Program helps patients maintain their lifestyles
March 1, 2002
Program helps patients maintain their lifestyles
Coordinators help patients cheat on their diets
Respect for cultural differences and understanding a patient’s lifestyle are key component of success for the program administered by RMS Disease Management Inc. (RMS) of McGraw Park, IL, says Jan Nielsen, RN, MPA, vice president of health service coordination.
"Often, patients are sent to diabetic educators who are white and middle class, but if they are from Cambodia, they may eat vegetables we have never seen in our lives. Yet, the dietitians talk to them about two bread exchanges and the patients have to translate it to what they eat," she says.
That’s why the RMS health service coordinators (HSCs) are urged to be culturally sensitive and to learn something about the diet and
background of each patient.
They work at helping patients eat a healthy diet, yet eat food they enjoy and can afford.
Many patients are on a limited budget and are likely to eat the 99-cent special at the local fast food restaurant for lunch. That’s OK if they plan in advance so it won’t interfere with their health, Nielsen says.
"We have to teach patients how to cheat," she adds. For instance, dialysis patients are not supposed to have any outside potassium, but there may be a patient who loves homegrown tomatoes during the summer.
The HSC tells the patient to eat the tomato on dialysis at midweek and arranges for a zero potassium bath on the machine. "That way, the patient can enjoy the tomato and not feel guilty. We can help them work it into their lifestyle," she says.
In some areas, the HSC has completely eliminated congestive heart failure admissions by understanding the dietary and cultural needs of the patients, putting a scale in the home, and asking them to weigh daily. For instance, if a patient wants to have cake for a birthday, the HSC might suggest that the patient limit fluid the day before, then weigh himself at night and the next morning. The nurse calls to ask about the patient’s weight and has backup arrangements in case the patient needs extra dialysis.
When patients enroll in the RMS’s chronic kidney program, an HSC does a risk assessment that includes clinical issues, past hospitalizations, medication usage, functional issues, such as whether they can climb stairs, and psychosocial issues.
"We look at whether they are they can afford the co-pays on the pharmacy benefit, if they are compliant with the medication regime, [whether] they understand it, and whether they are getting information that they can understand," Nielsen says.
The HSCs make sure the patients receive the information in their primary language, at a grade level they can understand, and in a form they will relate to. For instance, engineers like to see printed materials, and have time to think about it and ask questions, while people in construction work tend to learn best by being shown something, then showing it back, she says.
When the program started, all the educational materials were written at an eighth-grade level. They’ve dropped it to a sixth-grade level.
Everything is printed in a 20-point font on light yellow background — the easiest way for a diabetic to read it. Patients are classified into high-, low-, and medium-risk.
"This helps drive how often a health service coordinator sees the patient. When we produce the medical outcomes information for the physicians, we can show that we are comparing apples to apples," Nielsen says.
For instance, if an HSC discusses with a physician that his patients are having longer hospital stays, the excuse can’t be that his patients are sicker. The company produces quarterly outcomes and produces an action plan pointing out what issues in the delivery system may be roadblocks to care. For instance, the company may report that lab results are being lost or that a large number of patients have to go back because the tube was clotted.
"We can point out to the health plan what is being delivered to the patients compared to what is coming in as claims," Nielsen says.
The report may conclude that there are not enough providers of certain specialties to handle appointments, durable medical equipment is no longer being used, or certain pharmacies are overcharging on co-pays.
"We become a patient advocate as well as a health plan advocate," she says.
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