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1 Patient Assessment, Patient Plan of Care & Medical Record Review Presented by your ESRD Transition Team.

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Presentation on theme: "1 Patient Assessment, Patient Plan of Care & Medical Record Review Presented by your ESRD Transition Team."— Presentation transcript:

1 1 Patient Assessment, Patient Plan of Care & Medical Record Review Presented by your ESRD Transition Team

2 2 Patient Assessment, Plan of Care, Medical Record Review

3 3 The new Conditions of Patient Assessment & Patient Plan of Care are groundbreaking in the quest for optimal patient care!

4 4 Patient Assessment & Patient Plan of Care Whats New? Say Goodbye to Long Term Program & Short Term Care Plan approach! Say Goodbye to paper compliance patient care planning!

5 5 These new Conditions place high expectations on facilities for… Interdisciplinary approach for continually assessing individual patients care needs, & for planning & implementing the care. Interdisciplinary approach for continually assessing individual patients care needs, & for planning & implementing the care. Outcome goals that meet current professionally-accepted clinical practice standards Outcome goals that meet current professionally-accepted clinical practice standards

6 6 The ESRD community has done an excellent job of coming together in the past 15 years The ESRD community has done an excellent job of coming together in the past 15 years Consensus achieved Consensus achieved Clinical practice standards developed Clinical practice standards developed Why is this so great?

7 7 And another great thing…with these new Conditions: CMS joined with the ESRD community in a meaningful way CMS joined with the ESRD community in a meaningful way Now we surveyors have the great opportunity to really join with the ESRD community Now we surveyors have the great opportunity to really join with the ESRD community towards the common goal of…

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9 9 Objectives for This Session: Become familiar with: Complications which can result from ESRD Complications which can result from ESRD How to use the MAT for clinical practice standards How to use the MAT for clinical practice standards The requirements for patient assessment & patient plan of care The requirements for patient assessment & patient plan of care Medical record review to determine implementation of the patient plan of care Medical record review to determine implementation of the patient plan of care

10 10 ESRD Patient Population >100,000 new patients added on average per year >100,000 new patients added on average per year Existing co-morbid conditions Existing co-morbid conditions –40% diabetics (#1 primary cause) –55% cardiovascular disease –80% history of hypertension 2006: NW data: 345,260 dialysis patients 2006: NW data: 345,260 dialysis patients

11 11 The Functions of the Normal Kidney Include: Fluid volume control Fluid volume control Waste products removal Waste products removal Maintain homeostasis, acid/base balance Maintain homeostasis, acid/base balance Blood pressure (BP) controlRenin angiotensin Blood pressure (BP) controlRenin angiotensin Red blood cell (RBC) productionErythropoietin Red blood cell (RBC) productionErythropoietin Healthy bone maintenanceVitamin D conversion/ activation Healthy bone maintenanceVitamin D conversion/ activation

12 12 In the Absence of Kidney Function, ESRD Patients Frequently Have: Fluid overload/CHF Fluid overload/CHF Hypertension Hypertension Electrolyte imbalance Electrolyte imbalance Build up of wastes Build up of wastes Acidosis Acidosis Anemia Anemia Renal osteodystrophy Renal osteodystrophy Significant psychosocial changes Significant psychosocial changes

13 13 Adequate Replacement Therapy Conventional dialysis, aka 3x/week replaces 10-15% of normal kidney function Conventional dialysis, aka 3x/week replaces 10-15% of normal kidney function Important to get Important to get enough dialysis = adequacy

14 14 What are the Clinical Practice Standards? Developed by renal community workgroups & coalitions; e.g. Developed by renal community workgroups & coalitions; e.g. –National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) Guidelines –National Quality Forum (NQF): Clinical Performance Measures (CPM) Address management of complications of ESRD Address management of complications of ESRD

15 15 A New Day… The new CfCs of Patient Assessment & Plan of Care require defined Standards The new CfCs of Patient Assessment & Plan of Care require defined Standards The new CfCs use Standards developed by the ESRD community The new CfCs use Standards developed by the ESRD community You have a fabulous tool for reference of these Standards in the MAT You have a fabulous tool for reference of these Standards in the MAT If an individual patient does not meet a goal on the MAT, expect to see revised plan for that aspect If an individual patient does not meet a goal on the MAT, expect to see revised plan for that aspect

