Renal Care and Liver Disease: Disease Trajectory and Hospice Eligibility

Transcription

1 Renal Care and Liver Disease: Disease Trajectory and Hospice Eligibility Terri L. Maxwell PhD, APRN VP, Strategic Initiatives Weatherbee Resources/HEN Course Materials & Disclosure Course materials including handout(s) and conflict of interest disclosure statement are available to download with this course. This presentation is for educational and informational purposes only. It is not intended to provide legal, technical or other professional services or advice. Learning Objectives List the stages and understand the clinical course of end stage renal(esrd) and liver disease (ESLD) Identify secondary and co-morbid conditions commonly associated with ESRD and ESLD Recognize the body structure(s) and body function(s) related to ESRD and ESLD Recognize activity/participation and environmental components related to ESRD and ESLD Describe clinical documentation that supports medical necessity and substantiates hospice eligibility for patients with ESRD and ESLD 1

2 Renal Care Palmetto LCD Guideline (L31538) International Classification of Functioning, Disability and Health (ICF) Structure Function Activity Participation Environment 5 End Stage Renal Disease (ESRD) Results when kidney function declines to the point where it no longer can sustain life <10% of normal kidney function Acute or chronic 2

3 Causes of Renal Disease Diabetes and hypertension are the most common cause of ESRD African Americans disproportionately affected Common Co-morbidities HTN (Note: HTN may be a related condition if it is a complication of ESRD) Coronary artery disease CHF Peripheral vascular disease Osteoporosis Stages of Chronic Kidney Disease Stage Description GFR 1 Signs of mild kidney disease > 90% with nml or better GFR 2 Mild kidney disease with 60-89% reduced GFR 3 Moderate chronic renal 15-29% insufficiency 4 Severe chronic renal 15-29% insufficiency 5 End-stage renal failure < 15% National Kidney Foundation,

4 Signs of ESRD Oliguria High BUN and serum Creatinine levels Anemia Fluid and electrolyte imbalances Hyperkalemia Hypophosphatemia Hypomagnesmia Palmetto Guidelines: Renal Functional impairments Urinary excretory function Water, mineral and electrolyte function Endocrine gland function Secondary conditions Hyperkalemia Fluid overload Secondary HTN and/or CHF or stroke Secondary hyperparathyroidism Anemia Infections ESRD Symptoms Loss of appetite Nausea Vomiting Diarrhea Constipation Fatigue Weight loss Confusion Irritability Depression Generalized edema Low urine output Generalized weakness Ecchymosis Pruritis Muscle cramps/ twitches Shortness of breath Pain 4

5 Final Stages ESRD Accumulated waste products and fluid can result in: Coma Seizures Death Anuric post-dialysis patients die within days; those with minimal residual renal function may live weeks or even mos however, 6-month survival is rare Hospice Care & ESRD 2.7% of hospice admissions* Patients electing to enroll in hospice usually are those who have d/c d or elected not to receive dialysis Those receiving care for condition not related to ESRD may receive covered services under both the ESRD benefit and hospice benefit; whereas hospices are financially responsible for dialysis related to the terminal diagnosis or related condition.** *NHPCO Facts and Figures, 2012 **CMS Pub Medicare Benefit Policy Manual, 2004 LCD for Renal Care (L31538) Identification and documentation of relevant secondary & co-morbid conditions, combined with specific structural/functional impairments and activity limitations associated with the end-stage renal disease condition may support a prognosis of 6 months or less. 5

6 Assessing and Documenting Disease Burden in ESRD History of illness Decision to d/c or to not seek dialysis Serum Cr, estimated GFR, Cr Clearance Co-morbid conditions- especially those associated with prognostic value or activity limitations Signs and symptoms Degree of impairment of ADLs/ Activity limitations Admission Documentation Mrs. Wilson is a 81 yr old residing in nursing home with PMH of diabetes, hypertension, vascular dementia, and chronic renal failure w/dialysis the past 2 yrs. Pt hospitalized 12/15/12 w/pneumonia. After meeting with the palliative care team, pt s husband (her health care proxy) requests to d/c dialysis and discharge her to the nursing home on hospice. Pt oliguric (UO approx 200 cc per day); serum Creatinine 8.9; Serum K 7.1; KPS 40; pt confused, restless Supporting/Ongoing Documentation for ESRD, cont d Changes in signs/symptoms Altered mental status lethargy, confusion Skin changes/edema/pressure ulcers Medication changes addition/ discontinuation/titration/route of administration, etc. Dietary changes 6

