Case Management for ESRD Patients

1
Case Management for ESRD Patients

• Susan Moore, RN, MHSA
• Managed Healthcare Resources, Inc.

2
Objectives

• Identify problems particular to renal case
  management
• Determine effective strategies for effective case
  management
• Identify how to meet NCQA standards while
  performing CM duties

3
Definition of Case Management

• A collaborative process which assesses, plans,
  implements, coordinates, monitors, and evaluates
  the options and services to meet the individuals
  needs using communication and available resources
  to promote quality cost effective outcomes.
• A system with many elements health assessment,
  planning, procurement, delivery and coordination
  of services, and monitoring to assure that the
  multiple service needs of the client are met.

4
What is Case Management?

• Definition
• A system by which one professional is responsible
  for assuring that a patient receives a full
  spectrum of services required
• A case manager acts as a broker to arrange both
  hospital and community services
• Case management includes
• comprehensive assessment of needs and resources,
  development of a care plan, referral follow-up,
  and periodic evaluation of the plan

5
Case Management Objectives

• Depend on
• the organizations perspective and the design of
  the case management system
• the population served and its health status
• the type of case management allowed or offered by
  an organization
• the case managers level of expertise
• the method by which case management is linked to
  the organization

6
Benefits of Case Management

• Increased satisfaction of patients and families
• Fits well with the principles of managed care
• Effective cost containment strategy
• Well-suited for use across the full continuum of
  care

7
Why case management with ESRD?

• High cost over 14,000 per month
• Prone to high ER and hospitalization use
• Disease involves multiple systems
• High amount of co-morbidities (those with
  diabetes and CHF have much higher
  hospitalizations, and CHF 37 higher than
  diabetes)

8
Burden of disease in U.S.

• Rising incidence and prevalence of kidney disease
  at all stages ESRD doubled in last 10 years
• 4 of the U.S. population (8 million people) have
  moderate to severe CKD
• Expected to increase with hypertension and
  diabetes and aging population
• Expected at 2015 to increase from 450,000 ESRD
  now to 600,000

9
Cost of ESRD

• In 2003, ESRD cost private insurers and Medicare
  more than 27 billion and was 6 of entire
  Medicare expenditures (9 billion absorbed by
  private insurers)1
• Annual cost averages 60,000, with highest cost
  the year of initiation of dialysis2
• Dialysis 2.8 times more costly than transplant3
• 1AmJ KidneyDis, 2003, 41
• 2J Am Soc Nephrol., 2005, 16
• 3Report to the Congress New Approaches in
  Medicare, June 2004

10
Impact

• Those under 65, Medicare begins after 3 months on
  dialysis UNLESS
• They have private insurance, then Medicare begins
  after 33 months on dialysis
• Analysis for CKD progression (before ESRD)
  estimated that if GFR decreased by only 10 per
  person, almost 20 billion could be saved in 10
  years3
• Nearly 45 of ESRD attributable to diabetes and
  20 to chronic hypertension4
• 3, 4Journal of Managed Care Pharmacy, April 2007

11
Utilization

• Between 1993 and 2001, rates of hospitalization
  per 1,000 patient years ranged from 2,019 to
  2,0625
• CKD Earlier referral to a renal team before
  ESRD led to lower risk of unplanned first
  dialysis, fewer complications, lower hospital
  costs and shorter durations of hospitalization in
  first 3 months of dialysis, likelier to have
  mature A-V fistulas (only 29 had in 2001, and
  90 need) 6
• 5,6Report to the Congress New Approaches in
  Medicare, June 2004

12
Impact of case management on ESRD

• Health plans with disease management programs for
  ESRD had
• 19 35 better survival rates than FFS Medicare
  ESRD
• 45 54 fewer hospitalizations than FFS Medicare
  ESRD7
• 7Report to the Congress New Approaches in
  Medicare, June 2004

13
Case Management Components

• Case identification and eligibility determination
• Assessment or evaluation
• Care plan development
• Implementation or coordination
• Follow-up
• monitoring
• reassessment
• discharge