16 16 Interdisciplinary Care vs. Multidisciplinary Care InterdisciplinaryMultidisciplinary Work collaboratively Work sequentially Communication by regular discussions about patient status & the evolving plan of care Medical record is the chief means of communication

17 17 The Interdisciplinary Team Includes at a minimum: Includes at a minimum: The patient or their designee (if the patient chooses) The patient or their designee (if the patient chooses) A registered nurse A registered nurse A physician treating the patient for ESRD A physician treating the patient for ESRD A social worker A social worker A dietitian A dietitian Found at Patient assessment (V501) Patient assessment (V501) Plan of care (V541) Plan of care (V541)

18 18 Patient Assessment and Patient Plan of Care These 2 Conditions: Are interrelated (cant have one without the other) Are interrelated (cant have one without the other) Address patient assessment & care delivery requirements in care areas associated with complications of ESRD Address patient assessment & care delivery requirements in care areas associated with complications of ESRD

19 19 § Patient Assessment The IDT must provide each patient an individualized comprehensive assessment (V501) The IDT must provide each patient an individualized comprehensive assessment (V501) 14 assessment criteria (V ) 14 assessment criteria (V ) Reassessments at defined frequencies (V ) Reassessments at defined frequencies (V )

20 20 § Patient Plan of Care (V541) The IDT must develop & implement a written, individualized comprehensive patient plan of care (POC) (V ) The IDT must develop & implement a written, individualized comprehensive patient plan of care (POC) (V ) –POC based upon the comprehensive assessment & addresses each patients care needs Outcome goals in accordance with clinical practice standards (V ) Outcome goals in accordance with clinical practice standards (V ) Frequencies, revisions (V ) Frequencies, revisions (V )

21 21 Correlation of PA & POC PAPOC Current health status (V502) Appropriateness of dialysis prescription (V503) Lab profile (V505) Medication/immunization history (V506) Incorporated into all POC tags, including adequate clearance (V544) BP/fluid management needs (V504) Manage volume status (V543) Assess anemia (V507) Manage anemia (V547) Home pt ESA (V548) ESA response (V549) Assess renal bone disease (V508) Manage mineral metabolism (V546)

22 22 Correlation of PA & POC PAPOC Nutritional status (V509) Effective nutritional status (V545) Psychosocial needs (V510) Evaluate family support (V514) Psychosocial counseling/referrals/ assessment tool (V552) Access type/maintenance (V511) VA monitor/referral (V550) Monitor/prevent failure (V551) Evaluate for self/home care (V512) Home dialysis plan (V553) Transplantation referral (V513) Transplantation status: plan or why not (V554) Evaluate current physical activity level & voc/physical rehab (V515) Rehab status addressed (V555)

23 23 Patient Assessment & Patient Plan of Care Consolidated into care areas for discussion Consolidated into care areas for discussion Each will include: Each will include: –Patient assessment requirements –Plan of care: use of the MAT –How to survey –What to review in the medical record for implementation

24 24 Health Status & Co-morbid Conditions

25 25 Health Status & Co-morbid Conditions Assessment What is expected: (V502) Use of medical & nursing histories & physical exams Use of medical & nursing histories & physical exams APRN or PA may conduct medical areas of assessment as allowed by states APRN or PA may conduct medical areas of assessment as allowed by states Must include etiology of kidney disease & listing of co-morbid conditions Must include etiology of kidney disease & listing of co-morbid conditions

26 26 Dialysis Access

27 27 Dialysis Access: Assessment What is expected: (V511) IDT comprehensive assessment: Expect assessment for most appropriate access for the patient: AVF, graft, CVC, PD catheter Expect assessment for most appropriate access for the patient: AVF, graft, CVC, PD catheter Consider co-morbid conditions/risk factors, patient preference Consider co-morbid conditions/risk factors, patient preference The efficacy of HD & PD patients access correlates to adequacy of dialysis treatments The efficacy of HD & PD patients access correlates to adequacy of dialysis treatments

