1. Case Management for ESRD Patients
Susan Moore, RN, MHSA
Managed Healthcare Resources, Inc.

2. 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

3. 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.”

4. 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

5. 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

6. 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

7. 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)

8. 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

9. 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

10. 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

11. 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

12. 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

13. Case Management Components
Case identification and eligibility determination
Assessment or evaluation
Care plan development
Implementation or coordination
Follow-up
monitoring
reassessment
discharge

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Physical issues with ESRD patients
Fatigue – secondary to anemia
Itching – phosphorus
Vascular access patency
Sleep disorders
Pain and restless legs

21. 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

22. 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

23. Special issues for Medicaid
Homelessness or group homes
Drug abuse
Transportation needs
Mental health issues
Greater problems with missing dialysis treatments

24. 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

25. 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

26. 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

27. 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…..

28. Telephonic vs. On-site? Telephonic On-site 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

29. Who’s on the dialysis team?
Renal social worker (MSW)
Nephrologist
Nephrology nurses
Renal technologists
Patient care technicians
Dieticians
Financial counselor (sometimes)

30. 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

31. Teaching needs (by dialysis team or case manager)
ESRD
Diet and fluid restrictions
Vascular access
Drugs

32. 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

33. 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

34. 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.

35. Issues typically addressed by dialysis team
Anemia
Depression
Noncompliance

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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)

42. 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

43. 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

44. So what about all this information?
We’ll apply the information from the first presentation and this presentation to the case studies to follow.

45. Resources
Those wanting any of the documents used for background data used for the presentation, please feel free to me at
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