Case Management for ESRD Patients

Susan Moore, RN, MHSAManaged 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

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

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

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* 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 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 self-

management 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 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 skmoore627@comcast.net

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