Psychosocial Considerations of the New Dialysis Conditions for Coverage presentation

About This Presentation

Transcript and Presenter's Notes

Title: Psychosocial Considerations of the New Dialysis Conditions for Coverage

1
Psychosocial Considerations of the New Dialysis
Conditions for Coverage

Teri Browne, MSW, LSW
Chairperson, Council of Nephrology Social Workers
Assistant Professor, University of South Carolina
September 17, 2008
CNSW Meeting
Burbank, CA

2
Acknowledgements

Thank you
CMS Judith Kari, Glenda Payne
CNSW Conditions for Coverage Education Task Force
Members Teri Browne, Mary Beth Callahan, Deborah
Collinsworth, Sandie Dean, Duane Dunn, Phyllis
Ermann, Lisa Hall, Jeff Harder, Tom Lepetich,
Wendy Funk Schrag, Chris Simon
Special thanks to Aaron Herold, Task Force Chair
CNSW would also like to especially thank member
Beth Witten, for her astounding work and
dedication to nephrology social workers and the
kidney community.

3
Disclaimers

This presentation was put together by the Council
of Nephrology Social Workers (CNSW) to help
inform and educate the kidney community about the
psychosocial aspects of the new conditions. The
implementation and interpretation of the new
Conditions for Coverage is anticipated to be a
dynamic process. This presentation reflects the
information available to the kidney community as
of its version date.

4
Disclaimers

Information provided by CNSW is not intended to
establish or replace policies and procedures
provided by dialysis providers to their
facilities.
Please check with your dialysis facility
management before implementing any information
provided here.

How many of you have heard about the new Medicare
conditions for coverage for dialysis facilties?

How many of you have heard about the new Medicare
conditions for coverage for dialysis facilties?
How many of you know exactly how your practice
will change on October 14, 2008?

How many of you have heard about the new Medicare
conditions for coverage for dialysis facilties?
How many of you know exactly how your practice
will change on October 14, 2008?
How many of you listened to the CNSW webinar
about the conditions for coverage?

How many of you have heard about the new Medicare
conditions for coverage for dialysis facilties?
How many of you know how your practice will
change on October 14, 2008?
How many of you listened to the CNSW webinar
about the conditions for coverage?
How many of you are freaking out?

How many of you have heard about the new Medicare
conditions for coverage for dialysis facilties?
How many of you know how your practice will
change on October 14, 2008?
How many of you listened to the CNSW webinar
about the conditions for coverage?
How many of you are freaking out?

10
Objectives

Review the psychosocial considerations of the new
dialysis conditions for coverage
Just the facts
Highlight psychosocially relevant aspects of the
conditions- terrific opportunities for social
workers to help facilities meet the new
conditions
More tools to help social workers on the way
Interpretive guidelines not final yet!
Information provided here from IGs subject to
change!

11
Glossary

Conditions for Coverage (CfC)
Preamble
Interpretive Guidelines (IG)
Clinical Performance Measures (CPM) Project
CNSW (Council of Nephrology Social Workers)

12
Two Critical Documents
Your job and what you do is greatly influenced by
two federal documents

Conditions For Coverage (CfCs)
First published in 1976
Not significantly revised until April 15, 2008
Interpretive Guidelines (IGs)for ESRD
Draft version published for comment on August 8,
2008

13
History

Since 1976, same conditions for coverage for
dialysis facilities (CMS rules and regulations
that dictate the practice of dialysis)
1970s-1990s Technical Updates
1994 Community forum meeting to begin rewrites
2005- Proposed updates to dialysis and transplant
conditions
CNSW led effort social workers responded more
than any other professional

14
History

2007- CMS Community Forum about interpretive
guidelines for the proposed conditions for
coverage
April 15, 2008 - New Conditions for Coverage
published by the Department of Health and Human
Services, Centers for Medicare Medicaid
Services (CMS)
August 8, 2008 Draft interpretive guidelines
published by CMS, comments due 8/18/08
To go into effect October 14, 2008 in every U. S.
( territory) dialysis unit

15
What is Next?

Final Interpretive Guidelines will come out (date
unknown)
New Conditions for Coverage will go into effect
October 14, 2008 in every U. S. ( territory)
dialysis unit
February 1, 2009 (??) All units will have to
electronically submit outcomes data to CMS
At the same time, focus on Clinical Performance
Measures (CPMs)
http//www.cms.hhs.gov/CPMProject/

16
(No Transcript)
17
CNSW Conditions for Coverage Education Task Force

PURPOSE
Educate social workers about the new conditions
Provide social workers with the tools to address
the requirements of the new conditions
To educate the broader kidney community about the
CfCs as related to social work or areas of
particular interest to social work

