involuntary discharge: a closer look and patient satisfaction...nov 10, 2019 · disease (esrd)...
TRANSCRIPT
Involuntary Discharge: A Closer Look and Patient Satisfaction
Karen Lofty, MSW, LICSW October 10, 2019
No Disclosures
Case Reviews
To Discharge or Not to Discharge...
• Male patient, rural out-patient clinic
• Middle aged, well liked by the staff
• Incident
• Patient frequently jokes with the staff, good sense of humor, friendly and personable. His jokes sometimes border inappropriate but because he is so well liked by the staff, they just laugh. A staff member was looking at houses to buy and saw the sexual offender register, where he was listed. Word spread and eventually the staff complained to the CM that his jokes made them uncomfortable.
• CM put patient on a behavior contract. He was very confused and became angry with his care givers. When he found out the reason, he confronted the staff member who saw the register and she felt unsafe. Patient was IVD and lost to follow up
• Male Patient dialyzes in inner city, out-patient clinic
• History of being rude to staff and noncompliant, refuses to wash access frequently
• Incident
• Patient comes in late due to ongoing transportation issue; he is told his time has changed and because he missed his last treatment when the notifications went out; his new time is effective the next treatment. Patient tells nurse that is not possible due to tranpsortation, She says, it is not up to her and that’s the way the new schedule is, he walks into the unit, appears aggitated. Nurse asks patient to wash his access, as she does every treatment and like every treatment, he refuses but is already upset and tells her, “she better stop bossing him around”.
• The nurse stands in front of the patient and refuses to move until he washes his access. He pushes her shoulder with his hand and says, “you need to move out of my way”. Patient asked to wait in the lobby, police called, and patient became more upset. He was told that he would no longer be able to dialyze in that facility since he resorted to physical violence, effective immediately. Patient went out to dialysis in the hospital a few times, then discontinued and was lost to follow up.
• Female patient, rural clinic, in-center setting
• Nick name “Trouble”, Late 80’s, Ambulates with a walker
Incident
Patient likes to joke around with the staff, she jokes she has no reason to be shy anymore, she frequently pays more attention to a male staff member, calls him a pet name
He calls her into the unit, walks with her to the scale and on the way to her chair, she “gooses” him with her walker in his rear end and giggles. Witnessed by other patients, no one complained including staff member the target of the “goosing”.
No action taken, staff tell the story and rember the patient fondly
What if that had been a different patient?
Trends and Network Comparison
2015-2019 By Network and IVD Reason
2015-2019 Aggregate IVD Trends by Network
CMS Regional Office
0
10
20
30
40
50
60
70
80
90
2015 2016 2017 2018 2019
Disruptive/Abusive/NOSby
Regional Office
Boston RO Dallas RO Kansas RO Seattle RO
0
5
10
15
20
25
30
35
2015 2016 2017 2018 2019
Physical Harmby
Regional Office
Boston RO Dallas RO Kansas RO Seattle RO
CMS Regional Office
0
50
100
150
200
250
300
350
400
2015 2016 2017 2018 2019
Repeated Verbal Abuse (EA & FX)
Repeated Verbal Abuse by
Regional Office
Boston RO Dallas RO Kansas RO Seattle RO
CMS Regional Office
0
1
2
3
4
5
6
7
8
2015 2016 2017 2018 2019
Property Damage by
Regional Office
Boston RO Dallas RO Kansas RO Seattle RO
CMS Regional Office
0
10
20
30
40
50
60
70
80
90
100
2015 2016 2017 2018 2019
Physical/Weapon Threat by
Regional Office
Boston RO Dallas RO Kansas RO Seattle RO
CMS Regional Office
Why should we do anything different? The patients don’t treat us with respect, why should we treat them differently than they treat us?
Why Does Any of this Matter?Aren’t “patients that are involuntarily discharged the problem”?How would you feel in their shoes? Think of your own stories.
My thoughts on the doctor cannot be expressed during
this presentation as most of you are
mandated reporters....
Don’t worry, he is a perfectly healthy pre-teen, grumpy and thinks he is
hilarious...
The Why Behind Working with Patients vs IVD (other than CMS)• When we are scared, anxious, depressed, tired or angry, how do we act towards other
people?
• Improving the patients’ satisfaction and experience will improve employee morale
• Increased employee and patient satisfaction with the dialysis experience changes the cycle of negativity to one of mutual respect
• Improved outcomes and quality of life, not being lost to follow up or dialyzing in a hospital long term because they have been “black listed”.
