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Care Coordination: Improving Clinical Care Coordination: Improving Clinical Outcomes in Patients with Chronic Outcomes in Patients with Chronic Kidney Disease (CKD) Receiving Kidney Disease (CKD) Receiving
DialysisDialysis
Debra Castner, MSN, RN, APNC, CNNDebra Castner, MSN, RN, APNC, CNN
DisclosuresDisclosures
Castner Castner – Speaker bureau – Sanofi, AmgenSpeaker bureau – Sanofi, Amgen
ObjectivesObjectives
Examine care coordination in patients with Examine care coordination in patients with chronic illness, focusing on "costs" of chronic illness, focusing on "costs" of hospitalization in patients with CKD on hospitalization in patients with CKD on dialysis.dialysis.List nationally recognized priorities and List nationally recognized priorities and goals toward providing well coordinated goals toward providing well coordinated care.care.Explore nursing strategies aimed toward Explore nursing strategies aimed toward improved care coordination. improved care coordination.
Case PresentationCase Presentation
JM is a 78 year old female with ESRD JM is a 78 year old female with ESRD secondary to diabetes mellitus 2. She secondary to diabetes mellitus 2. She was hospitalized for 5 days for an infected ulcer on was hospitalized for 5 days for an infected ulcer on her right foot. her right foot.
The charge nurse calls the doctor on call for orders The charge nurse calls the doctor on call for orders and is told to “continue previous orders.” He does and is told to “continue previous orders.” He does not order continuation of her IV medication nor does not order continuation of her IV medication nor does he adjust the dose of ESA. No adjustments are he adjust the dose of ESA. No adjustments are made to her dry weight.made to her dry weight.
Other comorbidities include HTN, COPD, CAD with Other comorbidities include HTN, COPD, CAD with h/o MI and h/o CHF. She presents on Friday for her h/o MI and h/o CHF. She presents on Friday for her
first dialysis after dischargefirst dialysis after discharge. .
Case PresentationCase Presentation
No discharge summary is available No discharge summary is available and JM did not bring in her discharge and JM did not bring in her discharge sheet. She is unsure of any new medications. sheet. She is unsure of any new medications.
The discharge coordinator is off today. Attempts to The discharge coordinator is off today. Attempts to reach JM’s family are unsuccessful. reach JM’s family are unsuccessful.
JM presents at her target weight. Her blood pressure JM presents at her target weight. Her blood pressure is 172/90. She undergoes dialysis without is 172/90. She undergoes dialysis without complications. No fluid is pulled as she is at her complications. No fluid is pulled as she is at her target weight. No labs are checked. The usual target weight. No labs are checked. The usual meds are given. meds are given.
Case PresentationCase Presentation
Five days after discharge JM is readmitted Five days after discharge JM is readmitted to the hospital with c/o SOB and fever. to the hospital with c/o SOB and fever.
Hospitalizations and Hospitalizations and ReadmissionsReadmissions
19.6 % of nearly 12 million Medicare beneficiaries (1 in 5) 19.6 % of nearly 12 million Medicare beneficiaries (1 in 5) discharged from the hospital were re-hospitalized within 30 days; discharged from the hospital were re-hospitalized within 30 days; 34% within 90 days34% within 90 days
Leading diagnosisLeading diagnosis
CHF, PNACHF, PNA
PredictorsPredictors
# of Rehospitalizations, LOS > DRG# of Rehospitalizations, LOS > DRG
Jencks, et al., NEJM, 2009, 360: 1418-1428.
ESRD
Financial CostsFinancial Costs
Cost to Medicare of unplanned re- Cost to Medicare of unplanned re- hospitalizations in 2004 was $17.4 billionhospitalizations in 2004 was $17.4 billion1
ESRD - $23.9 billion on dialysis care (5.8% ESRD - $23.9 billion on dialysis care (5.8% of Medicare budget) - 1/3 spent on of Medicare budget) - 1/3 spent on hospitalizationhospitalization22
Bundle – Empty dialysis chairs – Bundle – Empty dialysis chairs – cost $$$cost $$$– hospital stays reduce monthly reimbursementhospital stays reduce monthly reimbursement
1.Jencks, et al., NEJM, 2009, 360: 1418-1428.2.USRDS, 2009.