28 28 Dialysis Access: Assessment What is expected: (V511) IDT evaluation may include: Evaluation for/of HD access: Evaluation for/of HD access: –Communication with radiologist, interventionist, vascular surgeon –Venous mapping, vascular access surveillance, new access placement Evaluation of PD access Evaluation of PD access –Absence of infection (exit site/tunnel, peritonitis) –Patency & function

29 29 Dialysis Access: POC What is expected: (V550) IDT comprehensive plan shows evidence of: Patient evaluation as candidate for AVF Patient evaluation as candidate for AVF –If CVC >90 days, action plan for a more permanent vascular access Location of patient access to preserve future sites, for long term patient survival Location of patient access to preserve future sites, for long term patient survival Monitoring to ensure capacity to achieve & sustain adequate dialysis treatments Monitoring to ensure capacity to achieve & sustain adequate dialysis treatments

30 30 Dialysis Access: POC What is expected: (V551) IDT comprehensive plan shows evidence of: Vascular access surveillance Vascular access surveillance Early detection of failure Early detection of failure Timely referrals for interventions Timely referrals for interventions Medical record documentation of the action taken Medical record documentation of the action taken

31 31 Adequacy (the Dialysis Rx)

32 32 Adequacy: Assessment What is expected: (V518) IDT comprehensive assessment includes: HD patient- initially & monthly Kt/V (or equivalent measure, URR) HD patient- initially & monthly Kt/V (or equivalent measure, URR) PD patient- initially & at least every 4 months Kt/V (or equivalent measure, none currently) PD patient- initially & at least every 4 months Kt/V (or equivalent measure, none currently)

33 33 Adequacy: POC What is expected: V544 POC Demonstrates: Achievement of target: Kt/V of at least 1.2 (3 x/week HD) or 1.7 (PD) Achievement of target: Kt/V of at least 1.2 (3 x/week HD) or 1.7 (PD) –Alternative equivalent (URR), currently none for PD, OR

34 34 Adequacy: POC (V544) Modification of the dialysis prescription Modification of the dialysis prescription –HD: change dialyzer size, time on dialysis, BFR, DFR, type of access –PD: change number of exchanges, volume (ml), dialysate dextrose content (%), dwell time; consider membrane integrity, infections (peritonitis) –Efficacy of the vascular access can also affect adequacy OR Rationale for not achieving the expected target Rationale for not achieving the expected target

35 35 Access & Adequacy: Medical Record Documentation If expected outcomes for dialysis access or adequacy are not achieved, there should be evidence of reassessment for that aspect of care If expected outcomes for dialysis access or adequacy are not achieved, there should be evidence of reassessment for that aspect of care If patient is not achieving the expected targets, expect to see documentation of the reason WHY & a change in plan If patient is not achieving the expected targets, expect to see documentation of the reason WHY & a change in plan Adjust the plan/implement the changes Adjust the plan/implement the changes

36 36 Access & Adequacy: Medical Record Documentation Where to look: IDT Assessment IDT Assessment Plan of care Plan of care Implementation of care plan Implementation of care plan –Flowsheets –Progress notes –Physician orders, etc.

37 37 Clicker Question!!! Evaluation of a patient for dialysis access placement includes: Evaluation of a patient for dialysis access placement includes: 1.Patients co-morbid conditions 2.Appropriateness of access type for patient 3.Calcium & phosphorus level 4.1 & 2

38 38 Clicker Question!!! The efficacy of the dialysis access correlates to the adequacy of the dialysis treatment. The efficacy of the dialysis access correlates to the adequacy of the dialysis treatment. 1.True 2.False

39 39 Clicker Question!!! If the patient does not meet the community based standard for dialysis access, a complete reassessment needs to be performed. If the patient does not meet the community based standard for dialysis access, a complete reassessment needs to be performed. 1.True 2.False

40 40 Blood Pressure & Fluid Management

41 41 Blood Pressure & Fluid Management Assessment What is expected: (V504) IDT assessment should include: Patients BP on & off dialysis Patients BP on & off dialysis Interdialytic weight gains Interdialytic weight gains Target weight & intradialytic symptoms Target weight & intradialytic symptoms

