CM program cuts hospital stays for ESRD patients

Face-to-face meetings key to initiative's success

An intensive case management program for patients with end-stage renal disease resulted in an 83% drop in hospitalization in just six months for members of DaVita VillageHealth's Special Needs Plan.

DaVita VillageHealth is a subsidiary of DaVita Inc., one of the largest providers of dialysis care in the United States, says Cristina Walter, MS, RN-BC, CCM, CCP, regional operations director.

The company offers the Medicare Special Needs plan in five markets for Medicare beneficiaries and dual eligible Medicare and Medicaid beneficiaries who have end-stage renal disease and are receiving dialysis in a DaVita clinic, Walter says.

The case managers work from their homes and cover a centralized area. They can go into any of the clinics, log on to the health plan's medical management system, and document on their laptop.They have an average caseload of about 40 patients.

"In my mind, you can't provide the kind of intensive case management these patients need with a larger caseload. This is such a totally different aspect of case management than telephonic case management. Telephonic case management has its role, but these patients benefit most from a personalized one-on-one visit," Walter says.

The case management program targets patients who are most at risk for hospitalization and who need assistance in adhering to their treatment plan, Walter says. Case managers see the patients face to face at least once a month in the clinic and make home visits.

"We have a huge subset of patients who are not case-managed. These patients take their medication and follow their dietary plans," she adds.

Once dialysis patients enroll in the plan, the case manager schedules a time to meet face-to-face with the new member. The initial assessment takes between one and two hours and usually is conducted during a dialysis treatment, says Terri Whitley, RN, BNS, CNN, case manager.

"During that time, I try to get to know the member and find out their lifestyle and what kind of family support is available. I complete a health history and a depression screening and review medication with them. After that, we talk about their needs and what they feel I can help them achieve," she says.

The case managers receive training on motivational interviewing and willingness to change. They work with the member, his or her nephrologist, and other members of the treatment team to create a specialized care plan.

"I explain my role and help them come up with goals. I try to use motivational interviewing techniques to encourage members to take action on their own. Some have a goal of being able to walk to the mailbox. Others want to get to the place where they can have a transplant. Others just want to be able to get medication assistance," Whitley says.

Patients with end-stage renal disease present a challenge to case managers, because their needs are so intense, Walter says.

"This is a hard population to case manage. Medication adherence and dietary issues are huge problems for this population. They need very intensive one-on-one support to comply with their medication regimen and stay on their diet. Their general health problems combined with medication and dietary issues can often cause them to go into the hospital," she says.

Many of the patients have multiple co-morbidities, such as hypertension, diabetes, or congestive heart failure. The average patient in the special needs plan has six co-morbidities and may be taking as many as 16 different medications. They are on low-salt, low-sugar diets, and need to restrict their fluids, Walter says.

Emphasizing treatment adherence

The case managers try to help the patients understand their treatment regimen and the importance of following it, she adds.

"Some members have a hard time with treatment adherence. Most treatments are scheduled three times a week for four hours. Sometimes members miss treatments in an effort to normalize their lifestyle or because of transportation problems. Others may skip their medications because of side effects, inconvenience, or because they cannot afford them. The renal diet also requires a huge commitment on the part of the patient and the family," she says.

Whitley makes regularly scheduled visits with her patients in the dialysis clinic once a month and often visits them informally to check on how things are going. She calls them at intervals, depending on the patients' needs and gives them a phone number they can call 24-7 if they have questions or concerns.

"When I'm in the clinic, I stop by and say hello. Often they'll bring up an issue and I'll sit down and talk to them about it," Whitley says.

She participates in the monthly quality assurance meetings with the treatment team at the clinic and collaborates with her patients' nephrologists to coordinate care.

"If a patient has an issue between visits, I call the physician and let him or her know. Sometimes it's as simple as increasing the dose of an antidepressant. I have access to the patients' lab tests, and if I see a problem, I can discuss it with the team at the clinic and call the patients to discuss it," she says.

The case managers take a proactive approach to any problems the patients have to help them avoid hospitalizations.

For instance, dialysis patients frequently have problems with their grafts or fistulas clotting. The graft or fistula is a vessel that provides access to the patient's blood for the dialysis treatment. If it clots, dialysis treatment cannot be done, she says.

"If a case manager gets a call over the weekend, she's able to get the patient into the outpatient access center on Monday morning so the procedure can be performed and the patient can receive dialysis that afternoon. If the patient didn't have a case manager, he or she would likely end up in the hospital," she says.

Having a case manager arrange for a visit to the access center is more cost-effective than having the same procedure performed in the hospital where the patient could be exposed to disease, she adds.

"Having a case manager coordinating the care saves money and assures them of a better outcome," she says.

DaVita operates more than 4,000 dialysis clinics in 43 states. DaVita VillageHealth launched the Special Needs Plan in January in Alabama and Ohio and in Washington, DC, Georgia, and Virginia in March. Plans are under way to expand it into other areas.

Another branch of DaVita offers disease management for patients who have chronic kidney disease in the earlier stages.

Those case managers work from their homes and cover a centralized area. They contact members by phone and use motivational interviewing techniques to encourage the patients to follow their treatment plan and delay the progression of their disease as long as possible.

End-stage dialysis patients who have commercial insurance are covered by another branch of VillageHealth. The case managers for that group visit members during their dialysis and function much like the case managers in the Medicare program.