Financial IncentivesFinancial Incentives
Medicare Payment Advisory Counsel Medicare Payment Advisory Counsel recommended to Congress (MedPac)recommended to Congress (MedPac)– penalize hospitals with higher than expected penalize hospitals with higher than expected
readmission ratereadmission rate– Beginning 10/2012 – payments Beginning 10/2012 – payments 1% 1%
2013 – payments 2013 – payments 2% 2% 2014 – payments 2014 – payments
3%3%
Patient Protection and Affordable Care Act of 2010
Patient “Costs”Patient “Costs”
Decline in functional capacityDecline in functional capacity
Nosocomial InfectionNosocomial Infection
Adverse event Adverse event
Decreased quality of lifeDecreased quality of life
In hospital - mortalityIn hospital - mortality
Care CoordinationCare Coordination
““Care coordination is a client-centered, Care coordination is a client-centered, assessment-based interdisciplinary approach assessment-based interdisciplinary approach to integrating health care and social support to integrating health care and social support services in which an individual’s needs and services in which an individual’s needs and preferences are assessed, preferences are assessed, a comprehensive a comprehensive care plan is developed care plan is developed and services are and services are managed and monitored by an identified care managed and monitored by an identified care coordinator following coordinator following evidence-based standards of care.””
Brown, R. 2009.The National Coalition on Care Coordination N3C
Care CoordinationCare Coordination
Coordinated CareCoordinated Care
Transitions of CareTransitions of Care
Transitional CareTransitional Care
Disease ManagementDisease Management
Case ManagementCase Management
Guided Care ModelGuided Care Model
Patient-Centered Medical HomePatient-Centered Medical Home
Care Coordination - ChallengesCare Coordination - Challenges
Decreased length of stay (LOS), continuing Decreased length of stay (LOS), continuing therapy after dischargetherapy after discharge
Aging population – greater complexity, Aging population – greater complexity, many co-morbiditiesmany co-morbidities
Many care venues, many providersMany care venues, many providers
Practice defined by location (i.e hospitalist, Practice defined by location (i.e hospitalist, PCP)PCP)
Current Fee for Service does not reimburse Current Fee for Service does not reimburse care coordinationcare coordination
Increase Risk of RehospitalizatonIncrease Risk of Rehospitalizaton
Risk Assessment Tool: 8PsRisk Assessment Tool: 8Ps– Problem medicationProblem medication– PsychologyPsychology– Principle diagnosisPrinciple diagnosis– PolypharmcyPolypharmcy– Poor health literacyPoor health literacy– Patient supportPatient support– Prior hospitalizationPrior hospitalization– Palliative CarePalliative Care
http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/html_CC/06Boost/03_Assessment.cfm
Medication ErrorsMedication Errors
Adverse events after dischargeAdverse events after discharge
Examined random discharges at a Examined random discharges at a Canadian teaching hospitalCanadian teaching hospital
23% (76 of 328) of patients experience an 23% (76 of 328) of patients experience an AEAE
Most common cause: drug events 72%, Most common cause: drug events 72%, therapeutic errors 16%, nosocomial therapeutic errors 16%, nosocomial infections (12%)infections (12%)
Forster, A. J. et al. Annals of Internal Medicine, 2003. 138: 161-167..
Adverse Drug Events (ADEs)Adverse Drug Events (ADEs)
Transitions - care setting changeTransitions - care setting change
ADEs - > 50% follow discharge, readmissions up to ADEs - > 50% follow discharge, readmissions up to 25%, increases cost, morbidity and mortality25%, increases cost, morbidity and mortality
Risk FactorsRisk Factors– Drug change (especially discontinuation)Drug change (especially discontinuation)– High risk drugs (antibiotics, CV drugs, insulin, warfarin)High risk drugs (antibiotics, CV drugs, insulin, warfarin)– High risk medical conditions (PNA, COPD, UTI, CHF, AKI, High risk medical conditions (PNA, COPD, UTI, CHF, AKI,
Dehydration, blood sodium or K+ disorder)Dehydration, blood sodium or K+ disorder)
Boockvar, KS et al, Arch Int Med, 2004. 165; 545.;Forester AJ et al, Ann Int Med. 2003, 138: 161. Forster AJ et al. 2004, Can Med Assoc J, 2004. 170:345-9.
