present a general guide to dealing with these financialissues.

However, a basic understanding of what these programs arecan help. Further, there are some rules for managing financesthat will apply across the board.

Medicare

Medicare is the federal insurance program created in 1965 toprovide healthcare for the elderly and disabled. Medicare PartA, or Hospital Insurance, is free for eligible citizens. It is fi-nanced through the Social Security or FICA tax paid by work-ers and employers. Medicare Part A helps cover the cost ofstays in the hospital, surgery and recovery, lab work, X-rays,and some rehabilitation (Fig.1-12). Currently, MedicarePart A pays for some care ina nursing home following ahospital stay. However,Medicare does not cover con-tinuing care in a nursing fa-cility, nor does Medicarecurrently cover the costs ofhome health care unless thepatient is officially home-bound and in need of someskilled nursing services.Some assistance with pre-scription drugs is availableunder the Medicare Prescrip-tion Drug Improvement and

Modernization Act of 2003. To find out if your loved one is eli-gible, visit www.medicare.gov. Check back with the site often;this is new legislation and there are likely to be changes.

Medicare Part B, or Medical Insurance, deducts monthly pre-miums from the Social Security checks of those who enroll.Part B covers some costs of doctor’s visits and other medicalexpenses.

Call the Medicare Hotline (1-800-MEDICARE, or 1-800-633-4227) for more information and to obtain brochures explainingcurrent Medicare benefits and procedures.

Medicaid

Also established in 1965, Medicaid is a joint federal-state pro-gram intended to help finance health care for the poor and thelong-term care needs of people impoverished by medical ex-penses. People of any age whose income falls below a certainlevel can be eligible for Medicaid coverage. People in need oflong-term care, whether at home or in a facility, can become el-igible for Medicaid assistance after their own assets have beendepleted (Fig. 1-13).

Private Long-Term Care Insurance

More insurers are offering long-term care policies in responseto consumer fears of asset depletion and confinement to sub-standard long-term care facilities. People who have substantialassets to protect and a family history of needing long-term careas they age may wish to consider private long-term care insur-ance. To qualify, applicants must be in good general physicaland mental health. Premiums may be high, and benefits vary

Fig. 1-12. Medicare Part A pays forsome hospital and surgery expenses.

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greatly. Deal with reputable agents only; check insurers’ rat-ings. Understand the benefits and restrictions clearly beforemaking a commitment to purchase a policy.

GUIDELINES

Handling Finances

Keep all financial records. Make notes of phone calls, withwhom you spoke, the date, and what you were told.

Separate the papers regarding the person you are caring forfrom your own financial papers. Create a file box, even just acardboard box, where you can keep your loved one’s records.

Ask questions. Healthcare billing can be confusing. Be sure youunderstand what you are paying for, how much you are beingreimbursed, and when another payment is due.

Be persistent. Follow up with the business office, the claims de-partment, or the Medicare office when you need something re-solved. Put your concerns in writing if that makes it easier tocommunicate and keep records.

Ask for help. There may be someone among your friends or rel-atives who is more comfortable dealing with finances than care-giving. Helping you pay the bills, balance the checkbook, fileinsurance claims, or keep medical records could be a way forthat person to lighten your burden.

Other Legal Issues

Last Will and Testament

Everyone should have a will prepared and signed. If this hasnot been done, it should be done soon. A simple will can beprepared using prewritten legal forms purchased at an officesupply store. An attorney should handle any complicated situations.

Power of Attorney

Creating a Power of Attorney gives authority to a designatedparty to make financial and legal decisions for someone else.Execute a new Power of Attorney every few years so that the in-tention to delegate authority is clearly established.

Fig. 1-13. Some people in need of long-term care may be eligible for benefitsfrom Medicaid.

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Advance Directives

Various documents can be executed to establish a person’s in-structions for health care at the end of life or in critical care sit-uations. Living Wills, Health Care Proxies, and Do NotResuscitate Orders are all ways of clarifying a person’s wishesor designating someone to make decisions in the event of inca-pacitation (Fig. 1-14). The forms for these directives vary butare generally easy to obtain from doctors, hospitals or nursinghomes. You can also download your state’s packages/forms atwww.choices.org. Fill them out and have them signed and wit-nessed right away; update them periodically.

ResourcesThe official U.S. government site for Medicare has links for compar-ing nursing homes, home health agencies, and dialysis centers inyour area.

Centers for Medicare & Medicaid Services (CMS)7500 Security BoulevardBaltimore MD 21244-1850www.medicare.gov

FirstGov.gov is a government site with information to help seniorsconduct business with federal agencies more quickly and easily.

FirstGov.gov for SeniorsU.S. General Services Administration1800 F Street NWWashington, DC 20405800-FED-INFO (800-333-4636) www.seniors.gov

Fig. 1-14. Advance directives let you know a person’s wishes regarding treat-ment if he or she should become incapacitated. (Reprinted with permission ofBriggs Corporation, 800-247-2343)

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The Administration on Aging website educates older people andcaregivers about benefits and services that can help them.

The U.S. Administration on AgingWashington, DC 20201202-619-0724www.aoa.dhhs.gov

The American Association of Retired Persons (AARP) website hasinformation, education, advocacy, and community information forpeople over 50.

American Association of Retired Persons (AARP)601 E. Street NWWashington, DC 20049888-OUR-AARP (888-687-2277)www.AARP.org

The Healthy Aging for Older Adults website sponsored by the Na-tional Center for Chronic Disease Prevention and Health Promo-tion provides information on a wide range of topics including thefollowing: health-related behaviors, chronic diseases, infectious dis-eases, immunizations for adults, and injuries among older adults.

National Center for Chronic Disease Prevention and HealthPromotion: Healthy Aging for Older Adults1600 Clifton RdAtlanta, GA 30333 404-639-3311www.cdc.gov/aging

NOTE: In the United States every state regulates healthcare facili-ties differently. In your state, private home health agencies may not

be formally regulated. The same holds true for assisted living homesand adult foster homes. Quality can vary widely. We direct you tolocal resources because they are the BEST source of up-to-date infor-mation in your community. Make contacting them a priority.