18
Where do I find the new conditions?

http//edocket.access.gpo.gov/2008/pdf/08-1102.pdf

19
Interpretative Guidelines

The purpose of the procedures and
guidelines is to provide suggestions,
interpretations, checklists, and other
tools for surveyors to use throughout
the survey process.
Draft Interpretative Guidelines
http//www.cms.hhs.gov/SurveyCertificationGenInfo/
downloads/SCletter08-31.pdf

19
20
Where do I find resources for social workers?

http//www.kidney.org/professionals/CNSW/condition
s.cfm

21
THE CONDITIONS FOR COVERAGE WILL BE THE NEW
DIALYSIS LAWS!
22
Minimum Expectations

Reminder The CfCs state minimum expectations.
They do not specify how you
meet the expectations, in most
cases
They do not prevent you from
exceeding the expectations
There is often more than one acceptable way to
meet many of the minimum expectations.

22
23
Remember- we are only talking about the
psychosocial aspects of the conditions- there is
lots more in the conditions!
24
Major Themes

Patient Participation in assessment and care
Interdisciplinary focus in patient care
Less prescriptive / Outcome focus

25
Condition 494.140 Personnel qualifications

All dialysis facility staff must meet the
applicable scope of practice board and licensure
requirements in effect in the State in which they
are employed. The dialysis facilitys staff
(employee or contractor) must meet the personnel
qualifications and demonstrated competencies
necessary to serve collectively the comprehensive
needs of the patients. The dialysis facilitys
staff must have the ability to demonstrate and
sustain the skills needed to perform the specific
duties of their positions.

26
Condition 494.140 Personnel qualifications

All dialysis facility staff must meet the
applicable scope of practice board and licensure
requirements in effect in the State in which they
are employed. The dialysis facilitys staff
(employee or contractor) must meet the personnel
qualifications and demonstrated competencies
necessary to serve collectively the comprehensive
needs of the patients. The dialysis facilitys
staff must have the ability to demonstrate and
sustain the skills needed to perform the specific
duties of their positions.

Social workers must be licensed in their states
according to state social work licensure law
27
Condition 494.140 Personnel qualifications

(d) Social Worker
The facility must have a social worker who
(1) Holds a masters degree in social work with a
specialization in clinical practice from a school
of social work accredited by the Council on
Social Work Education OR

28
Condition 494.140 Personnel qualifications

(d) Social Worker
The facility must have a social worker who
(2) Has served at least 2 years as a social
worker, 1 year of which was in a dialysis unit or
transplantation program prior to September 1,
1976, and has established a consultative
relationship with a social worker who qualifies
under 494.140(d)(1).

29
Condition 494.140 Personnel qualifications

(d) Social Worker
The facility must have a social worker who
(2) Has served at least 2 years as a social
worker, 1 year of which was in a dialysis unit or
transplantation program prior to September 1,
1976, and has established a consultative
relationship with a social worker who qualifies
under 494.140(d)(1).

Qualified social workers are required to have an
MSW (MASTERS IN SOCIAL WORK) unless they worked
in dialysis prior to September 1, 1976 there
are no exceptions!
30
Personnel Qualifications- IGs

V691 Only masters-prepared social workers may do
assessments, develop psychosocial plans of care,
provide counseling to patients and families, and
participate in QAPI program
Exception If you served at least 2 years as a
social worker, 1 year of which was in a dialysis
unit or transplant program prior to September 1,
1976 and has established a consultative
relationship with a social worker. Cosigning is
not sufficient evidence.

30
31
Condition 494.140 Personnel qualifications

(e) Patient care dialysis technicians
Patient care dialysis technicians must(3) Have
completed a training program that is approved by
the medical director and governing body, under
the direction of a registered nurse, focused on
the operation of kidney dialysis equipment and
machines, providing direct patient care, and
communication and interpersonal skills, including
patient sensitivity training and care of
difficult patients.

32
Condition 494.180 Governance

(b) Standard Adequate number of qualified and
trained staff.
The governing body or designated person
responsible must ensure that
(1) An adequate number of qualified personnel are
present whenever patients are undergoing dialysis
so that the patient/staff ratio is appropriate to
the level of dialysis care given and meets the
needs of patients and the registered nurse,
social worker and dietitian members of the
interdisciplinary team are available to meet
patient clinical needs

33
Condition 494.180 Governance
Adequate staff means staffing must be
sufficient so that quality care is provided to
dialysis patients that is consistent with the
patient plan of care and professional practice
standards.
34
Governance Staffing IG

V758 If the facility shares the social worker
or dietitian with multiple clinics or requires
professional staff to perform non-clinical tasks,
it must not negatively impact the time available
to provide clinical interventions required to
achieve the goals identified in the patients
plan of care.