Patients with ESRD Patients with ESRD The “Perfect” StormThe “Perfect” Storm
• Prior hospitalization – 2/year Prior hospitalization – 2/year 14 hospital days per year 14 hospital days per year
• Polypharmacy – Polypharmacy – pill burden pill burden • Problem medications Problem medications • Problem diagnosis (DM, CHF)Problem diagnosis (DM, CHF)• Psychology - Depression Psychology - Depression
Patients with ESRD Patients with ESRD The “Perfect” StormThe “Perfect” Storm
“Resume Previous Orders”
Components of Successful Components of Successful Care CoordinationCare Coordination
Targeting patients Targeting patients at risk of hospitalizationat risk of hospitalization
In- Person ContactIn- Person Contact – did use telephonic contact with face – did use telephonic contact with face to face once per monthto face once per month
Access to Access to timely information timely information
Demonstrated close Demonstrated close interactioninteraction between care coordinators between care coordinators and PCPand PCP
Provided services that focused on assessing, care Provided services that focused on assessing, care planning, educating, monitoring, coaching on planning, educating, monitoring, coaching on self self managementmanagement, teaching how to take medications, and , teaching how to take medications, and assistance with social supports assistance with social supports
Relied on Relied on registered nurse registered nurse to deliver the bulk of the to deliver the bulk of the interventionintervention
Brown, R. 2009.The National Coalition on Care Coordination N3C
Care Coordination ModelsCare Coordination Models
Care Transition Model for Heart FailureCare Transition Model for Heart Failure
Insurance Driven Disease Management Insurance Driven Disease Management Programs – Kaiser, Aetna, BCBSPrograms – Kaiser, Aetna, BCBS
Fresenius Right Start, DaVita Impact Fresenius Right Start, DaVita Impact Renal Venture CareRenal Venture Care
JCAHO “Hand Off” Initiative & “SPEAK UP” JCAHO “Hand Off” Initiative & “SPEAK UP” InitiativeInitiative
BOOST – Better Outcomes for Older adults BOOST – Better Outcomes for Older adults through Safe Transitionsthrough Safe Transitions
ESRD Demonstration ProjectsESRD Demonstration Projects
BOOSTBOOST Better Outcomes for Older adults through Safe TransitionsBetter Outcomes for Older adults through Safe Transitions
Developed from 1.4 million dollar grantDeveloped from 1.4 million dollar grant
National initiative led by Society of Hospital National initiative led by Society of Hospital MedicineMedicine
Vision:Vision:– Reduce readmission ratesReduce readmission rates– Improve patient satisfaction related to discharge (DC)Improve patient satisfaction related to discharge (DC)– Improve flow of informationImprove flow of information– Identify high risk patients and target intervention to Identify high risk patients and target intervention to
mitigate risk for AEmitigate risk for AE– Improve patient and family preparation for DCImprove patient and family preparation for DC
http://www.hospitalmedicine.org/boost
BOOSTBOOSTBetter Outcomes for Older adults through Safe TransitionsBetter Outcomes for Older adults through Safe Transitions
BOOST toolkit available at BOOST toolkit available at
http://www.hospitalmedicine.org/boost http://www.hospitalmedicine.org/boost
Risk assessment tool, Patient Pass: Risk assessment tool, Patient Pass: transition record, education rescourcestransition record, education rescources
Early Data (60 sites): 21% reduction in 30 Early Data (60 sites): 21% reduction in 30 day all-cause readmissions day all-cause readmissions
http://www.hospitalmedicine.org/boost
ESRD Demonstration ProjectESRD Demonstration ProjectFresenius Health Partners – care management Fresenius Health Partners – care management team team
Nurse Care Managers – centerpiece of the Nurse Care Managers – centerpiece of the integrated care modelintegrated care model
Included in activities:Included in activities:– Address the needs of high-risk patients (follow-hospital Address the needs of high-risk patients (follow-hospital
patients and assist with discharge planning and conduct patients and assist with discharge planning and conduct follow-up contacts post dischargefollow-up contacts post discharge
– Assist patient with new or changed medicationsAssist patient with new or changed medications– Work with patient’s healthcare team to facilitate Work with patient’s healthcare team to facilitate
continuity of carecontinuity of care
http://www.fmchp.com
Fresenius Health PartnersFresenius Health Partners
http://www.fmchp.com
Preventing HospitalizationPreventing HospitalizationPatient AssessmentPatient Assessment
MedicationErrors
Malnutrition
Volume Overload
Infection
JM
Worsening anemia
\\ The Perfect Opportunity!The Perfect Opportunity!