14
Case Identification

• Efforts to define and target the desired
  population
• Claims or encounters dialysis revenue codes of
  0821, 0831, 0841, 0851
• Hospital discharge data
• Pharmacy data aluminum hydroxide (Alucaps),
  calcium carbonate (Calcichew, Titralac), calcium
  acetate (Phosex), lanthanum carbonate (Fosrenol),
  Sevelamer (Renagel)
• Data collected through the UM process
• 2007 NCQA QI 7 Element A

15
Access to Case Management

• Health information line referral
• DM program referral
• Discharge planner referral
• UM referral
• Member self-referral
• Practitioner referral
• 2007 NCQA QI 7 Element B

16
IT support

• Case management systems should support
• Using evidence-based guidelines to conduct
  assessments
• Automatic documentation of date, time, and
  individual for actions/patient interactions
• Automated prompts for follow-ups
• 2007 NCQA QI 7 Element C

17
Assessment

• Determines the needs and provides information to
  develop an individual care plan
• may be conducted by an individual case manager
  (e.g., social worker or nurse) or by a
  multidisciplinary team
• goal is to obtain a complete view of the
  individual and their circumstances

18
Initial Assessment

• Members health status, including
  disease-specific issues
• Clinical history, including medications
• Activities of daily living
• Mental health status, including cognitive
  function
• Evaluation of cultural and linguistic needs,
  preferences or limitations
• Evaluation of caregiver resources
• Evaluation of available benefits
• Assessment of life planning activities
• 2007 NCQA QI 7 Element E

19
Medical complications of ESRD and dialysis

• Anemia erythropoeitin not produced in kidney
• Bone disease calcium and phosphorus imbalance
• Hypertension primary disease, fluid retention
• Fluid overload little to no output of kidneys
• Pericardial effusion and pericarditis
  inadequate dialysis, fluid overload, and
  infection
• Hyperkalemia inadequate dialysis and
  noncompliance with dietary restrictions
• Peripheral neuropathy uremic toxins
• Infection of vascular access

20
Physical issues with ESRD patients

• Fatigue secondary to anemia
• Itching phosphorus
• Vascular access patency
• Sleep disorders
• Pain and restless legs

21
Emotional/psychosocial issues

• Change in social position/role in family
• Marital problems
• Employment loss of
• Impaired libido and impotency
• Diet
• Compliance or motivation to comply
• Appearance and clothing restrictions
• Frequent loss of independence and control
• Depression (upwards of 40) and anxiety
• Reported increased incidence of cocaine, heroin,
  and methamphetamine use

22
Additional factors

• Age
• Social or ethnic background and response to
  illness
• Recent other life crises
• Personality of the patient
• Psychiatric history of the patient and family
• Cognitive ability of the patient and family

23
Special issues for Medicaid

• Homelessness or group homes
• Drug abuse
• Transportation needs
• Mental health issues
• Greater problems with missing dialysis treatments

24
Reasons for ER or hospitalization

• Clotted access (decreased inpatient 24 as these
  have moved outpatient)
• Infection due to catheter use, up 23 in last
  10 years
• CHF due to fluid overload/anemia
• Cardiomyopathy
• Hyperkalemia
• Hypertension
• Co-morbid conditions

25
Care Plan

• Development of short and long term goals
• Identification of barriers to meeting goals or
  compliance with plans
• Development of schedules for follow up and
  communication with members
• Development and communication of self-management
  plans for members
• Assessment of progress against case management
  plans and goals and modification as necessary
• 2007 NCQA QI 7 Element F

26
Care Plan

• Developed to address the needs and problems
  identified in the assessment
• includes agreement with the individual and
  involved family members on goals and priorities
• outlines the problems, type and level of
  assistance needed, the roles of the
  patient/client and family who will provide the
  services and desired outcomes
• knowledge of service options, local resources,
  delivery systems, qualified providers, financial
  alternatives, available benefits, and eligibility
  requirements for assistance are critical to the
  plan

27
Important issues for case managers

• Maintaining confidentiality, patient rights, and
  privacy
• Building relationships with MSWs and nurse
  managers at dialysis units
• On-site or telephonic case management..

