raynel wilson quality improvement director the renal · pdf filewhat are the clinical practice...

Raynel WilsonQuality Improvement Director

The Renal Network, Inc.

What’s New?Say Goodbye to Long Term Program

&“Short Term” Care Plan approach!

The new Conditions place high expectations on facilities for…

Interdisciplinary approach for continually assessingindividual patient’s care needs, & for planning &implementing the careOutcome goals that meet current professionally‐accepted clinical practice standards

A New Day…The new CfCs of Patient Assessment & Plan of Care require defined StandardsThe new CfCs use Standards developed by the ESRD communityThere is a fabulous tool for reference of these Standards in the MATIf an individual patient does not meet a goal on the MAT, the surveyors will expect to see a revised POC for that aspect of care

What are the Clinical PracticeStandards?

Developed by renal community workgroups & coalitions; e.g.

– National Kidney Foundation Kidney DiseaseOutcomes Quality Initiative (NKF KDOQI)

Guidelines– National Quality Forum (NQF): Clinical

Performance Measures (CPM)Address management of complications of ESRD

Work collaboratively

Communication by regular discussions about patient status & the evolving plan of care

Work sequentially

Medical record is the chief means of communication

Multidisciplinary

The Interdisciplinary TeamIncludes at a minimum:

The patient or their designee (if the patient chooses)A registered nurseA physician treating the patient for ESRDA social workerA dietitian

Patient Assessment (V501) andPatient Plan of Care (V541)

These 2 Conditions:Are interrelated (“can’t have one without the other”)Address patient assessment & care delivery requirements in “care areas” associated with complications of ESRD

§ 494.80 Patient Assessment

The IDT must provide each patient an individualized comprehensive assessment (V501)14 assessment “criteria” (V502‐515)Reassessments at defined frequencies (V516‐520)

§ 494.90 Patient Plan of Care (V541)

The IDT must develop & implement a written, individualized comprehensive patient plan of care (POC)POC based upon the comprehensive assessmentAddresses each patient’s care needsOutcome goals in accordance with clinical practice standards

Current health statusAppropriateness of dialysis prescriptionLab profileMedication/immunization history

___________________________________________________________________________

BP/fluid management needs___________________________________________________________________

Assess anemia

___________________________________________________________________

Assess renal bone disease

All incorporated into POC, including adequacy of dialysis

___________________________________________________________________________________________________________

Manage volume status___________________________________________________________________________________________

Manage anemiaESA response/Home pt. ESA

___________________________________________________________________________________________

Manage mineral metabolism

Plan of Care

Nutritional status___________________________________________________________________________

Psychosocial needsEvaluate family support

___________________________________________________________________________

Access type/maintenance

___________________________________________________________________________

Evaluate for self/home care___________________________________________________________________________

Transplantation referral

_______________________________Evaluate current physical activity level & voc/rehab

Effective nutritional status___________________________________________________________________________________________________

Psychosocial counseling/ referrals/ assessment tool

_____________________________________________________________________________________________________________________

Vascular access monitor/referralMonitor/prevent failure

_____________________________________________________________________________________________________________________

Home dialysis plan______________________________________________________________________________________________________________________

Transplantation status‐plan or why not

______________________________________________________________________________________________________________________

Rehab status addressed

Plan of Care

References for Patient Assessment & Plan of Care

Measures assessment tool (MAT)Surveyor Training Manual – Lesson #6

Interpretive guidance

TimelinesHas begun!

October 14, 2008Initial assessments for New patients –New = new to ESRD or modality change PA = 30 days/13 treatments, whichever is laterPOC implemented within this same timelineReassessment for New patients ‐3 months after initial assessment completed

POC updated and implemented within 15 days of reassessment

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

Tag Number V557

(3) If the expected outcome is not achieved, the interdisciplinary team must adjust the patient’s plan of care to achieve the specified goals. When a patient is unable to achieve the desired outcomes, the team must—(i) Adjust the plan of care to reflect the patient's current condition; (ii) Document in the record the reasons why the patient was unable to achieve the goals; and (iii) Implement plan of care changes to address the issues identified in paragraph (b)(3)(ii) of this section.

Interpretive guidance Page 219 ‐ 220

If the current plan of care has not been successful in achieving the goals identified by and for the patient within the identified timetables, there must be evidence that barriers to achievement of the goals were identified and that the plan was reviewed and revised, as indicated.

For example, if the patient's Kt/V is below the expected goal for more than one month, the physician or the non‐physician practitioner might adjust the dialysis prescription by extending the treatment time or changing the dialyzer. If the patient’s Kt/V remained below target the following month, the team should collaboratively identify the potential reasons the patient is not reaching the minimum goal for hemodialysis adequacy and implement changes in the plan of care to address and resolve the identified barriers. This example would not require a reassessment and completely new plan of care; if this is the only area where the goal was not met, the patient could be considered “stable,” and only the plan of care for adequacy would require adjustment.