The Perfect Storm!The Perfect Storm!
Nurses lead the way!Nurses lead the way!
Barriers to Care CoordinationBarriers to Care Coordination
Lack of resourcesLack of resources
Lack of education and/or understandingLack of education and/or understanding
Lack of communicationLack of communication
Lack of effective systemsLack of effective systems
Lack of nursing leadershipLack of nursing leadership
The General Nature of NursingThe General Nature of Nursing
Nursing is collaborative with all other Nursing is collaborative with all other healthcare professions.healthcare professions.
– Florence NightingaleFlorence Nightingale
NIH NIH
The Institute of Medicine has identified The Institute of Medicine has identified care transitions as a priority area for care transitions as a priority area for performance measurement.performance measurement.
Assessing the quality of transitional care: further applications of the care transitions measure. Assessing the quality of transitional care: further applications of the care transitions measure. Parry C, Mahoney E, Chalmers SA, Parry C, Mahoney E, Chalmers SA, Coleman EA.Coleman EA.
National Quality ForumNational Quality Forum
National Quality ForumNational Quality Forum
CKD CertificationCKD CertificationThe Joint Commission's Certificate of Distinction The Joint Commission's Certificate of Distinction for Chronic Kidney Disease recognizes for Chronic Kidney Disease recognizes organizations that make exceptional efforts to organizations that make exceptional efforts to foster better outcomes for CKD patients. foster better outcomes for CKD patients. The Joint Commission and the National Kidney The Joint Commission and the National Kidney Foundation have identified that the most Foundation have identified that the most successful CKD programs possess the following successful CKD programs possess the following critical attributes:critical attributes:– A standard method of delivering or facilitating A standard method of delivering or facilitating
coordinated care coordinated care from diagnosis to management, from diagnosis to management, based on the National Kidney Foundation’s KDOQI based on the National Kidney Foundation’s KDOQI evidence-based clinical practice guidelines.evidence-based clinical practice guidelines.
– A secure and timely system for sharing information A secure and timely system for sharing information across settings and providers, which safeguards across settings and providers, which safeguards patient rights and privacy.patient rights and privacy.
““Readmissions are not primarily about Readmissions are not primarily about people being rehospitalized because people being rehospitalized because of mistakes made in the hospital. of mistakes made in the hospital. Readmissions are about making Readmissions are about making transitions effectively. Taking care of transitions effectively. Taking care of people with ongoing problems or people with ongoing problems or chronic illnesses and frailty. chronic illnesses and frailty. Transitions of care not done well…Transitions of care not done well…evidence suggests they wind up back evidence suggests they wind up back in the hospital.” in the hospital.” Stephen Jencks, M.D., former senior clinical adviser to Stephen Jencks, M.D., former senior clinical adviser to CMSCMS
Case PresentationCase PresentationThe real storyThe real story
It is 4 days post discharge and JM is speaking to the RN assigned It is 4 days post discharge and JM is speaking to the RN assigned to her and shares she is feeling worse than when she was in the hospital. She is to her and shares she is feeling worse than when she was in the hospital. She is very weak, dizzy, and short of breath. She just doesn’t feel like eating. very weak, dizzy, and short of breath. She just doesn’t feel like eating.
The nursing assessment finds that JM has 4+ pedal edema and crackles, though she is at EDW, there is green drainage on her foot dressing.
The RN calls the acute facility RN to review data from discharge and finds Hb was 8.4, WBC 12,000, her ESA doses pre and post DC do not match, and albumin was 2.3. She makes a call to the NP on call.
Case Study Case Study (continued)(continued)
The NP orders a CBC to be sent to an outside lab and JM’s EDW The NP orders a CBC to be sent to an outside lab and JM’s EDW is readjusted. Her family was called and they tell the NP JM does is readjusted. Her family was called and they tell the NP JM does not have any supplements to take and they are just giving meds not have any supplements to take and they are just giving meds like they “always do”. They also are concerned that JM was not like they “always do”. They also are concerned that JM was not given any antibiotics to take for her foot infection. given any antibiotics to take for her foot infection.