34
35
Condition 494.180 Governance

(b) Standard Adequate number of qualified and
trained staff.
The governing body or designated person
responsible must ensure that
(4) All employees have an opportunity for
continuing education and related development
activities.

36
Physical Environment

494.60 Condition Physical Environment
The dialysis facility must be designed,
constructed, equipped, and maintained to provide
dialysis patients, staff, and the public a safe,
functional, and comfortable treatment
environment.

Wouldnt it be nice!
36
37
Physical Environment

V401 Comfortable environment means
maintaining a comfortable temperature
providing sufficient space for patient privacy
and access for needed equipment
and maintaining a
reasonable noise level,
e.g., requiring the use
of earphones when
televisions or other
entertainment devices
are in use which may disturb
others.

V draft IG
37
38
Physical Environment - Temperature

Standard Patient Care Environment.
(2) The dialysis facility must
Maintain a comfortable temperature and make
reasonable accommodations for the patients who
are not comfortable at this temperature.
V405 The facility must develop an acceptable
plan to determine the temperature in the patient
treatment area.
Continued

38
39
Physical Environment - Temperature

V405 Example acceptable plan to set the
thermostat for a reasonable temperature, inform
patients and staff of the set temperature, and
suggest patients may want to bring a light
blanket.
It is not acceptable to allow the temperature to
be randomly raised or lowered
Reasonable accommodations would include moving
patients who are not comfortable
Continued

39
40
Physical Environment - Temperature

V405 If patients choose to use a blanket or
other covering, their vascular access site,
bloodline connections, and face must be visible
throughout the treatment.

40
41
Condition 494.70 Patients Rights

(a) Standard Patients rights. The patient has
the right to
(1) Respect, dignity, and recognition of his or
her individuality and personal needs, and
sensitivity to his or her psychological needs and
ability to cope with ESRD

42
Patient Rights - Information

494.70 Condition Patients rights.
Receive all information in a way that he or she
can understand
V453 Staff should consider literacy levels,
communication disorders (low vision/blindness,
hearing loss, and speech impairment)
A facility should have a method to assess
patient needs barriersand to develop ways to
address those barriers.

42
43
Patient Rights - Information

V453 There should be a reasonable facility plan
for communicating information in various
languages.
Facilities must comply with legal requirements
of Limited English Proficiency (LEP) polices
and procedures.

43
44
Physical Environment - Privacy

Standard Patient Care Environment.
(3) The dialysis facility must
make accommodations to
provide patient privacy
V406 Arrangements for private conversations may
need to be outside of the patient treatment area
in a private location.

44
45
Patient Rights Privacy/Confidentiality

494.70 Condition Patients rights.
(3) Privacy and confidentiality in all aspects
of treatment
V454 Staff should allow the patient to
direct where discussions of sensitive
topics should occur, and ask the
patient if he/she wants to schedule
a time to discuss a sensitive issue
away from the treatment area.

45
46
Patient Rights Privacy/Confidentiality

V454 To allow for private conversations between
patients and staff members, there should be ready
access to a room in the facility where patient
and/or family meetings can be held.

46
47
Patient Rights Advance Directives

494.70 Condition Patients rights.
(6) Be informed about his or her
right to execute advance
directives, and the facilitys policy
regarding advance directives
V457 If a facility will not honor the advance
directive (and state laws dont require them to
honor it), there must be a protocol in place for
facilitating the patients transfer to a facility
that will honor the advance directive, if the
patient so chooses.

47
48
Condition 494.70 Patients Rights

(a) Standard Patients rights. The patient has
the right to
(7) Be informed about all treatment modalities
and settings, including but not limited to,
transplantation, home dialysis modalities (home
hemodialysis, intermittent peritoneal dialysis,
continuous ambulatory peritoneal dialysis,
continuous cycling peritoneal dialysis), and
in-facility hemodialysis. The patient has the
right to receive resource information for
dialysis modalities not offered by the facility,
including information about alternative
scheduling options for working patients.

49
Condition 494.70 Patients Rights

(a) Standard Patients rights. The patient has
the right to
(14) Be informed of the facilitys internal
grievance process
(15) Be informed of external grievance mechanisms
and processes, including how to contact the ESRD
Network and the State survey agency

50
Condition 494.70 Patients Rights

(b) Standard Right to be informed regarding the
facilitys discharge and transfer policies. The
patient has the right to
(1) Be informed of the facilitys policies for
transfer, routine or involuntary discharge, and
discontinuation of services to patients
(2) Receive written notice 30 days in advance of
an involuntary discharge, after the facility
follows the involuntary discharge procedures
described in 494.180(f)(4). In the case of
immediate threats to the health and safety of
others, an abbreviated discharge procedure may be
allowed.