• Our patients need us to understand “the why” behind the behaviors
• We cannot discharge patients for being noncompliant, we can work with them to individualize the care plans and treatment prescriptions
Emotional Side Effects• ESRD, diagnosis and how each person was told
• Clinic operations: Changing times, on the machine late
• Watching a code or adverse event
• Being stuck with needles (ICH CAHPS question)
• Mental Illness and substance abuse
• Patient is dependent on staff for life saving treatment and sometimes ability to choose who provides care in the facility is limited
• Often options for care are limited (ex. rural settings)
Mental Illness and Sleep• There is limited data available specific to ESRD because psychiatric clinical trials
usually exclude patients with ESRD. Unfortunately, data regarding the effectiveness and safety of psychotherapeutic agents in ESRD patients is also limited
• Patients with ESRD are at higher risk for sleep disturbance and may have pain associated with their condition. All these challenges are placed on top of the usual demands of regular living. ESRD has a higher rate of comorbid depression than other chronic medical conditions.
• Treatment burden is a major issue. Having additional outpatient appointments can be overwhelming for many dialysis patients, consider non-conventional modalities to supplement sessions in the event of exhaustion, dialysis schedule change or illness.
https://esrdnetworks.org/resources/toolkits/patient-toolkits/new-toolkit-dialysis-patient-depression-toolkit/dialysis-patient-depression-toolkit-english/appendix-information-for-professionals/at_download/file
CMS Regulations
V-Tags, CMS CFF, Policies and Procedures
• V466 (15) Be informed of external grievance mechanisms and processes, including how to contact the ESRD Network and the State survey agency;
• The facility must establish a procedure for informing patients about seeking external help to resolve grievances that cannot be resolved internally or if patients are not comfortable using the internal process. The facility staff must inform each patient/designee how to contact the appropriate external entity to file a grievance, including the ESRD Network and the State survey agency.
• Refer to V470 for the requirement of posting contact information for the Network and State survey agency.
Grievances
Things to Note
• The ESRD Network Annual Report from 2011 (the most recent one) reported that IVD complaints had increased 25% in 2011 from 2010. It further reported that facilities had involuntarily discharged 442 patients that year, an increase of 13% from 2010.
https://homedialysis.org/news-and-research/blog/60-involuntary-discharge-what-happened-to-the-oath-first-do-no-harm
• The Conditions for Coverage (CfC) for End-Stage Renal Disease Facilities require facilities to notify both the Network and the State Survey Agency of involuntary discharges and transfers. The Centers for Medicare and Medicaid Services (CMS) expects the Network and State Survey Agencies to work collaboratively to ensure facilities follow the requirements of the CfC and to protect the rights of Medicare beneficiaries. Involuntary discharge should be an option of last resort.
When Should a Patient be Involuntarily Discharged per CFC? V-TAGS & INTERPRETIVE GUIDANCE REGARDING PATIENT INVOLUNTARY DISCHARGE; CMS End Stage Renal Disease (ESRD) Program Interim Final Version Interpretive Guidance
V766 Governance
(f) Standard: Involuntary discharge and transfer policies and 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;
The transfer is necessary for the patient’s welfare because the facility can no longer meet the patient’s documented medical needs; or
(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 problems(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
Involuntary Discharge Procedures• The involuntary discharge procedures described at V767 identify the steps that a facility must follow prior to
the involuntary discharge of a disruptive and abusive patient. After following the required procedures, a facility must give at least 30-days prior notice to any patient whom they opt to discharge involuntarily, except in the case of a patient who makes severe and immediate threats to the health and safety of others.
• An "immediate threat to the health and safety of others" is considered to be a threat of physical harm. For example, if a patient has a gun or a knife or is making credible threats of physical harm, this can be considered an “immediate threat.” Verbal abuse is not considered to be an immediate threat. In instances of an immediate threat, facility staff may utilize "abbreviated" involuntary discharge or transfer procedures. -In this scenario, advance notice is not possible or required and there may not be time or opportunity for reassessment, intervention, or contact with another facility for possible transfer, as outlined at V767.
• Documentation should indicate that the State Survey Agency (SSA) was notified of the involuntary discharge or transfer. Documentation should reflect the date, time, and person the involuntary discharge or transfer was reported
NOTIFY THE NETWORK PRIOR TO AN INVOLUNTARY DISCHARGE: •The Network requires 30-day notification prior to the involuntary discharge of any patient to provide an opportunity for the Network Patient Services Department to review the issue(s) with facility staff, the reassessments, ongoing problem(s), and efforts that have been made to resolve the problem(s). The Network Patient Services Department and facility staff can explore if other actions might be utilized to prevent the involuntary discharge.
•The facility staff should thoroughly document the patient’s behavior: steps taken to assist the patient in addressing and modification of the problematic behavior, referral assistance provided, and outcomes of those referrals. The documentation should include:
◦Conflict management steps taken by the staff in addressing any disruptive patient situations and Physician and medical director’s discharge orders concurring with the discharge actions, Documentation indicating the patient was informed of the Network 13 Grievance Procedure and was provided the patient toll-free number
•Any patient considered at-risk for involuntary discharge or transfer must be considered “unstable” triggering a comprehensive interdisciplinary team (IDT) patient reassessment due to “significant change in psychosocial needs.” Note that V767 requires that patients at risk for involuntary discharge be reassessed. ◦“Significant change in psychosocial needs” would include any event that interferes with the patient’s ability to follow aspects of the treatment plan.