The next day the NP is called and told the Hb is now 7.5 and WBC is 20,000. JM is set up for transfusions and an RD consult, IV Antibiotics are ordered which were missed on discharge.
We’re Not In Kansas Anymore, We’re Not In Kansas Anymore, TotoToto
12 Ways To Reduce Hospital 12 Ways To Reduce Hospital ReadmissionsReadmissions
• Discharge Summaries within Discharge Summaries within 24hrs24hrs
• Lengthen the Handoff Lengthen the Handoff ProcessProcess
• Provide Medications on Provide Medications on DischargeDischarge
• Make a follow up plan before Make a follow up plan before dischargedischarge
• TelehealthTelehealth• Identify Frequent FlyersIdentify Frequent Flyers
• Understand What’s Understand What’s Happening After DischargeHappening After Discharge
• Provide Home Care on Provide Home Care on WheelsWheels
• Consider Physician Consider Physician Medication ReconciliationMedication Reconciliation
• Make Sure Patients Make Sure Patients Understand – “teach back”Understand – “teach back”
• Focus on High Risk PatientsFocus on High Risk Patients• Listen to the PatientListen to the Patient
JCAHO Hand- Off CommunicationsJCAHO Hand- Off Communications
JCAHO Survey found………..JCAHO Survey found……….. 37% of the time hand-offs were defective & did not 37% of the time hand-offs were defective & did not
ensure safety for patient careensure safety for patient care 21% of the time receivers were dissatisfied with the 21% of the time receivers were dissatisfied with the
quality of the hand-offquality of the hand-off
AndAnd 80% of serious medical errors involve miscommunication 80% of serious medical errors involve miscommunication
when pts are transferred or handed offwhen pts are transferred or handed off Poor hand-off is a contributor to sentinel events, delays Poor hand-off is a contributor to sentinel events, delays
in treatment, inappropriate treatment, and increased in treatment, inappropriate treatment, and increased length of staylength of stay
Communicate, Communicate, CommunicateCommunicate, Communicate, Communicate
Review, Don’t Just ResumeReview, Don’t Just Resume
7 day window post discharge7 day window post discharge
As professional nurses we can no longer As professional nurses we can no longer accept “resume previous orders”accept “resume previous orders”
SHARESHARES tandardize critical contentS tandardize critical content
H ardwire within your systemH ardwire within your system
A llow opportunities to ask questionsA llow opportunities to ask questions
R einforce quality and measurementR einforce quality and measurement
E ducate and coachE ducate and coachwww.centerfortransforminghealthcare.orgwww.centerfortransforminghealthcare.org
Standardize Critical ContentStandardize Critical Content
Provide details of the patient history to the Provide details of the patient history to the receiverreceiver
Emphasize key informationEmphasize key information
Synthesize patient information from Synthesize patient information from separate sources before passing to the separate sources before passing to the receiverreceiver
Hardwire Within Your SystemHardwire Within Your System
Develop standardized forms, tools, and methods Develop standardized forms, tools, and methods such as checklists such as checklists
Use a quiet workspace or setting that is Use a quiet workspace or setting that is conducive to sharing informationconducive to sharing information
State expectations on how to conduct a State expectations on how to conduct a successful hand-offsuccessful hand-off
Identify new and existing tools to assist in hand-Identify new and existing tools to assist in hand-offoff
I visited with_________________________today.I visited with_________________________today.