Tag Number V557 Continued –(3) If the expected outcome is not achieved, the interdisciplinary team must adjust the patient’s plan of care to achieve the specified goals. When a patient is unable to achieve the desired outcomes, the team must—(i) Adjust the plan of care to reflect the patient's current condition; (ii) Document in the record the reasons why the patient was unable to achieve the goals; and (iii) Implement plan of care changes to address the issues identified in paragraph (b)(3)(ii) of this section.

Interpretive guidance Page 219 – 220 Continued ‐

This requirement is not met if the patient's plan of care is not adjusted and there is no evidence the IDT is working to address ongoing problems (e.g., uncontrolled hypertension, hyperkalemia, missed treatments, inaccurate or unattainable target weight) which may result in adverse outcomes for the patient. This requirement is not satisfied if the only reason documented for failure to achieve goal(s) is “patient non‐compliance” or “non‐adherence.” If the team believes the cause of the failure to reach the goal is non‐adherence, the IDT efforts should focus on identifying potential causes of the non‐adherence and addressing those causes. The IDT must recognize each patient has the right to choose less than optimal care when the patient determines optimal care would negatively impact his/her quality of life.

These regulations require the IDT to demonstrate its members are actively attempting to meet each patient’s plan of care goals. This Condition does not “require” a patient to meet every goal. Any member of the IDT, including the patient, may document why goals are not met or cannot be met.

Who Is “Unstable?”

Per V520, includes but is not limited to:Extended or frequent hospitalization (>15 days or > 3 x a month)Marked deterioration in health statusSignificant change in psychosocial needsConcurrent poor nutritional status, unmanaged anemia and inadequate dialysisFacility can identify unstable “add‐ons” – if documented in P&P make sure reassessments are done per policy

What About Current Patients?As of October 14, 2008:

A plan must be in place to implement this new systemSome assessments/POCs completed each monthuntil all are doneAll current patients to be included in the newsystem within 12 months of 10/14/08 (10/14/09)Surveyors told not to expect 3 month reassessment for current patientsSurveyors told to expect updates for any aspect of care that does not meet targets

Transfer of Current PatientsAfter 10/14/08, when a patient is transferred,

A Copy of most current IDT assessment and POC from the transferring facility in patient’s medical recordReassessment within 3 months of admissionRevision and implementation of POC within 15 days of completion of the reassessment

Also in POCV 560

Dialysis facility must ensure that all patients be seen by a physician, APNP or PA at least monthly, and periodically, for in‐center HD patients, while the patient is on dialysisIf patients are seen in the physician’s office, facility must have a system to ensure transfer of visit information

Tag Number V560

Referencing home dialysis physician visits

Interpretive guidance Page 221

This requirement applies equally to home patients, who are expected to receive equivalent care to in‐center patients. A monthly visit is required for each home patient by either a physician, an advanced practice registered nurse, or a physician assistant. This visit may be conducted in the dialysis facility, at the physician’s office, or in the patient’s home. Any patient may choose not to be seen by a physician every month. However, if there is a pattern of a patient consistently missing physician visits, the IDT should determine whether or not the patient is unstable according to these regulations, and should address the lack

14 assessment “criteria” (V502‐515)

As outlined on the MAT and

within the Interpretive Guidance

V502 Health Status and Co‐morbid Conditions Assessment

What is expected?• Use of medical & nursing histories and physical exams

• APRN or PA may conduct medical areas of assessment as allowed by states

• Must include etiology of kidney disease and listing of co‐morbid conditions

V518 Adequacy Management Assessment

(Dialysis Prescription V503)What is expected?

IDT comprehensive assessment includes:HD patient – initial & monthly Kt/V (or equivalent measure, URR)PD patient – Initially & at least every 4 months Kt/V

V544 Adequacy Management Plan of CareWhat is expected?