51
Condition 494.70 Patients Rights

The dialysis facility must prominently display a
copy of the patients rights in the facility,
including the current State agency and ESRD
network mailing addresses and telephone complaint
numbers, where it can be easily seen and read by
patients.

52
Patient Rights- IGs

V450 Condition level non-compliance should be
considered if there are serious and/or pervasive
deficient practices identify that seriously
threaten one or more of these rights. Examples
Failure to treat patients with respect and
dignity, to provide an opportunity for private
communication, or to prevent exposure of private
body areas
Patients/designees not being aware of their
options for treatment modalities or grievance
mechanisms.

52
53
Patient Rights Time to Inform

V451 Within the first 3 treatments after
admission to the facility.
While basic information about all the rights
must be provided within those first 3 treatments,
it is expected that more in-depth discussions
may extend over a longer period of time.

53
54
Patient Rights Interactions

V452 Interactions should demonstrate observance
of patients rights and consideration for a
patients physical condition, emotional state,
and cultural background.
Continued

54
55
Patient Rights Interactions

V452 Rude or demeaning behavior, physical or
mental harassment, punishment, or the use of
restraints or involuntary seclusion are not
acceptable and must not be imposed for purposes
of discipline or staff convenience.
Continued

55
56
Patient Rights Punishment

V452 Punishment would include requiring patients
to forfeit treatment time if they have to use the
restroom occasionally during dialysis.

56
57
Patient Rights Participate in Care

V456 Patients should be notified in advance when
their physician recommends changes to their
dialysis prescription and the reason for those
changes. Patients have the right to refuse the
change without fear of discharge.
Patients have the right to refuse any aspect of
treatment
Do facilities notify patients in advance
regarding dry weight changes, etc.?

57
58
Condition 494.180 Governance

(e) Standard Internal Grievance Process
The facilitys internal grievance process must be
implemented so that the patient may file an oral
or written grievance with the facility without
reprisal or denial of services. The grievance
process must include
(1) A clearly explained procedure for the
submission of grievances.
(2) Timeframes for reviewing the grievance.
(3) A description of how the patient or the
patients designated representative will be
informed of steps taken to resolve the grievance.

59
Condition 494.180 Governance

(e) Standard Involuntary discharge transfer
policies procedures
The governing body must ensure that all staff
follow the facilitys patient discharge and
transfer policies and procedures. The medical
director ensures that no patient is discharged or
transferred from the facility unless
(1) The patient or payer no longer reimburses the
facility for the ordered services
(2) The facility ceases to operate
(3) The transfer is necessary for the patients
welfare because the facility can no longer meet
the patients documented medical needs
(4) The facility has reassessed the patient and
determined that the patients behavior is
disruptive and abusive to the extent that the
delivery of care to the patient or the ability of
the facility to operate effectively is seriously
impaired, in which case the medical director
ensures that the patients interdisciplinary
team
(i) Documents the reassessments, ongoing
problem(s), and efforts made to resolve the
problem(s), and enters this documentation into
the patients medical record
(ii) Provides the patient and the local ESRD
Network with a 30-day notice of the planned
discharge
(iii) Obtains a written physicians order that
must be signed by both the medical director and
the patients attending physician concurring with
the patients discharge or transfer from the
facility
(iv) Contacts another facility, attempts to place
the patient there, and documents that effort and
(v) Notifies the State survey agency of the
involuntary transfer or discharge.
(5) In the case of immediate severe threats to
the health and safety of others, the facility may
utilize an abbreviated involuntary discharge
procedure

60
Condition 494.80 Patient Assessment

The facilitys interdisciplinary team consists
of, at a minimum, the patient or the patients
designee (if the patient chooses), a registered
nurse, a physician treating the patient for ESRD,
a social worker, and a dietitian. The
interdisciplinary team is responsible for
providing each patient with an individualized and
comprehensive assessment of his or her needs. The
comprehensive assessment must be used to develop
the patients treatment plan and expectations for
care.

61
(No Transcript)
62
(No Transcript)
63
(No Transcript)
64
(No Transcript)
65
(No Transcript)
66
Condition 494.80 Patient Assessment

(a) Standard Assessment criteria. The patients
comprehensive assessment must include, but is not
limited to, the following
(7) Evaluation of psychosocial needs by a social
worker
(11) Evaluation of family and other support
systems

67
Condition 494.80 Patient Assessment

(a) Standard Assessment criteria. The patients
comprehensive assessment must include, but is not
limited to, the following
(9) Evaluation of the patients abilities,
interests, preferences, and goals, including the
desired level of participation in the dialysis
care process the preferred modality
(hemodialysis or peritoneal dialysis), and
setting, (for example, home dialysis), and the
patients expectations for care outcomes

68
Condition 494.80 Patient Assessment

(a) Standard Assessment criteria. The patients
comprehensive assessment must include, but is not
limited to, the following
(10) Evaluation of suitability for a
transplantation referral, based on criteria
developed by the prospective transplantation
center and its surgeon(s). If the patient is not
suitable for transplantation referral, the basis
for non-referral must be documented in the
patients medical record

69
Condition 494.80 Patient Assessment

(a) Standard Assessment criteria. The patients
comprehensive assessment must include, but is not
limited to, the following
(12) Evaluation of current patient physical
activity level
(13) Evaluation for referral to vocational and
physical rehabilitation services.

