5/21/2012. Beth Witten, MSW, ACSW, LSCSW

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Beth Witten, MSW, ACSW, LSCSW beth@wittenllc.com 1 Consultant with Medical Education Institute, Inc.

1 Beth Witten, MSW, ACSW, LSCSW 1 Consultant with Medical Education Institute, Inc. which administers KDQOL COMPLETE & multiple other websites Consultant to ESRD Survey & Certification Group, Centers for Medicare & Medicaid Services & member of ESRD Training & Support Team 2 Describe why & how to measure health-related quality of life (HRQOL) Explain how to review scores & set goals List interventions have improved scores State surveyors expectations for HRQOL measurement Describe the ICH CAHPS survey State how to fulfill 2014 QIP requirements 3 1

2 What s your discipline? Social worker Dietitian Nurse Physician, APRN or PA What patients do you work with In-center HD only In-center & home Home only Do other members of your TEAM use KDQOL results in planning care? 4 Patient s perceived mental health 1 Patient s perceived physical health 1 How a chronic disease interferes with day-to-day life 1 1 CDC Research findings (Fresenius 2 & DOPPS 3 ) that HRQOL scores independently predicted hospitalization & death National Quality Forum recommended HRQOL as clinical performance measure to CMS (April 1, 2008) ESRD Conditions for Coverage & Interpretive Guidance 2 Lowrie EG et al. Am J Kidney Dis 41(6): , Mapes DL et al., Kidney Int 2003, 64:

It takes a team to: Improve physical function Improve mental function Help relieve burden of kidney disease Manage symptoms Reduce effects of kidney disease on daily life Social workers can t do this

3 It takes a team to: Improve physical function Improve mental function Help relieve burden of kidney disease Manage symptoms Reduce effects of kidney disease on daily life Social workers can t do this alone! 7 On dialysis <3 months Under age 18 PedsQL is only kidney-specific HRQOL survey: Other pediatric HRQOL surveys: Can t complete due to cognitive impairment, dementia, active psychosis Non-English speakers/readers, if no translation or interpreter available Several translations are available on the KDQOL Working Group (free) site & KDQOL COMPLETE Refuse 8 To help patients see what s in it for me consider saying Medicare wants to focus on how you see your physical and mental functioning You can t give us a wrong answer just tell us how you think and feel Your answers are important to us so we need you to complete the survey here The first 12 questions give us two key scores (PCS & MCS) that can help us help you live longer & better 9 3

4 Speak clearly, confirm that patient understands Timeframe (if question states one) Which are generic (1-12, 17-28) Which questions are kidney-specific (13-16, 29-36) Use a tip sheet for groups of questions (choices & timeframe if applicable) Ask patient to respond with first thought Do not interpret questions for patients Repeat as needed; avoid sounding frustrated 10 FREE KDQOL-36 survey (translations) Excel scoring template to download Basic instructions Manual age x gender (DOPPS) No patient report (register for downloads) SUBSCRIPTION KDQOL-36 survey (translations) Automatic age x gender x diabetes (DOPPS) Text patient report (translations) Graphical clinic reports for POC & QAPI 11 Discuss scores & share patient report ASAP Congratulate patient on areas where patient is doing well Focus on areas needing improvement Look at individual questions for +/- changes that might direct plan & interventions If scores are low or declining, to instill hope remind the patient the team can help 12 4

5 Suboptimal 1 st dialysis (hospital; with catheter; not on modality of choice) 4 Anxiety & depression 5 Poor sleep quality 6 Higher malnutrition-inflammation score 7 Longer travel times to dialysis 8 4 Mendelssohn et al., BMC Nephrol 2009 Aug 12;10:22 5 Kao TW et al., Artif Organs Jan;33(1): Unruh ML et al., Clin J Am Soc Nephrol Jul;1(4): Rambod M et al., Am J Kidney Dis Feb;53(2): Moist LM et al., Am J Kidney Dis Apr;51(4): Short daily or nocturnal HD reduced cramps, headaches, hypotension, shortness of breath, and other symptoms, and improved HRQOL vs. standard HD 9,10 Switching to CCPD allowed patients more time to enjoy life 11 Switching to icodextrin (Extraneal) PD solution reduced symptoms 12 9 Heidenheim AP et al. Am J Kidney Dis Jul;42(1 Suppl): Ting GO et al. Am J Kidney Dis Nov;42(5): Bro S et al. Perit Dial Int Nov-Dec;19(6): Guo A et al. Kidney Int Suppl Oct;(81):S

Adjusting dry weight 13 IV iron(more than oral iron) 14 Treating anemia with ESAs 15 Reducing PTH with cinacalcet 16 13 Chang ST et al. Nephron Clin Pract. 2004;97(3):c90-7 14 Agarwal R et al.