42 42 Blood Pressure & Fluid Management: POC IDT develops & implements POC to achieve established targets in fluid management (V543) IDT develops & implements POC to achieve established targets in fluid management (V543) Fluid management & blood pressure are closely linked: Fluid management & blood pressure are closely linked: –BP medications affect ability to reach target without symptoms –Insufficient fluid removal exacerbates hypertension –Symptomatic Drops in BP during treatment require plan revision Outcome oriented plan Outcome oriented plan If expected interdialytic or intradialytic goals for fluid management are not achieved, reassess this aspect If expected interdialytic or intradialytic goals for fluid management are not achieved, reassess this aspect Adjust the plan/implement the changes Adjust the plan/implement the changes

43 43 Clicker Question!!! Pre-dialysis hypertension: Pre-dialysis hypertension: 1.May be a result of medication hold 2.May be a result of fluid overload 3.May be inadequately controlled primary hypertension 4.May require revision in POC 5.All of the above

44 44 Clicker Question!!! Repeated rapid symptomatic drop in BP during treatment: Repeated rapid symptomatic drop in BP during treatment: 1.Is used to tell when the patient reaches his/her target weight 2.Is a normal part of the dialysis treatment 3.May be managed by the unit clerk or SW 4.Requires plan revision for this aspect of care

45 45 Immunization Management & Medication History

46 46 Immunization: Assessment What is expected: IDT to evaluate the patients immunization history/status for hepatitis, influenza, pneumococcus (V506) IDT to evaluate the patients immunization history/status for hepatitis, influenza, pneumococcus (V506) Evaluate for tuberculosis screening what is expected: (V506) Evaluate for tuberculosis screening what is expected: (V506) Evaluate Anti-HBs on all vaccinees (V127) Evaluate Anti-HBs on all vaccinees (V127)

47 47 Immunization: POC What is Expected (V506) CDC Recommendations for Dialysis Patients Be tested for at least once for baseline tuberculin skin test results, retest if exposure is suspected Be tested for at least once for baseline tuberculin skin test results, retest if exposure is suspected Be offered influenza & pneumococcal vaccines Be offered influenza & pneumococcal vaccines (V126) Vaccinate all susceptible patients for Hepatitis B (V126) Vaccinate all susceptible patients for Hepatitis B

48 48 Medication: Assessment What to expect (V506) Initial review of current medications & allergies Initial review of current medications & allergies Ongoing assessment of home medications Ongoing assessment of home medications

49 49 Immunization Medical Record Documentation What to expect (V506,V126, V127) Record of testing & immunizations Record of testing & immunizations Documentation of immunity or acknowledgement of absence of immunity Documentation of immunity or acknowledgement of absence of immunity Documentation of further action planned if required Documentation of further action planned if required

50 50 Anemia Management

51 51 Anemia Management: Assessment What is expected: (V507) IDT to evaluate the patients laboratory values (Hct, Hgb, serum ferritin, transferrin saturation, iron stores) IDT to evaluate the patients laboratory values (Hct, Hgb, serum ferritin, transferrin saturation, iron stores) Evaluate co-morbid conditions Evaluate co-morbid conditions Evaluate for ESA &/or iron therapy Evaluate for ESA &/or iron therapy

52 52 Anemia Management: POC IDT develops & implements POC to achieve established targets in anemia management (V547) IDT develops & implements POC to achieve established targets in anemia management (V547) Goals based on current clinical practice standards Goals based on current clinical practice standards MAT specifies targets for Hgb, Hct, & iron MAT specifies targets for Hgb, Hct, & iron Outcome oriented plan Outcome oriented plan If expected outcomes for anemia management are not achieved, IDT to reassess this aspect If expected outcomes for anemia management are not achieved, IDT to reassess this aspect Must adjust the plan/implement the changes Must adjust the plan/implement the changes

53 53 Anemia Management: POC Laboratory results reviewed monthly Laboratory results reviewed monthly Medication adjustment (may use algorithms/ESA protocols) Medication adjustment (may use algorithms/ESA protocols) Home patients: evaluate ESA administration & storage Home patients: evaluate ESA administration & storage