To assist with their continued care I am asking you to:To assist with their continued care I am asking you to: Send in an updated medication list.Send in an updated medication list. Send in all medications for me to review on _________.Send in all medications for me to review on _________. Call me at the office, 732- ______________to discuss my suggestions Call me at the office, 732- ______________to discuss my suggestions
or concerns.or concerns. Make the following change,Make the following change, ________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Thank you for your assistance, and please call me if you have any Thank you for your assistance, and please call me if you have any questions,questions,
Debby Castner RN, MSN, APNC, CNNDebby Castner RN, MSN, APNC, CNN
Nurse Practitioner Jersey Coast Nephrology & HypertensionNurse Practitioner Jersey Coast Nephrology & Hypertension
Coordination of Care ChecklistCoordination of Care ChecklistCheck all that applyCheck all that apply within 7 days of discharge and confirm within 7 days of discharge and confirm changes with physician or NPchanges with physician or NP
ESA dose, form or method of administration changedESA dose, form or method of administration changed Vitamin D analog dose or form changedVitamin D analog dose or form changed Phosphate binder placed on hold or dose adjustedPhosphate binder placed on hold or dose adjusted Heparin dose been put on hold or adjustedHeparin dose been put on hold or adjusted Dialysis treatment changes: dialyzer, dialysate, hours, frequency, Dialysis treatment changes: dialyzer, dialysate, hours, frequency,
access in useaccess in use EDW changedEDW changed Protein supplement added or other diet changesProtein supplement added or other diet changes Follow-up labs or tests neededFollow-up labs or tests needed New medication(s)New medication(s) Patient discharged to home with home care services, to a rehab, or Patient discharged to home with home care services, to a rehab, or
skilled nursing facility. If so where, duration, treatment provided?skilled nursing facility. If so where, duration, treatment provided?
BOOST 8Point Risk AssessmentBOOST 8Point Risk Assessment
BOOST Universal Checklists BOOST Universal Checklists
Allow Opportunities to Ask Allow Opportunities to Ask QuestionsQuestions
Use critical thinking skills when discussing a Use critical thinking skills when discussing a patient casepatient case
Share and receive information as an Share and receive information as an interdisciplinary teaminterdisciplinary team
Expect to receive all key information from the Expect to receive all key information from the sendersender
Exchange contact information for additional Exchange contact information for additional questionsquestions
Scrutinize and question the dataScrutinize and question the data
Reinforce Quality & MeasurementReinforce Quality & Measurement
Demonstrate leadership commitment to Demonstrate leadership commitment to successful hand-offssuccessful hand-offs
Hold staff accountable for managing a Hold staff accountable for managing a patient’s carepatient’s care
Monitor compliance with standardized Monitor compliance with standardized forms, tools, and methods forms, tools, and methods
Use data to determine a systematic Use data to determine a systematic approach for improvementapproach for improvement
Educate and CoachEducate and Coach
Teach staff what constitutes a successful Teach staff what constitutes a successful hand-offhand-off
Standardize training Standardize training
Provide real-time performance feedback to Provide real-time performance feedback to staffstaff
Make successful hand-offs an organization Make successful hand-offs an organization prioritypriority
Reconciliation of Medication ListReconciliation of Medication ListPatients carry a complete list of their Patients carry a complete list of their medications (purpose, dose, typical side effects)medications (purpose, dose, typical side effects)
Discrepancies between new orders and prior Discrepancies between new orders and prior meds are identified and explained to the patient meds are identified and explained to the patient and caregiver (in writing)and caregiver (in writing)
Reconciliation of med lists occur throughout Reconciliation of med lists occur throughout hospitalization especially upon a transfer and as hospitalization especially upon a transfer and as close to discharge as possibleclose to discharge as possible
Consider implementation of an electronic systemConsider implementation of an electronic system
Effectiveness of Dialysis Specific Effectiveness of Dialysis Specific Patient Education ProgramsPatient Education Programs
Right Start (FMC) – 120dRight Start (FMC) – 120d
IMPACT (DaVita) – 90dIMPACT (DaVita) – 90d
RV Care (Renal Ventures) – 120dRV Care (Renal Ventures) – 120d
Right Return (FMC ) – nursing directed Right Return (FMC ) – nursing directed education programeducation program
ESRD Seamless Care Organization ESRD Seamless Care Organization (ESCO)(ESCO)
ESCO is now Comprehensive ESRD Care (CEC)ESCO is now Comprehensive ESRD Care (CEC)•CMS Innovation Center new service delivery and payment CMS Innovation Center new service delivery and payment model model •Will test if offering providers financial risk arrangements Will test if offering providers financial risk arrangements with guaranteed discounts to MCR will improve health care with guaranteed discounts to MCR will improve health care outcomes and reduce costsoutcomes and reduce costs•To promote comprehensive medical care and care To promote comprehensive medical care and care coordinationcoordination•Request for quality measures appropriate for ESRD, Request for quality measures appropriate for ESRD, promotes care beyond renal issues and will slow costs to promotes care beyond renal issues and will slow costs to CMSCMS
Patient Directed InterventionsPatient Directed Interventions
My HealthMy Healthdoctor visits doctor visits
names of specialists and nurses names of specialists and nurses
medications and what they treat medications and what they treat
laboratory test results laboratory test results
activity status activity status
overall knowledge of kidney disease and its side overall knowledge of kidney disease and its side effectseffects
stored in a safe, secure location that is stored in a safe, secure location that is accessible anywhere there’s an internet accessible anywhere there’s an internet connection. connection.