2005 Oct;68(4):1793-800 16 Promoting exercise improves depression, HRQOL, & stamina 17-21 17 Levendoglu F et al. J Nephrol. 2004 Nov-Dec;17(6):826-32 18 Painter P et al. Am J Kidney Dis.

6 Adjusting dry weight 13 IV iron(more than oral iron) 14 Treating anemia with ESAs 15 Reducing PTH with cinacalcet Chang ST et al. Nephron Clin Pract. 2004;97(3):c Agarwal R et al. Am J Nephrol. 2006;26(5): Beusterien KM et al. J Am Soc Nephrol May;7(5): Cunningham J et al. Kidney Int Oct;68(4): Promoting exercise improves depression, HRQOL, & stamina Levendoglu F et al. J Nephrol Nov-Dec;17(6): Painter P et al. Am J Kidney Dis Feb;39(2): Painter P et al. Am J Kidney Dis Sep;36(3): Tawney KW et al. Am J Kidney Dis Sep;36(3): Molsted S et al. Nephron Clin Pract. 2004;96(3):c Adaptation training 22 & group counseling 23 help patients cope with stresses of ESRD & improved HRQOL more than usual care (no intervention) Goal setting & interdisciplinary collaboration significantly improved patients perception of their health status, specifically physical & emotional role functioning Tsay SL et al. J Adv Nurs Apr;50(1): Lii YC et al. J Clin Nurs Nov;16(11C): Callahan MB et al., Nephrol News Issues 1999 Jan; 13(1):

7 Facility policy determines where to file survey (medical record or file cabinet) Chart notes should include: Scores & how they compare to mean (average) Risk for hospital/death (low, average, high) Patient-reported factors contributing to low scores Patient & team goals, roles, timelines Outcomes 19 Review scores & responses with patients soon after survey is completed Address areas where things are going well in an effort to maintain From areas where improvement is needed, ask the patient to choose one area to work on 20 Plan must be effective & individualized to patient Meetings can be at chairside, if patient agrees, or in a meeting room Phone participation is OK (patient, IDT member) Each IDT member should share information from his/her comprehensive patient assessment Invite patient to offer input/feedback; patient participation should be more than signing a form Any substitute for a meeting must promote information sharing 21 7

If you don't know where you are going, you'll end up someplace else. Yogi Berra www.extension.

8 If you don't know where you are going, you'll end up someplace else. Yogi Berra Somewhat bothered; ++ Moderately bothered; +++ Very much bothered Patient Assessment Sore muscles Chest pain+ Cramps++ Itchy skin++ Dry skin++ Short of breath+++ Possible IDT Intervention Plan Evaluate, review labs, activities, Evaluate, educate/reinforce salt/fluid limit, refer to cardiologist, pulmonologist Review/revise dialysis Rx as needed Review labs, PO 4 intake, educate about binder, seek financial help for binders Evaluate bathing regimen, lotion tips, refer to dermatology Evaluate, educate/reinforce salt/fluid limit, refer to cardiology, pulmonology 23 + Somewhat bothered; ++ Moderately bothered; +++ Very much bothered Patient Assessment Possible IDT Intervention Plan Faint/dizzy+++ Evaluate, review BP meds & timing, fluid removal rate (HD, PD) Lack of appetite+++ Monitor adequacy, treat depression, promote socialization, refer for meal help Washed out/drained+++ Treat anemia, depression, low BP, refer to PT Numb hands/feet+ Monitor adequacy, labs, meds, refer to neurology, educate to control DM (if applicable) Nausea/upset stomach++ Monitor dialysis adequacy, meds, refer to GI Problems with access site (HD) Problems with catheter site (PD) Evaluate & treat infection, educate about access care, evaluate & correct flow problems Evaluate & treat infection, educate about access care, use prophylactic antibiotic cream, evaluate & correct flow problems 24 8