54 54 Anemia Management: Medical Record IDT assessment IDT assessment Plan of care with measurable goals & timelines Plan of care with measurable goals & timelines Implementation of care plan: Implementation of care plan: –Flowsheets, –Progress notes, –Medication administration, –Physician orders, etc

55 55 Clicker Question!!! The dietitian & social worker do not have to be involved in patient assessment & plan of care? The dietitian & social worker do not have to be involved in patient assessment & plan of care? 1.True 2.False

56 56 Clicker Question!!! If the patient does not meet current clinical practice standards for anemia management, a complete reassessment of the patient must be performed. If the patient does not meet current clinical practice standards for anemia management, a complete reassessment of the patient must be performed. 1.True 2.False

57 57 Nutritional Management

58 58 RD Evaluation of Nutritional Status Nutritional status Nutritional status Hydration status Hydration status Metabolic parameters, e.g. glycemic control (DM) & CV health Metabolic parameters, e.g. glycemic control (DM) & CV health Anthropometric data (ht, wt & wt history/changes, volume status, amputations) Anthropometric data (ht, wt & wt history/changes, volume status, amputations) Appetite & intake Appetite & intake Ability to chew & swallow Ability to chew & swallow GI issues GI issues Use of prescribed/OTC nutritional, dietary, herbal supplements Use of prescribed/OTC nutritional, dietary, herbal supplements Previous diets &/or nutrition education Previous diets &/or nutrition education Route of nutrition Route of nutrition Self-management skills Self-management skills Attitude to nutrition, health, & well-being Attitude to nutrition, health, & well-being Motivation to make changes to meet nutrition, other goals Motivation to make changes to meet nutrition, other goals

59 59 Nutrition: Assessment What is expected: RD participates with the IDT in evaluation of patients in all clinical assessment areas RD participates with the IDT in evaluation of patients in all clinical assessment areas RD required to conduct an individualized comprehensive review of the patients nutritional status to include diet, hydration status, metabolic/catabolic & cardiovascular status (V509) RD required to conduct an individualized comprehensive review of the patients nutritional status to include diet, hydration status, metabolic/catabolic & cardiovascular status (V509)

60 60 Nutrition: POC IDT develops & implements POC to achieve established targets in nutritional management (V545) IDT develops & implements POC to achieve established targets in nutritional management (V545) Goals based on community-based standards Goals based on community-based standards MAT specifies targets for albumin, body weight MAT specifies targets for albumin, body weight Outcome oriented plan Outcome oriented plan If expected outcomes for nutrition management are not achieved, reassess this aspect If expected outcomes for nutrition management are not achieved, reassess this aspect Adjust the plan/implement the changes Adjust the plan/implement the changes

61 61 Nutrition: POC Laboratory results reviewed monthly Laboratory results reviewed monthly Medication adjustment as needed Medication adjustment as needed RD & IDT work with patient on dietary adjustments RD & IDT work with patient on dietary adjustments

62 62 Nutrition: Medical Record Documentation IDT assessment IDT assessment Plan of care with measurable goals & timelines Plan of care with measurable goals & timelines Implementation of care plan Implementation of care plan –Flowsheets, –Progress notes, –Medication administration, –Physician orders, etc.

63 63 Clicker Question!!! Nutrition assessment includes all of the following except: Nutrition assessment includes all of the following except: 1.Laboratory values 2.Patient weight 3.Medications 4.Shoe size

64 64 Clicker Question!!! The dietitian need not participate with the interdisciplinary team in assessing the patient if she maintains good individual notes & the other team members are not interested in nutrition. The dietitian need not participate with the interdisciplinary team in assessing the patient if she maintains good individual notes & the other team members are not interested in nutrition. 1.True 2.False

65 65 Mineral Metabolism AKA CKD Mineral & Bone Disorder

66 66 CKD Mineral & Bone Disorder: Assessment What is expected (V508): IDT to evaluate the patients laboratory values (calcium, phosphorous, PTH) IDT to evaluate the patients laboratory values (calcium, phosphorous, PTH) Evaluate medications for management of bone disease (phosphate binders, vitamin D analogs, calcimimetic agents) Evaluate medications for management of bone disease (phosphate binders, vitamin D analogs, calcimimetic agents) Evaluate relevant dietary factors Evaluate relevant dietary factors