POC demonstrates:• Achievement of target: Kt/V of at least 1.2 (3x/week HD) or 1.7 (PD)

OR• Modification of the dialysis prescription

* HD – change dialyzer size, time on dialysis, BFR, DFR, type and efficacy of access* PD – Change number of exchanges, volume, dextrose content, dwell time, consider membrane integrity and infection rate

OR• Rationale for not achieving the expected target

Adequacy ManagementMedical Record Documentation

• If expected outcomes are not achieved there should be evidence of re‐evaluation for that aspect of care

• If the 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

Adequacy ManagementMedical Record Documentation

Where to look?• IDT Assessment• Plan of Care• Implementation of plan of care‐Flow sheets‐Progress notes‐Physician orders

V504 Blood Pressure and Fluid Management Assessment

What is expected?IDT assessment should include:• Patients BP on and off dialysis• Interdialytic weight gains• Target weight and intradialytic symptoms

Blood Pressure and Fluid ManagementPlan of Care

What is expected?POC demonstrates:• Fluid management and 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

Blood Pressure and Fluid ManagementMedical Record Documentation

• If expected interdialytic or intradialytic goals for fluid management are not achieved there should be evidence of re‐evaluation for that aspect of care


Blood pressure and Fluid ManagementMedical Record Documentation


V506 Immunization ManagementAssessment

What is expected?IDT assessment should include:• Evaluation of the patient’s immunization history/status for hepatitis, influenza, and pneumococcus

• Evaluate for tuberculosis screeningEvaluate anti‐HBs on all vaccinees

Immunization ManagementPlan of Care

What is expected?CDC recommends and the POC demonstrates:• Dialysis patients are tested at least once for baseline tuberculin skin test and retested if exposure is suspected

• Dialysis patients be offered influenza and pneumococc al vaccines

• Vaccinate all susceptible patients for Hepatitis B

Immunization ManagementMedical Record Documentation

What is expected?• Record of testing and immunizations• Documentation of immunity or acknowledgement of absence of immunity

• Documentation of further action planned if required

Immunization ManagementMedical Record Documentation

Where to look?• IDT Assessment• Plan of Care• Implementation of plan of care‐Flow sheets‐Immunization logs‐Progress notes‐Physician orders

V507 Anemia ManagementAssessment

What is expected?IDT assessment should include:• Evaluate the patient’s laboratory values ( Hct, Hgb, serum ferritin, transferrin saturation, iron stores)

• Evaluate co‐morbid conditionsEvaluate for ESA &/or iron therapy

V547 Anemia ManagementPlan of Care

What is expected?POC demonstrates:

• Laboratory results are reviewed monthly• Medication adjustment (may use algorithms/ESA protocols)

• Home patients are evaluated for ESA administration and storage

• Outcome oriented plan

Anemia ManagementMedical Record Documentation

• If expected outcomes for anemia management are not achieved there should be evidence of re‐evaluation for that aspect of care


Anemia Management Medical Record Documentation

Where to look?• IDT Assessment• Plan of Care• Implementation of plan of care‐Flow sheets‐Progress notes‐Medication administration‐Physician orders

V508 Mineral Metabolism ManagementAssessment

What is expected?IDT assessment should include:• Evaluate the patient’s laboratory values (calciun, phosphorous, PTH)

• Evaluate medications for management of bone disease (phosphate binders, vitamin D analogs, calcimimetic agents)Evaluate relevant dietary factors

V540 Mineral Metabolism ManagementPlan of Care


• Laboratory results are reviewed monthly• Medication adjustment as indicated• Outcome oriented plan

Mineral Metabolism ManagementMedical Record Documentation

• If expected outcomes for mineral metabolism management are not achieved there should be evidence of re‐evaluation for that aspect of care


Mineral Metabolism ManagementMedical Record Documentation

Where to look?• IDT Assessment• Plan of Care• Implementation of plan of care‐Flow sheets‐Progress notes‐Medication administration‐Physician orders

V511 Dialysis Access ManagementAssessment

What is expected?IDT assessment should include:• Assessment for the most appropriate access for the patient: AVF, graft, CVC, PD catheter

• Consider co‐morbid conditions/risk factors, patient preferenceEfficacy of HD & PD patient’s access correlates to adequacy of dialysis treatments

Dialysis Access Management Assessment

IDT Evaluation for/of HD Access • Communication with radiologist, interventionist, vascular surgeon

• Venous mapping, vascular access surveillance, new access placement

IDT Evaluation of PD Access• Absence of infection (exit site/tunnel, peritonitis)• Patency & function

V550 Dialysis Access ManagementPlan of Care


• 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

• Monitoring to ensure capacity to achieve & sustain adequate dialysis treatments

V551 Dialysis Access ManagementPlan of Care


• Vascular access surveillance• Early detection of failure • Timely referrals for interventions• Medical record documentation of the action taken

Dialysis Access ManagementMedical Record Documentation

• If expected outcomes are not achieved there should be evidence of re‐evaluation for that aspect of care

• If the patient is not achieving the expected targets, expect to see documentation of the reason WHY & a change in plan


Dialysis Access Management Medical Record Documentation


Questions????

raynel wilson quality improvement director the renal · pdf filewhat are the clinical practice...

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