9 Scale PCS MCS Burden Effects Possible IDT Intervention Plan Treat anemia, encourage physical activity, advise about safe exercise, educate about salt/fluid, suggest protein sources Build hope through mentors, encourage enjoyed hobbies, socialization, encourage step-by-step planning toward goals, treat depression &/or anxiety Encourage independence, questioning & education about CKD & treatment, discuss ways to use treatment time productively, educate & evaluate ways to reduce PD burden Treat anemia, provide diet instruction, explain why more dialysis is better, encourage physical activity, promote positive attitude, sense of humor, & joy in activities, help to set realistic goals & expectations 25 What were the scores & how were individual questions marked this time & last? What scores should be maintained? What scores are worse on this survey? What scores are better on this survey? What does team think the patient should work on? What is patient s highest priority to work on? What interventions have been attempted? How effective were interventions attempted? How does the plan need to be adjusted? Goal Action IDT Member Start Date Check Date End Date Outcome 26 % of eligible patients taking survey on time (initial reassessment & annual) per CPM % of patients excluded & why % surveyed whose low score improved 1 point % surveyed whose score declined 10 points Relationship of scores to behaviors (e.g., high PCS & low MCS to skipping/shortening) Relationship of scores to hospitalizations & deaths What intervention(s) improved scores (doing KDQOL postintervention can aid in tracking outcomes) Problem Goal Action QAPI Member Target Dates Outcome Monitor 27 9

10 Do an in-service on the KDQOL, it s uses, and research-based outcomes using fact sheet Share data in POC & QAPI Individual patients in POC Aggregate scores in QAPI Low or declining scores, share responses that another discipline may be able to address Ask social work colleagues how they got their team on board & use techniques with your team 28 If KDQOL-36 or age appropriate survey was not administered Did patient meet exclusion criteria? If refused, did patient acknowledge refusal & were other attempts made? Was survey scored & results reported: To patient? To interdisciplinary team? Was survey used by IDT in plan of care? 29 Did staff adhere to regulations, facility policies & procedures? Does the medical record include scores & plans to address or valid reason to exclude Is documentation (POC & QAPI) confirmed by interviews: Patients? Social worker? Other members of interdisciplinary team? 30 10

11 One of top 25 citations in FY2010 & 2011 Psychosocial counseling Referrals HRQOL survey Since plan of care is team responsibility, the citation is for IDT, not just social worker Avoid citation by administering, sharing, & using survey in plan of care 31 I have made the KDQOL the center of the work I do with patients. I spend a lot of time on the KDQOL with patients and make it the cornerstone of what I discuss in care plan meetings, and I find that this makes most other processes quicker. With a thorough QOL discussion, I find assessments and care plans go faster, make more sense and are truly patient centered. QOL helps us identify patient goals that we can work together as a team to help them achieve. -- Megan Prescott, LCSW University of Colorado Hospital Chronic Dialysis Unit 32 1 Point in PCS RR mortality 2% RR hosp. 2% 1 Point in MCS RR mortality 2% RR hosp. 1% 2 Lowrie EG et al. Am J Kidney Dis 41(6): ,

ESRD Quality Incentive Program Measure for Payment Year 2014 34 Full: 58 core+20 supplemental ones Staff competence and

of complaints Patient involvement in decision-making Safety and care environment Patient education Patient rights Privacy 35 If

12 ESRD Quality Incentive Program Measure for Payment Year Full: 58 core+20 supplemental ones Staff competence and professionalism Staff communication, care, & emotional support Nephrologist communication and care Coordination of care Handling of complaints Patient involvement in decision-making Safety and care environment Patient education Patient rights Privacy 35 If answer these = Complete survey: Eligibility: Q1, Q2, Q56 Composites: Q20, Q23, Q37, Q41 Primary ratings: Q8, Q32, Q35 Demographics: Q45, Q

13 Administer the ICH CAHPS following recommendations in the fielding guide: Should not be administered by dialysis staff or in clinic Should not be administered face-to-face Should be fielded by 3 rd party vendor Low response in pilot if surveyed by mail only; best results if surveyed by mail with phone follow-up Attest to administration via CROWNWeb by 11:59 pm 1/30/2013 Any clinic assigned CCN >6/30/2012 must do & attest If no eligible patients, clinic must attest it does not apply 37 Use Google to search for ICH CAHPS vendor CSS Research DSS Research Jennifer Todd: jennifer.todd@dssresearch.com Group/cahps/ichcahps.aspx 38 Adult (>18) in-center HD patients only Excludes pediatric & home patients Excludes patients with <3 months in-center HD experience at current clinic Survey all patients if <200 at clinic If >200 patients, random sample % response rate expected 39 13

14 Individual items Global ratings Overall rating of kidney doctors Overall rating of dialysis facility staff Overall rating of dialysis facility Composites Nephrologists communication & caring Quality of dialysis center care & operations Providing information to patients Attestation only (no scores) for QIP PY

Beth Witten, MSW, ACSW, LSCSW

This Session will Begin Momentarily. The Session is Being Recorded. Please mute your phone lines (*6). Following the Presentation, Lines will be Open for Q & A Beth Witten, MSW, ACSW, LSCSW beth@wittenllc.com