70
Condition 494.80 Patient Assessment

(a) Standard Assessment criteria. The patients
comprehensive assessment must include, but is not
limited to, the following
(7) Evaluation of psychosocial needs by a social
worker
(9) Evaluation of the patients abilities,
interests, preferences, and goals, including the
desired level of participation in the dialysis
care process the preferred modality
(hemodialysis or peritoneal dialysis), and
setting, (for example, home dialysis), and the
patients expectations for care outcomes
(10) Evaluation of suitability for a
transplantation referral, based on criteria
developed by the prospective transplantation
center and its surgeon(s). If the patient is not
suitable for transplantation referral, the basis
for nonreferral must be documented in the
patients medical record
(11) Evaluation of family and other support
systems
(12) Evaluation of current patient physical
activity level
(13) Evaluation for referral to vocational and
physical rehabilitation services.

Plus medical, nursing and dietary aspects also!
71
Patient Assessment- IGs

V500 Examples of Condition level noncompliance
Assessments not being completed for multiple
patients within the timelines required
One or more professional members of the
interdisciplinary team (IDT) not participating in
the patient assessment
A pattern of use of a standardized assessment
without evidence that individual patient needs
are assessed.

71
72
Frequency of Assessment

New Patients
The later of 30 calendar days or 13
outpatient hemodialysis sessions
3 month reassessment
Patient Reassessment
At least annually for stable patients
At least monthly for unstable patients
CNSW Understanding Each assessment must at least
touch on the 13 assessment criteria.

72
73
Frequency What is new?

V516 New patients included those transferring
into the facility. In some instances, all or
parts of a current patient assessment for
transferring patients may be used.
In the case of a large number of patients being
admitted to a facility (e.g., after disasters),
the facility should develop a plan to triage
and complete the assessments promptly.

73
74
Unstable Patients

Unstable patients include, but are not limited
to, patients with

Extended or frequent hospitalizations
Marked deterioration in health status
Significant change in psychosocial needs
Concurrent poor nutritional status, unmanaged
anemia and inadequate dialysis

74
75
Unstable Patients IG Definitions

V520
Extended hospitalizations
hospitalizations longer than 8 days
Frequent hospitalizations more than three
hospitalizations a month
Significant change in psychosocial needs
include any event that interferes with the
patients ability to follow aspects of the
treatment plan.
If the reason for unstable status is within the
purview of a specific team member, participation
of some team members may be limited.

75
76
Patient Assessment- IGs

V501 must demonstrate a congruent integration
of the evaluations completed by each team
member.
Team members may choose to conduct one-on-one
interviews .. or may opt to set up team meetings
which would include the patient
The assessment may be incorporated into one
document or composed of sections

76
77
Patient Assessment

V501 Patients must be given the option and
encouraged to participate in their assessment and
care planning process.
Comprehensive means covers and addresses all
issues that are actionable by the dialysis
facility this could include referrals to
specialists for assessments that are beyond the
capacity of the dialysis facility.

77
78
Condition 494.90 Patient plan of care

The interdisciplinary team as defined at 494.80
must develop and implement a written,
individualized comprehensive plan of care that
specifies the services necessary to address the
patients needs, as identified by the
comprehensive assessment and changes in the
patients condition, and must include measurable
and expected outcomes and estimated timetables to
achieve these outcomes. The outcomes specified in
the patient plan of care must be consistent with
current evidence-based professionally-accepted
clinical practice standards.

No more Long Term Care Plan
79
494.90 The Plan of Care must be

Individualized
Specify the services necessary to address the
patients needs identified in the assessment
Include measurable and expected outcomes
Estimated timetables to achieve outcomes
Outcomes must be consistent with current
evidence-based professionally-accepted clinical
practice standards

80
Plan of Care - Psychosocial
The Plan of Care must address, but not be limited
to, the following (item of interest) (6)
Psychosocial Status The interdisciplinary team
must provide the necessary monitoring and social
work interventions. These include counseling
services and referrals for other social services,
to assist the patient in achieving and sustaining
an appropriate psychosocial status as measured by
a standardized mental and physical assessment
tool chosen by the social worker
81
Plan of Care Counseling Services

V552 Counseling services to patients and their
families should be directed at helping the
patient and family cope with kidney failure and
dialysis, following the treatment plan, and
achieving the patients goal for rehabilitation.

