Transcript conditions for coverage

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
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.
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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.
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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.
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• How many of you have heard about the new
Medicare conditions for coverage for dialysis
facilties?
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• 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?
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• 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?
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• 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?
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• 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?
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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 IG’s subject to change!
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Glossary
•
•
•
•
Conditions for Coverage (CfC)
Preamble
Interpretive Guidelines (IG)
Clinical Performance Measures
(CPM) Project
• CNSW (Council of Nephrology
Social Workers)
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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
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History
• Since 1976, same conditions for coverage for
dialysis facilities (CMS rules and regulations that
dictate the practice of dialysis)
• 1970’s-1990’s: 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
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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
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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 (CPM’s)
http://www.cms.hhs.gov/CPMProject/
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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
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Where do I find the new conditions?
http://edocket.access.gpo.gov/2008/pdf/08-1102.pdf
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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
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Where do I find resources for social
workers?
http://www.kidney.org/professionals/CNSW/conditions.cfm
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THE CONDITIONS FOR COVERAGE
WILL BE THE NEW DIALYSIS LAWS!
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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.
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Major Themes
• Patient Participation in assessment and care
• Interdisciplinary focus in patient care
• “Less prescriptive” / Outcome focus
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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 facility’s staff (employee or contractor)
must meet the personnel qualifications and
demonstrated competencies necessary to serve
collectively the comprehensive needs of the
patients. The dialysis facility’s staff must have the
ability to demonstrate and sustain the skills needed
to perform the specific duties of their positions.
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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 facility’s staff (employee or contractor)
must meet the personnel qualifications and
demonstrated competencies necessary to serve
collectively the comprehensive needs of the
patients. The dialysis facility’s staff must have the
ability to demonstrate and sustain the skills needed
to perform the specific duties of their positions.
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Condition 494.140 Personnel qualifications
(d) Social Worker
• The facility must have a social worker who—
• (1) Holds a master’s 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
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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).
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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).
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Personnel Qualifications- IG’s
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.
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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.
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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
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Condition 494.180 Governance
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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 patient’s plan of care.
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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.
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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.’
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Wouldn’t it be nice!
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Physical Environment
V401 “Comfortable environment” means:
V = draft IG
 “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.”
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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…
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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…
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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.”
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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
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Patient Rights - Information
494.70 Condition: Patients’ rights.
(1) 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… barriers…and to develop ways to address
those barriers.”
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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.
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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.”
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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.”
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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.”
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Patient Rights – Advance Directives
494.70 Condition: Patients’ rights.
(6) Be informed about his or her
right to execute advance
directives, and the facility’s policy
regarding advance directives;
V457 If a facility will not honor the advance directive (and
state laws don’t require them to honor it), “there must be a
protocol in place for facilitating the patient’s transfer to a
facility that will honor the advance directive, if the patient
so chooses.”
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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.
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Condition 494.70 Patients’ Rights
(a) Standard: Patients’ rights. The patient has the
right to:
– (14) Be informed of the facility’s internal grievance
process
– (15) Be informed of external grievance mechanisms and
processes, including how to contact the ESRD Network
and the State survey agency
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Condition 494.70 Patients’ Rights
(b) Standard: Right to be informed regarding the
facility’s discharge and transfer policies. The
patient has the right to—
– (1) Be informed of the facility’s 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.
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Condition 494.70 Patients’ Rights
• The dialysis facility must prominently display a copy
of the patient’s 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.
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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.”
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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.”
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Patient Rights – Interactions
V452 Interactions “should demonstrate
observance of patients’ rights and
consideration for a patient’s physical
condition, emotional state, and cultural
background.”
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Continued…
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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.”
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Continued…
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Patient Rights – Punishment
V452 “Punishment would include requiring patients
to forfeit treatment time if they have to use the
restroom occasionally during dialysis.”
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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 patient’s in advance –
regarding dry weight changes, etc.?
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Condition 494.180 Governance
(e) Standard: Internal Grievance Process
• The facility’s 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 patient’s
designated representative will be informed of steps taken
to resolve the grievance.