67 67 Mineral Metabolism: POC IDT develops & implements individualized POC to achieve established targets in renal bone disease management (V546) IDT develops & implements individualized POC to achieve established targets in renal bone disease management (V546) Goals based on community based standards Goals based on community based standards MAT specifies targets for calcium, phosphorous & intact PTH MAT specifies targets for calcium, phosphorous & intact PTH

68 68 Mineral Metabolism: POC Outcome oriented plan Outcome oriented plan Laboratory results reviewed monthly Laboratory results reviewed monthly Medication adjustment as indicated Medication adjustment as indicated If expected outcomes for bone management are not achieved, reassess this aspect If expected outcomes for bone management are not achieved, reassess this aspect Adjust the plan/implement the changes Adjust the plan/implement the changes

69 69 Mineral Metabolism: Medical Record Documentation IDT Assessment IDT Assessment Plan of care with measurable goals & timelines Plan of care with measurable goals & timelines Implementation of care plan; look at: Implementation of care plan; look at: –Flowsheets –Progress notes –Medication administration –Physician orders, etc.

70 70 Clicker Question!!! If the patient does not meet community based standards for renal bone disease management, a plan (or plan revision) might include: If the patient does not meet community based standards for renal bone disease management, a plan (or plan revision) might include: 1.Medication adjustment 2.Dietary consultation 3.Dialysis prescription adjustment 4.All of the above

71 71 Clicker Question!!! CKD mineral & bone disorder assessment: CKD mineral & bone disorder assessment: 1.Must be done with every assessment & reassessment 2.Need only be done once throughout a patients course of treatment 3.Is unnecessary for most dialysis patients 4.Was considered an event in the 2008 Summer Olympics

72 72 Social Worker Evaluation of Psychosocial Needs Cognitive status/capacity to understand Cognitive status/capacity to understand Ability to meet needs Ability to meet needs Ability to follow Rx Ability to follow Rx Mental health history Mental health history Substance abuse history Substance abuse history Coping ability Coping ability Expectations for future Expectations for future Education/employment status, concerns, goals Education/employment status, concerns, goals Home environment Home environment Legal issues (guardian, advance directive status) Legal issues (guardian, advance directive status) Advocacy needs Advocacy needs Financial capability & resources Financial capability & resources Access to community resources Access to community resources Eligibility for Federal, state, or local resources Eligibility for Federal, state, or local resources

73 73 Psychosocial Assessment V tag Psychosocial Elements in Assessment V512 Patients abilities, interests, preferences & goals for participation in care, modality & setting V513 Psychosocial factors related to interest in & candidacy for transplantation V514 Family & other support systems V515 Physical activity & vocational rehab status & need for referral for physical & voc rehab services V520 Other psychosocial factors that may influence instability V767 Reassessment related to involuntary discharge

74 74 Clicker Question!!! The psychosocial assessment would NOT be expected to include: The psychosocial assessment would NOT be expected to include: 1.Patients expectations, goals, preferences 2.Family & other support systems 3.Vocational status & goals 4.Physical activity level 5.Home dialysis & transplant candidacy 6.Vascular access patency

75 75 Psychosocial: POC V Tag Psychosocial Elements in Plan of Care V552 Use a standardized survey to assess pts physical & mental functioning, provide counseling & referral V555 Help patient to achieve & sustain desired level of rehabilitation, including education for pediatric pts V562 Educate pt about quality of life, rehab, psychosocial risks/benefits related to access type, following the treatment plan & modality selection V Address other elements as needed to assure pts achieve & sustain appropriate psychosocial status V766 Planning with IDT for involuntary discharge/transfer V767 Help to resolve psychosocial factors related to involuntary discharge & to transfer to another facility

76 76 Clicker Question!!! In which of these areas would the social worker NOT be expected to be involved in care planning: In which of these areas would the social worker NOT be expected to be involved in care planning: 1.Dose of dialysis received (Kt/V or URR) 2.Nutritional status 3.Dose of ESAs 4.Access selection 5.Modality selection