81
82
Condition 494.90 Patient plan of care

(a) Standard Development of patient plan of care
The interdisciplinary team must develop a plan of
care for each patient. The plan of care must
address, but not be limited to, the following
(6) Psychosocial status. The interdisciplinary
team must provide the necessary monitoring and
social work interventions. These include
counseling services and referrals for other
social services, to assist the patient in
achieving and sustaining an appropriate
psychosocial status as measured by a standardized
mental and physical assessment tool chosen by the
social worker, at regular intervals, or more
frequently on an as-needed basis.

CNSW recommends using the KDQOL
83
Kidney Disease Quality of Life (KDQOL)

gim.med.ucla.edu/kdqol
Required by CMS in the CPMs
Kidney Specific, Includes
Mental Component Score
Physical Component Score
Burden of Disease
Symptoms
Effects on daily life

84
www.lifeoptions.org
85
Plan of Care - Timelines

Implementation of the initial plan of care must
begin within the latter of 30 calendar days after
admission to the dialysis facility or 13
outpatient hemodialysis sessions
For each reassessment, implementation must be
performed within 15 days of completion of the
assessment.

86
Plan of Care - Transplant

(c) Standard Transplantation referral tracking.
The interdisciplinary team must
Track the results of each kidney transplant
center referral
Monitor the status of any facility patients who
are on the transplant wait list and
Communicate with the transplant center regarding
patient transplant status at least annually, and
when there is a change in transplant candidate
status.

87
Condition 494.90 Patient plan of care

(a) Standard Development of patient plan of care
The interdisciplinary team must develop a plan of
care for each patient. The plan of care must
address, but not be limited to, the following
(7) Modality.
(i) Home dialysis. The interdisciplinary team
must identify a plan for the patients home
dialysis or explain why the patient is not a
candidate for home dialysis.

88
Condition 494.90 Patient plan of care

(a) Standard Development of patient plan of care
The interdisciplinary team must develop a plan of
care for each patient. The plan of care must
address, but not be limited to, the following
(7) Modality. (ii) Transplantation status. When
the patient is a transplant referral candidate,
the interdisciplinary team must develop plans for
pursuing transplantation. The patients plan of
care must include documentation of the
(A) Plan for transplantation, if the patient
accepts the transplantation referral
(B) Patients decision, if the patient is a
transplantation referral candidate but declines
the transplantation referral or
(C) Reason(s) for the patients nonreferral as a
transplantation candidate as documented in
accordance with 494.80(a)(10).

89
Condition 494.90 Patient plan of care

(a) Standard Development of patient plan of care
The interdisciplinary team must develop a plan of
care for each patient. The plan of care must
address, but not be limited to, the following
(8) Rehabilitation status. The interdisciplinary
team must assist the patient in achieving and
sustaining an appropriate level of productive
activity, as desired by the patient, including
the educational needs of pediatric patients
(patients under the age of 18 years), and make
rehabilitation and vocational rehabilitation
referrals as appropriate.

90
Condition 494.90 Patient plan of care

(b) Standard Implementation of the patient plan
of care.
(1) The patients plan of care must
(i) Be completed by the interdisciplinary team,
including the patient if the patient desires and
(ii) Be signed by team members, including the
patient or the patients designee or, if the
patient chooses not to sign the plan of care,
this choice must be documented on the plan of
care, along with the reason the signature was not
provided.

91
Condition 494.90 Patient plan of care

(b) Standard Implementation of the patient plan
of care.
(1) The patients plan of care must
(i) Be completed by the interdisciplinary team,
including the patient if the patient desires and
(ii) Be signed by team members, including the
patient or the patients designee or, if the
patient chooses not to sign the plan of care,
this choice must be documented on the plan of
care, along with the reason the signature was not
provided.

Paper compliance without substantive compliance
is unproductive
92
Condition 494.90 Patient plan of care

(d) Standard Patient education and training
The patient care plan must include, as
applicable, education and training for patients
and family members or caregivers or both, in
aspects of the dialysis experience, dialysis
management, infection prevention and personal
care, home dialysis and self-care, quality of
life, rehabilitation, transplantation, and the
benefits and risks of various vascular access
types.

93
Condition 494.110 Quality assessment and
performance improvement

Condition Quality assessment and performance
improvement. The dialysis facility must develop,
implement, maintain, and evaluate an effective,
data-driven, quality assessment and performance
improvement program with participation by the
professional members of the interdisciplinary
team. The program must reflect the complexity of
the dialysis facilitys organization and services
(including those services provided under
arrangement), and must focus on indicators
related to improved health outcomes and the
prevention and reduction of medical errors. The
dialysis facility must maintain and demonstrate
evidence of its quality improvement and
performance improvement program for review by CMS.

