Transcript Case Management - Michigan State University

Case Management for ESRD
Patients
Susan Moore, RN, MHSA
Managed Healthcare Resources, Inc.
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
Definition of Case Management
 “A collaborative process which assesses, plans,
implements, coordinates, monitors, and evaluates
the options and services to meet the individual’s
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.”
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
Case Management Objectives
 Depend on:
– the organization’s 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 manager’s level of expertise
– the method by which case management is linked
to the organization
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
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)
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
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
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1AmJ
KidneyDis, 2003, 41
2J Am Soc Nephrol., 2005, 16
3Report to the Congress: New Approaches in Medicare, June 2004
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
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3, 4Journal
of Managed Care Pharmacy, April 2007
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
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5,6Report
to the Congress: New Approaches in Medicare, June 2004
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
Case Management Components
 Case identification and eligibility
determination
 Assessment or evaluation
 Care plan development
 Implementation or coordination
 Follow-up
– monitoring
– reassessment
– discharge
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
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
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
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
Initial Assessment*
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Member’s 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
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
Physical issues with
ESRD patients
 Fatigue – secondary to anemia
 Itching – phosphorus
 Vascular access patency
 Sleep disorders
 Pain and restless legs
Emotional/psychosocial issues
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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
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
Special issues for Medicaid
 Homelessness or group homes
 Drug abuse
 Transportation needs
 Mental health issues
 Greater problems with missing dialysis
treatments
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
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 selfmanagement plans for members
 Assessment of progress against case management
plans and goals and modification as necessary
*2007 NCQA QI 7 Element F
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
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…..
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
Who’s on the dialysis team?
 Renal social worker (MSW)
 Nephrologist
 Nephrology nurses
 Renal technologists
 Patient care technicians
 Dieticians
 Financial counselor (sometimes)
Role of the renal social worker
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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
Teaching needs (by dialysis team
or case manager)
 ESRD
 Diet and fluid restrictions
 Vascular access
 Drugs
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
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
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 ⅓ of normal RBCs.
Issues typically addressed by
dialysis team
 Anemia
 Depression
 Noncompliance
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
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
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
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
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
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)
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
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
So what about all this
information?
We’ll apply the information from the first
presentation and this presentation to the
case studies to follow.
Resources
Those wanting any of the documents used for
background data used for the presentation,
please feel free to email me at
[email protected]
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