Mortality, hospitalization cut for kidney patients
Coordinate care among providers, patients
A unique program to manage the care of patients with chronic kidney disease and end-stage renal disease has a mortality rate that is 20% lower than the national average and a hospitalization rate that is 35% lower than national benchmarks.
The program, administered by RMS Disease Management Inc. (RMS) of McGraw Park, IL, uses health service coordinators (HSCs) who manage patients’ care throughout the entire continuum and function as part of the treatment team, bridging the communications gap among the various providers, the family, and community services.
RMS, a division of Baxter Health Care Corporation, contracts with health plans to coordinate the care of chronic kidney patients. RMS is at full risk for the patient.
"The health service coordinators work as a team member and bring back information to other caregivers. They are not just someone who comes in and documents and leaves," says Jan Nielsen, RN, MPA, vice president of health service coordination for RMS.
In most cases, one health service coordinator manages 80 to 100 patients who are on dialysis. It is their responsibility to understand each patient’s specific needs and medical regime, and communicate them to the rest of the caregivers and providers in the patient’s delivery system.
For instance, an HSC may meet with the wound care nurse and the diabetes educator to make sure they understand the patient goals. They follow the patient in and out of the hospital and follow-up with the primary care physician and the nephrologist.
They visit the various physicians who care for the patient, the dialysis unit, and other places where care is given and collect data from the medical records.
Typical dialysis patients have five to six different co-morbidities and take as many as nine different medications a day. They go through dialysis three times a week.
"They need assistance that goes well beyond what a normal case manager or a telephonic program could provide. It has to be a field-based program. We’ve learned that you really need to look at the entire patient and what is going on in the home," Nielsen says. (See "Program helps patients maintain their lifestyles," in this issue.)
The HSCs visit with the patients in the home and in the community, taking many factors into account. For instance, many patients face home safety issues — stairs, throw rugs, or small dogs or cats that can trip them up.
"We look at whether they are taking care of a spouse who is quite ill, whether they are having trouble paying for their utilities — all the things that stop patients from being able to focus on their health," she adds.
Caregivers in the office, the hospital, or the dialysis unit don’t get a chance to see what is happening in patients’ homes, Nielsen points out.
"We go into the home and see what’s in the refrigerator and the cabinets. We look in the medicine cabinet, and we might notice that they are using a neighbor’s prescription. Or we might see green tea in the cabinet, and we know that gets in the way of the clotting factor," Nielsen says.
The nurses develop a close relationship with the patients to find out what they have been taking. "These patients deal with a lot of different providers. The nurses help communicate the care plan so no one becomes territorial and all of us are looking at this patient as our patient," she says.
Health care coordination can be a major black hole, particularly with diabetics. The primary care physician feels that the nephrologist is responsible for the diabetes care, but the nephrologist is handling just the dialysis end and the primary care physician should take care of the yearly eye exam, Nielsen says. Often things fall through the cracks.
Patients who have to take public transportation to dialysis may get into trouble because they are in transit most of the day and still take their insulin though they don’t eat.
"It’s all so easy to fix once you bring the care team together and discuss it," Nielsen says.
The HSCs are able to go outside the benefits package to meet patient needs. For instance, RMS provides nutritional supplements if the patient needs them and the pharmacy benefit doesn’t cover them. They arrange for transportation and pay for it. They encourage patients to get involved in community programs, such as swimming groups for the elderly or a mall-walking group.
"Many of the health benefits packages don’t come near to covering the health care needs and psychosocial issues for the patients," says Nielsen.
The health service coordinators all are bachelors’ prepared nurses with a minimum of five years renal experience.
The health service coordinators may work for more than one health plan, depending on their caseload. Each goes through "health plan school" once a year to learn about the benefits of each plan they handle.
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