94
Condition 494.110 Quality assessment and
performance improvement

(a) Standard Program scope.
(2) The dialysis facility must measure, analyze,
and track quality indicators or other aspects of
performance that the facility adopts or develops
that reflect processes of care and facility
operations. These Performance components must
influence or relate to the desired outcomes or be
the outcomes themselves. The program must
include, but not be limited to, the following
(viii) Patient satisfaction and grievances

95
Condition 494.110 Quality assessment and
performance improvement
Required by CPMsCAHPS In-Center Hemodialysis
Survey https//www.cahps.ahrq.gov/content/cahpskit
/files/509_ich_reporting_measures.htm Any
hemodialysis facility interested in using the
survey should contact Charles Darby at
Charles.Darby_at_ahrq.hhs.gov
96
Whats next?

CMS Recommends Implementation for Facilities
Read the whole document (preamble rule)
Review current practice ( policies) to be sure
they meet rules
Identify staffing, practice, equipment,
training needs
Develop documentation tools to match the new
rules (logs, audit tools, chart forms)
Interpretive guidelines still to come

97
(No Transcript)
98
HELP!

Kidney End of Life Coalition Advance Directives
Information
www.kidneyeol.org

99
HELP!

More information about the Clinical Performance
Measure (CPM) Project
www.cms.hhs.gov/CPMProject
More information on home dialysis options
www.homedialysis.org
Medical Education Institute Life Options
materials to help you with rehabilitation
www.lifeoptions.org

100
HELP!

More information about work rehabilitation
http//www.kidney.org/patients/pfc/control.cfm
Taking Control Money Matters For People With
Chronic Kidney Disease

101
HELP!

More information about transplant referrals
http//www.therenalnetwork.org/qi/resources/TransT
EPfinalrpt805.pdf

102
HELP!

Help with decreasing involuntary discharges
Decreasing Dialysis Patient-Provider Conflict
(DPC) Program Understanding and Managing the
Challenging Patient
Ask your ESRD Network for more materials!
http//www.esrdnetworks.org/dpc.htm

103
HELP!

CNSW projects
Searchable CNSW listserv archives now available!
More webinars- after interpretive guidelines are
published
Tools for social workers and CNSW chapters
Currently working on Sample Care Plan Ideas
Will do webinar on interpretive guidelines when
they come out
Special issue of JNSW compilation of tools to
help with the new conditions for coverage

104
HELP!

CNSW projects
Searchable listserv archives
More webinars trainings
Tools for social workers and CNSW chapters
Special issue of JNSW compilation of tools to
help with the new conditions for coverage

105
HELP!

CNSW projects
Searchable listserv archives
More webinars trainings
Tools for social workers and CNSW chapters
Special issue of JNSW compilation of tools to
help with the new conditions for coverage

106
HELP!

CNSW projects
Searchable listserv archives
More webinars trainings
Tools for social workers and CNSW chapters
Special issue of JNSW compilation of tools to
help with the new conditions for coverage

107

Where do I find these documents?http//www.kidne
y.org/professionals/webinar.cfm

108
CNSW Research Grants

New Conditions are a great opportunity for social
workers to show their administrators that what
they're doing works, and helps the unit meet the
new, more stringent requirements of the CfCs.
Number of projects that meet the needs of the
entire unit that could be spearheaded by a social
worker
Apply for funding for your research project-
individual or chapter research
Contact Jeff Harder for assistance
jharder_at_u.washington.edu

109
CNSW National Membership how to best stay
informed about the new conditions

Ask your employer if they will fund part or all
of the membership fee!
How do you join?
Go to www.kidney.org
or
Call (800) 622-9010
http//www.kidney.org/professionals/pdf/cnswform.p
df

110
Questions from members

Question I have a question regarding condition
494.90 part 6 where it indicates that the social
worker shall provide counseling to patients. When
listening to Webinar, it stated that the SW
should have private space to provide individual
counseling to patients as needed. I'm just
wanting clarification as to what type of
counseling is expected. I am worried that we will
now be expected to perform on going therapy for
patients on top of all the other duties and
tasks.
Answer The Condition for Patients' rights
requires the clinic to have a place where a
patient/designee/family can meet privately with
staff, including the social worker. Staff are
supposed to allow the patient to direct where
they would like to have discussions of sensitive
issues. MSWs have been including in the
regulations to counsel with patients to help them
cope with kidney disease and maximize their
functioning. The facility's governing body is
responsible for assuring that staffing for all
personnel, including social workers, is
sufficient, that professional members of the
interdisciplinary team meet the qualifications
required in the regulations (MSW unless working
in dialysis or transplant from 9/1/75 on). The
responsibilities that must be fulfilled by the
MSW or grandfathered non-MSW include
assessments/reassessments, plans of care, serving
on the QAPI program and counseling patients.
Non-MSWs could fill other roles in the dialysis
facility, including assisting the social worker
to help patients with day-to-day concerns related
to finances, transportation, medications,
housing, referrals for DME, promoting
exercise/rehab, administering physical and mental
functioning surveys and entering responses in
scoring programs, developing educational and
motivational materials, etc.