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Condition 494.180 Governance
(e) Standard: Involuntary discharge & transfer policies & procedures
•
The governing body must ensure that all staff follow the facility’s 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 patient’s welfare because the facility can no longer meet the patient’s
documented medical needs;
– (4) The facility has reassessed the patient and determined that the patient’s 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 patient’s
interdisciplinary team—
• (i) Documents the reassessments, ongoing problem(s), and efforts made to resolve the problem(s),
and enters this documentation into the patient’s medical record;
• (ii) Provides the patient and the local ESRD Network with a 30-day notice of the planned discharge;
• (iii) Obtains a written physician’s order that must be signed by both the medical director and the
patient’s attending physician concurring with the patient’s 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
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Condition 494.80 Patient Assessment
• The facility’s interdisciplinary team consists of, at a
minimum, the patient or the patient’s 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 patient’s treatment
plan and expectations for care.
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Condition 494.80 Patient Assessment
(a) Standard: Assessment criteria. The patient’s
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
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Condition 494.80 Patient Assessment
(a) Standard: Assessment criteria. The patient’s
comprehensive assessment must include, but is
not limited to, the following:
– (9) Evaluation of the patient’s 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 patient’s
expectations for care outcomes
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Condition 494.80 Patient Assessment
(a) Standard: Assessment criteria. The patient’s
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 patient’s
medical record
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Condition 494.80 Patient Assessment
(a) Standard: Assessment criteria. The patient’s
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.
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Condition 494.80 Patient Assessment
(a) Standard: Assessment criteria. The patient’s
comprehensive assessment must include, but is not limited
to, the following:
– (7) Evaluation of psychosocial needs by a social worker
– (9) Evaluation of the patient’s 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 patient’s
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 patient’s
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.
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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.”
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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.
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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.
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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
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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 patient’s
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.”
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Patient Assessment- IG’s
V501 “…must demonstrate a congruent
integration of the evaluations completed by each
team member.”
“Team members may choose to conduct one-onone 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…”
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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.”
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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 patient’s needs, as identified by
the comprehensive assessment and changes in the
patient’s 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 evidencebased professionally-accepted clinical practice standards.
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494.90 The Plan of Care must be
 Individualized
 Specify the services necessary to address the patient’s
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
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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…”
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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 patient’s
goal for rehabilitation.”
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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.
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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
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www.lifeoptions.org
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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.
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Plan of Care - Transplant
(c) Standard: Transplantation referral
tracking. The interdisciplinary team must
–
(1) Track the results of each kidney transplant center referral;
(2) Monitor the status of any facility patients who are on the
transplant wait list; and
(3) Communicate with the transplant center regarding patient
transplant status at least annually, and when there is a
change in transplant candidate status.
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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 patient’s home dialysis or explain why the
patient is not a candidate for home dialysis.
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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
patient’s plan of care must include documentation of the—
• (A) Plan for transplantation, if the patient accepts the transplantation
referral;
• (B) Patient’s decision, if the patient is a transplantation referral candidate
but declines the transplantation referral; or
• (C) Reason(s) for the patient’s nonreferral as a transplantation candidate
as documented in accordance with § 494.80(a)(10).
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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.
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Condition 494.90 Patient plan of care
(b) Standard: Implementation of the patient plan of
care.
• (1) The patient’s 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 patient’s 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.
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Condition 494.90 Patient plan of care
(b) Standard: Implementation of the patient plan of
care.
• (1) The patient’s 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 patient’s 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.
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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.
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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 facility’s 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.
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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
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Condition 494.110: Quality assessment
and performance improvement
Required by CPM’s:CAHPS®
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
[email protected]
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What’s 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
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HELP!
• Kidney End of Life Coalition: Advance Directives
Information
– www.kidneyeol.org
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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
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HELP!
•More information about work & rehabilitation:
http://www.kidney.org/patients/pfc/control.cfm
Taking Control: Money Matters For People With
Chronic Kidney Disease
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HELP!
•
More information about transplant referrals
http://www.therenalnetwork.org/qi/resources/TransTEPfinalrpt805.pdf
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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
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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
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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
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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
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Where do I find these documents?
http://www.kidney.org/professionals/webinar.cfm
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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:
[email protected]
108
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.pdf
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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.
110
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.
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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.
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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.
113
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 KDQOL36 (a survey containing the SF-12 plus 24 kidney-specific questions). Certain
patients are excluded, such as those <18, those new to dialysis (<3 mo), those
who are cognitively impaired, demented, or psychotic patients for whom there is
no translation/interpreter, patients who refuse.
114
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.
115
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.
116
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.
117
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 faceto-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.
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Thank You!
• Questions?
• To follow up with me:
Teri Browne, MSW, LSW
University of South Carolina College of Social Work
803-777-6258
[email protected]
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