JCAHO Speak Up InitiativeJCAHO Speak Up Initiative
SS peak up if you have questions or concerns peak up if you have questions or concernsPP ay attention to the care you are receiving ay attention to the care you are receivingEE ducate yourself about your diagnosis, medical ducate yourself about your diagnosis, medical
tests, treatment plantests, treatment planAA sk a trusted family member or friend to be your sk a trusted family member or friend to be your
advocateadvocateKK now your medications now your medicationsUU se a facility that has undergone evaluation se a facility that has undergone evaluation
based on quality standardsbased on quality standardsPP articipate in all decisions about your treatment articipate in all decisions about your treatment
20022002 www.jointcommission.orgwww.jointcommission.org
Case StudyCase Study
How would the case study change How would the case study change if there if there was coordination of care?was coordination of care?
Case PresentationCase PresentationCare CoordinationCare Coordination
The Acute Care Liaison NP at the acute care facility faxes JM’s dialysis discharge The Acute Care Liaison NP at the acute care facility faxes JM’s dialysis discharge checklist to the NP and Charge RN at the outpatient center. The dialysis primary checklist to the NP and Charge RN at the outpatient center. The dialysis primary care nurse and the acute care dialysis team have been in contact by phone care nurse and the acute care dialysis team have been in contact by phone during her stay.. during her stay..
The NP and charge nurse have a conference call to review and ask questions about her transition plan. The medication list is reconciled and dialysis orders are revised. ESA and Vitamin D analog doses have changed, antibiotics are to continue for 5 more days, her EDW is decreased and she is to continue Nepro at home
JM’s primary care nurse, PCT, RD, and Renal SW are updated on the changes planned and schedule time to update JM’s comprehensive care plan. JM is instructed and given a written handout on the changes from this admission.
Nurses Lead the WayNurses Lead the Way
A phone call to the IP case manager or familyA phone call to the IP case manager or family
Compare orders & ask questionsCompare orders & ask questions
Make or borrow forms for checklists Make or borrow forms for checklists
Have a brainstorming sessionHave a brainstorming session
Review and use the ANNA StandardsReview and use the ANNA Standards
Develop a process to get the discharge Develop a process to get the discharge summarysummary
Comprehensive Care Plans that are meaningfulComprehensive Care Plans that are meaningful
Educate and empower patientsEducate and empower patients
S even day target dateS even day target date
E valuate dataE valuate data
V alidate ordersV alidate orders
E ducate patientsE ducate patients
N ursing assessment & N ursing assessment & interventionsinterventions
Web SitesWeb SitesAmerican Nephrology Nurses Associationhttp://www.annanurse.org
American Nurses Associationhttp://www.nursingworld.org
BOOST:Better Outcomes for Older adults through Safe Transitions. Retrieved 02/26/11 from http://www.hospitalmedicine.org/Boost
Web SitesWeb SitesFacts about hand-off communications, 2010. Joint Commission Center for Transforming Healthcare accessed online on 11/18/2011 at http://www.centerfor transforminghealthcare.org/projects/about_handoff_communication
Facts about speak up initiatives, 2002. Joint Commission accessed online on 2/13/2011 at http://www.jointcommission.org/GeneralPublic/Speak+Up/about_speakup.htm
Fresenius Health Partners. Retrieved 02/26/11 from http://www.fmchp.com/
Web SitesWeb SitesHealth Leaders Media Retrieved 02/28/2011http://www.healthleadersmedia.com
National Quality Forum. Retrieved 02/26/11 from http://www.qualityforum.org/projects/care_coordination.aspx
ESRD Disease Management Demonstration Project Report Retrieved 2/28/2011http://nephronline.com/features.asp?F_ID=611
““It’s kind of fun to do the It’s kind of fun to do the impossible” - Walt Disneyimpossible” - Walt Disney
Please Share Your Questions, Please Share Your Questions, and Experiences and Experiences