77 77 Psychosocial: Medical Record V Tag Social Workers Documentation V730 Results of standardized survey of mental & physical assessment (chosen by social worker) Results of standardized survey of mental & physical assessment (chosen by social worker) –Results of KDQOL-36 survey after 3 months & annually (CMS CPM for eligible adult patients) Plan for psychosocial interventions (counseling & referral) to achieve & sustain appropriate psychosocial status Plan for psychosocial interventions (counseling & referral) to achieve & sustain appropriate psychosocial status Plan for other elements of care that may be influenced by psychosocial status Plan for other elements of care that may be influenced by psychosocial status

78 78 Psychosocial: Medical Record IDT assessment IDT assessment POC with goals & timelines POC with goals & timelines Implementation Implementation –Flowsheets –Progress notes –Results of psychosocial surveys –Plan of care

79 79 Clicker Question!!! The social worker is solely responsible for the psychosocial aspects of care. The social worker is solely responsible for the psychosocial aspects of care. 1.True 2.False

80 80 Timelines: All Begins 10/14/08 Initial Assessments for New Patients: PA=30 days/13 treatments whichever is laterPA=30 days/13 treatments whichever is later POC implemented within this same timelinePOC implemented within this same timeline Reassessment for New Patients: 3 months after initial assessment completed3 months after initial assessment completed POC updated & implemented within 15 days of reassessmentPOC updated & implemented within 15 days of reassessment

81 81 Then what? Stable patients = Annual reassessment Stable patients = Annual reassessment –POC updated & implemented within 15 days All patients: Continuous monitoring = any aspect of care where the target is not met = revise that aspect of POC All patients: Continuous monitoring = any aspect of care where the target is not met = revise that aspect of POC Unstable patients = monthly reassessment Unstable patients = monthly reassessment –POC updated & implemented within 15 days

82 82 Who Is Unstable? Per V520, includes but is not limited to: Extended or frequent hospitalization (>8 days or > 3 X a month) Extended or frequent hospitalization (>8 days or > 3 X a month) Marked deterioration in health status Marked deterioration in health status Significant change in psychosocial needs Significant change in psychosocial needs Concurrent poor nutritional status, unmanaged anemia & inadequate dialysis Concurrent poor nutritional status, unmanaged anemia & inadequate dialysis

83 83 What About Current Patients? As of October 14, 2008: Expect a plan to implement this new system Expect a plan to implement this new system Some assessments/POCs completed each month until all are done Some assessments/POCs completed each month until all are done All current patients to be included in the new system within 12 months of 10/14/08 All current patients to be included in the new system within 12 months of 10/14/08 Do not expect 3 month reassessment for current patients Do not expect 3 month reassessment for current patients Expect updates for any aspect of care that does not meet targets Expect updates for any aspect of care that does not meet targets

84 84 Transfer of Current Patients After 10/14/08, when a patient is transferred, expect: Copy of most current IDT assessment & POC from transferring facility in patients medical record Copy of most current IDT assessment & POC from transferring facility in patients medical record Reassessment within 3 months of admission Reassessment within 3 months of admission Revision & implementation of POC within 15 days of completion of the reassessment Revision & implementation of POC within 15 days of completion of the reassessment

85 85 Also in POC: V560 Dialysis facility must ensure that all patients be seen by a physician, APRN or PA at least monthly, & periodically, for in-center HD patients, while the patient is on dialysis Dialysis facility must ensure that all patients be seen by a physician, APRN or PA at least monthly, & periodically, for in-center HD patients, while the patient is on dialysis If patients are seen in the physicians office, facility must have a system to ensure transfer of visit information If patients are seen in the physicians office, facility must have a system to ensure transfer of visit information

86 86 Also in POC: Track transplant referrals (V561) Track patient/family education & training (V562)

87 87 Clicker Question!!! Expect all current patients to have an IDT assessment & POC by October 14, Expect all current patients to have an IDT assessment & POC by October 14, True 2.False

88 88 Clicker Question!!! For stable patients, the outcomes must be monitored on an on-going basis & For stable patients, the outcomes must be monitored on an on-going basis & 1.Patient assessments repeated monthly 2.POC updated every six months 3.POC revised for any care aspect where the target is not met 4.Only reviewed if the patient is hospitalized more than 8 days in a year

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