7 ESRD Documentation Example Patient is now completely bed bound and increasingly somnolent with more frequent episodes of confusion. Sleeping on avg 20/24 hrs per day. Po intake reduced due to severe lethargy and anorexia. Caregiver providing maximal assist with all ADLs and is upset re: pt s confusion. Conclusion Hospice eligibility and recertification for patient s with ESRD is based on the description of the effects of their condition on the structural, functional, activity, participation and environmental domains, plus documentation of secondary and co-morbid conditions. Liver Disease (L31536) 7

8 End Stage Liver Disease (ESLD): Background Irreversible condition leads to complete failure of the liver Usually a consequence of chronic liver diseases (alcohol abuse leading cause of ESLD in US) Life expectancy is very low unless patient is a candidate for liver transplant Causes of Liver Failure Chronic Failure Alcohol abuse Hepatitis B and C Cirrhosis Hemochromatosis Cancer Acute Failure Acetaminophen (Tylenol) overdose Viruses- hepatitis A, B, and C (especially in children) Reactions to certain prescription and herbal medications Liver Disease- Structure and Function Filters blood from digestive tract Detoxifies chemicals and metabolizes medications Secretes bile into the intestines Makes proteins involved in blood clotting 8

9 ESLD Symptoms Nausea Diarrhea Edema Jaundice Pruritus Nose bleeds Easy bruising Abdominal pain Weakness/fatigue Weight loss and muscle wasting Confusion ESLD Complications/Secondary Conditions Ascites Frequent infections Variceal bleeding Splenomegaly leading to decreased platelet count Encephalopathy Spontaneous bacterial peritonitis Hepatorenal syndrome Hepatopulmonary syndrome Hepatic hydrothorax/ pleural effusions Hyponatremia Barriers to Hospice Referral Comprises approximately 2% of hospice admissions* Lack of validated metrics to guide physician referral Delay in hospice referral/acceptance while awaiting transplant *NHPCO Facts and Figures,

10 LCD Guidelines for ESLD (L31536) Note: Patients awaiting liver transplant who fit criteria are eligible for the Medicare hospice benefit, but if organ is procured, patient must be discharged. Specific indicators required: 1. The patient should show both a and b: a. Prothrombin time prolonged >5 seconds over control or International Normalized Ratio (INR) >1.5 b. Serum albumin <2.5gm/dl And Palmetto ESLD Guideline, cont d 2. ESLD is present and the patient shows at least 1 of the following: a) Ascites, refractory to treatment or patient non-compliant b) Spontaneous bacterial peritonitis c) Hepatorenal syndrome (elevated creatinine and BUN with oliguria (<400ml/day) and urine sodium concentration <10mEq/l) d) Hepatic encephalopathy, refractory to treatment or patient non-compliant e) Recurrent variceal bleeding despite intensive therapy Palmetto LCD for ESLD, cont d 3. Documentation of the following will support eligibility: a) Progressive malnutrition b) Muscle wasting with reduced strength and endurance c) Continued active alcoholism (>80gm ethanol/day) d) Hepatocellular carcinoma e) HBsAg (Hepatitis B) positivity f) Hepatitis C refractory to interferon treatment 10

11 Assessing and Documenting Disease Burden in ESLD Labs PT/INR and albumin Complications encephalopathy, refractory ascites, recurrent variceal bleeding, etc. Severe impairment of ADLs, progressive weight loss, wasting, mental status changes, etc. Supporting/Ongoing Documentation Changes in signs/symptoms Mental status changes lethargy, confusion, coma Bleeding, nausea, etc. Medication changes addition/ discontinuation/titration/route of administration, etc. Supporting/Ongoing Documentation, cont d Increased service utilization Need for more frequent visits Greater involvement by members of IDT Caregiver burden 11

12 ESLD Documentation Example Pt is increasingly confused the past hrs. Daughter reports being up most of the night with pt, who was repeatedly trying to climb out of bed. Pt refusing all po, including medications. Appears more somnolent this am. He has 4 +LE edema, his abd girth is 64 (up 2 in past 2 weeks) with new redness on his sacral area. Will contact pharmacy to discuss changing route of administration for meds ESLD: Management Liver pain- NSAIDs, dexamethasone and opioids Nausea- antiemetics such as haloperidol Encephalopathy- protein and sodium restriction, bowel clearance with lactulose. Since hepatic encephalopathy is a terminal condition- treatment is usually focused on managing confusion, etc. Conclusion ESLD usually results from chronic conditions such as cirrhosis or hepatitis B or C Hospice eligibility is based on PT/INR & albumin values, as well as a list of complications and underlying conditions Initial and ongoing comprehensive patient assessment with documentation is necessary for enrollment and recertification. 12

13 Course Evaluation & Post-Test Thank you for viewing this course on the Hospice Education Network. To conclude this course and to obtain a certificate of completion, you must finish the evaluation and post-test. Contact information: Terri Maxwell PhD, APRN tmaxwell@weatherbeeresources.com info@hospiceonline.com 13