Program cuts LOS, ED visits for kidney patients 

Nurses monitor members face to face 

A field-based disease management care program in which nurses meet face to face with members with chronic kidney disease and end-stage renal disease has resulted in dramatic decreases in emergency department (ED) visits and hospital bed days for patients managed by RMS Disease Management Services in Vernon Hills, IL, an affiliate of DaVita Inc.

Hospital bed days for patients in the RMS programs were nearly 45% fewer than those of other patients in 2000. ED visits for RMS patients dropped 75% between 1998 and 2000. In 2001, 93% of RMS patients achieved or exceeded dialysis adequacy targets, compared to the national average of 80%.

RMS coordinates the care of health plan members with chronic kidney disease and end-stage renal disease for health plans across the country. The company hires community-based nurses with extensive nephrology experience who work with the members face to face.

Members in the program participate on a voluntary basis at no extra cost to them.

Achieving member stability and autonomy

"Empowering the members to manage their own disease is the key to the program. The nurses work with the entire health care team, including the dialysis facility, the primary care physician, the nephrologists, and the health plan case managers to coordinate and facilitate care. They also help the members adapt their lifestyles and tap into community resources," says Dorothy Hailston, CSN, RN, CNN, director of clinical services for RMS disease management services.

The nurses, called Health Service Coordinators (HSCs), meet with members in their homes, at the dialysis clinic, or in physician offices. Each nurse manages the care of between 80 to 100 patients, depending on geographic location.

"The health service coordinator serves as a means for achieving member stability and autonomy through advocacy, communication, education, identification of service resources, and service facilitation," Hailston adds.

The members are risk-stratified according to comorbidities and utilization of services. The HSC and the member jointly identify issues that need to be managed and develop a plan of care. The plan is delivered to the member and the entire care management team, which may include a nephrologist, multiple specialists, a primary care physician, and the dialysis center team.

Risk stratification drives the frequency of the contacts the HSCs make with the member. The nurses regularly see the patients face to face, but also may telephone them between visits.

"We follow the members very closely, ensuring that the prescribed medical regime, health promotion, and prevention screening are conducted and that all services are delivered. Therefore, the member doesn’t fall through the cracks, as sometimes happens in our fragmented health care system," she says.

Comorbidity management is a key to RMS’ advanced care model, Hailston says.

About 60% of the members with end-stage renal disease are diabetics. Many also have cardiovascular problems.

The HSCs follows national guidelines for each specific disease and tailor the member’s individualized care plan to meet the guidelines. For example, they examine the feet of diabetics at each visit and educate members as well as family members on how to perform a daily self-examination. If the member develops a wound, the HSC will refer him or her to a wound care management program.

The HSCs closely monitor members with a history of congestive heart failure, often speaking with them on a daily basis. They educate the members about fluid and dietary restrictions, daily self-monitoring of weight and blood pressure, and early warning signs of congestive heart failure.

Proactive care avoids hospitalizations 

"Through this proactive care and early intervention, hospitalizations are more frequently avoided," Hailston says.

The RMS HSCs work with other case managers throughout the continuum to coordinate patient care.

"Case managers can work hand in hand with the HSCs to reduce overall health care costs and improve outcomes for this fragile patient group. This team approach has proven to be successful for RMS and payers throughout the country," Hailston says.

If a patient is hospitalized, the RMS health services coordinator contacts the hospital discharge planner and collaborates on the discharge plan. Sometimes the treating physician isn’t aware that antibiotic therapy can be delivered during dialysis. In these cases, the HSC facilitates the infusion of antibiotics during the regular outpatient dialysis treatment.

The HSC contacts the members after discharge and schedules a home visit.

"The HSCs continue the proactive facilitation of the discharge plan by ensuring that referrals for home health, durable medical equipment, or home infusion therapy are implemented. We make certain the appropriate care is delivered at the appropriate time by the appropriate people," Hailston says.

The nurses and the patients work together to identify lifestyle changes that can help patients remain compliant. For instance, the health services coordinators teach the members how to choose appropriate food at restaurants so they can go out to eat and stay within their recommended diet.

Since patients on dialysis have to monitor their fluid consumption, the nurse demonstrates during the home visit how much the patient can drink each day by using the member’s own glass or pitcher.

"Our nurses open refrigerator doors and cupboards to determine what food sources the member has. They know if the member can afford their medication, their electrical bill, and their food," she says.

During the home assessment, the nurse makes sure the home is safe and the member has no mobility issues. If areas of concern are identified, she works with the member, family, and community to resolve them.

Nurses identify compliance problems 

The nurses also work with the patients to help overcome any compliance problems they may have. For instance, some kidney patients habitually skip some of their dialysis treatments. In those cases, the nurse educates the member on the benefits of dialysis and investigates why the member may skip his or her treatment.

Because the HSC builds a rapport with members, she often identifies problems that the member is reluctant to discuss with other providers.

"These issues may be financial or psychosocial. Sometimes people skip treatments to maintain a work life or because they need to be home when the grandchild they are caring for gets home from school. There may be other issues, like transportation," Hailston says.

In these cases, the nurse helps the member access community resources that can help with these types of problems.

The nurses monitor candidates for kidney transplants, ensuring they are referred to a transplant center and that the work-up is complete.

When patients choose to stop dialysis, the nurses educate them on end-of-life issues and put them and their families in touch with community resources such as hospice organizations.