28
Telephonic vs. On-site?

• Telephonic
• Less intrusive
• Less expensive

• On-site
• More intrusive
• Less likely to misconstrue objective of case
  management
• See patient and develop a relationship
• More coordination with the dialysis team

29
Whos on the dialysis team?

• Renal social worker (MSW)
• Nephrologist
• Nephrology nurses
• Renal technologists
• Patient care technicians
• Dieticians
• Financial counselor (sometimes)

30
Role of the renal social worker

• Initial assessment and intervention
• Crisis counseling
• Linkage with local, state, and federal resources
• Assistance with Medicare application
• Assisting the patient and family in adjusting to
  dialysis and ESRD
• Promotion of independence
• Identification of needs in the home
• Mediating staff/patient conflicts

31
Teaching needs (by dialysis team or case manager)

• ESRD
• Diet and fluid restrictions
• Vascular access
• Drugs

32
Diet

• Limited in phosphorus, potassium, sodium, and
  fluid
• Processed meat and cheese, dried fruit, beans,
  peanut butter, and eggs are high in phosphorus
• Challenge is to obtain enough protein and
  calories to prevent cell breakdown
• More challenging with diabetes and other dietary
  restrictions, such as low fat for heart disease

33
Drugs phosphate binders

• Types
• Calcium carbonate
• Calcium acetate (PhosLo - 0.20/pill)
• Sevalamer hydrochloride (RenaGel -1.50/pill)
• Lanthanum carbonate (Fosrenol - 2/pill)
• Noncompliance is common (frequently due to
  forgetting)
• In the Dialysis Outcome Study, fewer than 50 met
  the guideline recommendations for phosphorus
  control

34
Problems that occur during hemodialysis

• Cramping due to volume changes
• Hypotension ultrafiltration with inadequate
  vascular refilling
• Arrhythmias fluid and electrolyte changes
• Hypoxemia in 90 of patients, pO2 drops 5 35
  mm Hg.
• Hemolysis biochemical and toxic insults. Half
  life of RBC is ½ to ? of normal RBCs.

35
Issues typically addressed by dialysis team

• Anemia
• Depression
• Noncompliance

36
Anemia

• Goal keep Hgb. 11 12 gms/deciliter
• Iron levels are monitored and iron given IV
• Epogen given to combat anemia, but inappropriate
  use increases mortality
• Anemia can lead to LVH and CHF

37
Depression

• Actual clinical depression high
• Interferes with compliance with treatment regimen
• Identify when patients may be ready to give up
  withdrawal from dialysis occurs in about 20 of
  dialysis patients before their death
• Encourage evaluation by behavioral health, PCP,
  or nephrologist for an SSRI

38
Dealing with noncompliance

• Many reasons for noncompliance
• Execute a contract with the patient
• Work with the dialysis social worker
• Meet with family, if possible
• Refer to behavioral health as necessary
• Communicate with PCP/nephrologist

39
Do you discharge from CM?

• If patient is stable
• Verbalizes understanding of disease process(es)
  and care of access
• If no unnecessary hospitalizations or ER visits
• Compliant with medications, diet, and dialysis
  regimen
• Not depressed

40
Keys to effective case management

• Identify all of the main problems at the initial
  assessment
• Intervene very frequently initially to make sure
  you address all the key issues
• Keep your eyes on the care plan as you go along
  and update it as frequently as necessary

41
Keys to effective case management (cont.)

• Perform intermittent assessments for long term
  clients, because things change
• Develop relationships with the dialysis personnel
  and the nephrologist or PCP
• Remember preventive measures (immunizations,
  mammograms and cervical cancer screenings,
  condition-specific HEDIS measures)

42
Evaluation of case management

• Selection of three measures to evaluate
  effectiveness that are
• A relevant process or outcome
• A valid method with a quantitative result
• Set a performance goal
• Clear specifications
• Analyze results
• Identifies opportunities for improvement
• Develops plan for intervention and remeasurement
• 2007 NCQA QI 7 Element G, H

43
Evaluation of successful ESRD case management

• Lower costs
• Lower ER visits per 1,000
• Lower inpatient stays per 1,000
• Higher patient satisfaction
• Potential higher quality of life (QOL) scores

44
So what about all this information?

• Well apply the information from the first
  presentation and this presentation to the case
  studies to follow.

45
Resources

• Those wanting any of the documents used for
  background data used for the presentation, please
  feel free to email me at skmoore627_at_comcast.net
• Nephronline.com is a free registration for
  periodicals