Dialysis Facility Compare and the ICH CAHPS
The Transparency of Patient Satisfaction with Dialysis Center Care and Operations
ICH CAHPS
• ICH CAHPS (In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems) Survey is the first national, standardized, and publicly-reported survey of patients' perspectives of dialysis care; it is also the first CAHPS survey focusing solely on a chronic disease. ICH CAHPS measures perceptions of patients with End-Stage Renal Disease (ESRD) receiving life-sustaining in-center hemodialysis care. The ICH CAHPS is about the patient’s experience. The questions show the high bar CMS has set for all dialysis providers.
• Public reporting and policy relevance: Publicly-reported ICH CAHPS results will be based on two semi-annual administrations of patient surveys. CMS will publish ICH CAHPS results on the Dialysis Facility Compare website: http://www.medicare.gov/Dialysisfacilitycompare/search.aspx.
• ICH CAHPS is part of the ESRD Quality Incentive Program and is required as part of the value-based purchasing program for payments under the Medicare Program.
https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/ichcahps.html
Medicare DFC Website
About Us
• Hard working
• Professionals
• Lives of our own
• Fear of confrontation, violence
• Hard working (not a typo repeat)
What can we do?• Decreasing Patient Provider Conflict Toolkit (link in references)
• Increase skills on respectful ways to interact with patients and de-escalation techniques
• Learn more about mental illness and other comorbidities with dialysis patient
• Early detection of anxiety and depression (KDQOL, PHQ, Beck Depression Scale)
• Management of grievances to address issues before they become issues
• Be available when available (body language, sit down!)
• Listen to the problem from their perspective and acknowledge their feelings
• People do not always need a solution... What frustrates them is feeling ignored
Empathy and Improved Health Outcomes• A 2012 study from Italy analyzed the health outcomes of more than 20,000 patients with
diabetes, who were assigned to three different groups of physicians (pre-evaluated for their levels of empathy). The physicians who demonstrated the highest degrees of empathy achieved the best results with their patients; the patients had statistically significant lower levels of diabetic complications than the groups whose physicians had scored lower in empathy.
• The researchers also point out that patient outcomes may be affected by other factors such as “physician competence, patient compliance, availability and effectiveness of medical management, social support systems, cultural factors, ethnicity, disease severity, comorbidity, multidisciplinary interventions, and environment of care.” By attempting to recognize and empathize with patients, providers improve the odds of successful health outcomes for them.
https://www.healthaffairs.org/do/10.1377/hblog20140225.037133/full/
“Due to the frequency and duration of dialysis treatments, the setting potentially contributes to strong personal relationships. This relationship, if appropriate, can have a positive impact on the patients, or if inappropriate can contribute to the ever-growing issue of disruptive behavior in the dialysis unit.” (Crampton, 2001)
References
• https://esrdnetworks.org/resources/special-projects/dpc_provider_manual.pdf/at_download/file
• https://www.kevinmd.com/blog/2017/01/involuntary-discharge-dialysis-health-care-practice-like-no.html
• https://www.ackdjournal.org/article/S1548-5595(04)00182-X/fulltext
• https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease
• https://powerfulpatient.org/involuntary-discharge-from-dialysis/
• http://esrdnetwork18.org/pdfs/PS%20-%20Involuntary%20Pt%20Discharge/IVD_Checklist_Guidelines.pdf
• https://esrdncc.org/index/decreasing-dpc
• https://www.ajkd.org/article/S0272-6386(19)30775-9/fulltext
• https://www.healthaffairs.org/do/10.1377/hblog20140225.037133/full/
References
• https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/ichcahps.html
• https://homedialysis.org/news-and-research/blog/60-involuntary-discharge-what-happened-to-the-oath-first-do-no-harm
• http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/esrdpgmguidance.pdf
• https://www.hsag.com/contentassets/770094ebe58f457c97a0b8ceab2707b5/vtags-ivd-508.pdf
• Crampton, K., (2001). Professional Boundaries in the Dialysis Setting Dialysis & Transplantation., September 2001: 592-596
• http://www.esrdnetwork18.org/docs-misc/Interpretive_Guidance_V766_V767.pdf
• https://esrdnetworks.org/resources/toolkits/patient-toolkits/new-toolkit-dialysis-patient-depression-toolkit/dialysis-patient-depression-toolkit-english/appendix-information-for-professionals/view
Karen Lofty, MSW, LICSW• Director of Patient Experience Fresenius Medical Care• Certification in Patient Experience Leadership• Ipro Network of New England Council Member and Chair
of Grievance Subcommitte
Thank you!