111
Questions from members

Question Please ask her to address and define
our duty and responsibility to treat
depression.
Answer Social workers should assess patients for
depression and offer brief counseling. Referral
to outside counselors is not prohibited and may
be appropriate if patients need in-depth
treatment and have a way to obtain the counseling.

112
Questions from members

Question In the 2005 proposed Conditions of
Coverage there was a clause that said, " We
recognize that dialysis patients also need other
essential services including transportation and
information on Medicare benefits, eligibility for
Medicaid, housing, and medications, but these
tasks should be handled by other facility staff
in order for the MSW to participate fully with
the patient's interdisciplinary teams so that
optimal outcomes of care may be achieved". Is
there something along those lines in the approved
Conditions of Coverage, that will allow us to
provide more counseling support to our patients?
Answer This will depend on the effectiveness of
social workers' self-advocacy efforts on
facility/corporate policies. State surveyors
will be observing care, interviewing patients and
staff (may include the social worker), and
reviewing medical records for what social workers
assess psychosocial status of patients and plan
for care as part of the IDT as well as how they
intervene with patients to resolve psychosocial
concerns, including patient complaints/grievances
and their involvement in involuntary discharges.

113
Questions from members

Question I would like Teri to clarify if
quarterly notes will still be required under the
new regulations.
Answer There has never been and the new
regulations do not have a federal requirement for
social workers to chart quarterly. This may be a
facility policy or state regulation.

114
Questions from members

Question Will it now be required to document
which tool is being used to screen for
depression? Is the short form of SF-36
acceptable?
Answer The CfC does not require patients to be
screened for depression. It does require
facilities to use a standardized survey of
physical and mental functioning at least
annually. The survey can be chosen by the social
worker. That said, new clinical performance
measures were chosen by CMS 4/1/08 that includes
a requirement to survey eligible patients using
the KDQOL-36 (a survey containing the SF-12 plus
24 kidney-specific questions). Certain patients
are excluded, such as those lt18, those new to
dialysis (lt3 mo), those who are cognitively
impaired, demented, or psychotic patients for
whom there is no translation/interpreter,
patients who refuse.

115
Questions from members

Question Is there a new mandatory screening of
PD patients for depression to begin in October?
Answer PD patients will need to be assessed for
physical and mental functioning starting October
14, 2008 just like HD patients. These surveys
could coincide with established patients' annual
reassessments and should be completed with
incident patients before the end of the 4th month
of dialysis.

116
Questions from members

Question If a patient speaks a language that no
one speaks in the clinic, how can we administer
the Quality of life tool or be able to develop a
plan of care with measurable outcomes?
Answer The KDQOL-36 and SF-36 (or SF-12) are all
health-related quality of life surveys. There
are multiple translations available for the KDQOL
on the KDQOL website. They are for the longer
survey from which the questions on the KDQOL-36
are drawn. It is possible to reliably choose
just those questions that are on the KDQOL-36 and
get a translation that is equivalent to the
English survey.

117
Questions from members

Question If we have patients that have no desire
to change anything about their lives, how can we
develop plan of care with measurable outcomes for
them?
Answer If the social worker has performed a
comprehensive assessment and offered to provide
services to the patient, but the patient refuses
those services, the patient has this right.
However, remember that if the surveyor interviews
that patient and he/she reports psychosocial
concerns, the surveyor may cite the social worker
for not adequately addressing the patient's
psychosocial needs.

118
Questions from members

Question In developing the plan of care, are we
require to meet face to face with all team
members?
Answer Although it may be preferable for team
members to meet face-to-face to be able to be
able to obtain verbal and non-verbal cues from
other team members and the patient/designee, it
is possible for members of the team who cannot
attend an in-person meeting to meet by
teleconference. This may allow doctors who are
in their offices or hospitals, other team members
who are at other facilities and patients who are
at home to communicate about identified issues,
concerns, strengths, etc. and address team and
patient goals, expectations, responsibilities,
and timelines.

119
Thank You!

Questions?
To follow up with me
Teri Browne, MSW, LSW
University of South Carolina College of Social
Work
803-777-6258
browne_at_sc.edu

Write a Comment

User Comments (0)

About PowerShow.com