Transcript Transitions of Care in ESRD patient management

Transitions of Care in
ESRD Patient Management
Improving Handoffs
Antonia Harford, MD
UNM Nephrology
OBJECTIVES
• Review Epidemiology of ESRD
– Mortality/Hospitalization in ESRD
• Transitions of care in ESRD:
– Discharge Handoffs
• Future Collaborations
– Communication at transfer
– Nurse navigator
ESRD
Patient counts, by modality
Incident & December
31 point prevalent
ESRD patients.
Total Medicare ESRD
expenditures, by modality
Period prevalent ESRD patients, patients with Medicare as
secondary payor are excluded.
USRDS 2011
• ESRD patients have
higher rates of
hospitalization and
mortality than age
matched controls in
general population
• 20% of ESRD pts
account for 80% ESRD
Medicare expenditure
All-cause standardized
hospitalization & mortality ratios
in large dialysis organizations, 2009
Figure 10.19 (Volume 2)
January 1 point prevalent hemodialysis patients with Medicare as primary payor (SHRs); January 1 point prevalent
hemodialysis patients (SMRS). SHRS & SMRS are calculated based on national hospitalization & death rates; adjusted
for age, gender, race, & dialysis vintage.
ESRD
• Mortality
• Hospitalization
– Cardiovascular
– Cardiovascular
• Sudden Death
• CHF
• CAD
• Fluid overload
– Stroke
– Infection
• Vascular Access
• Pneumonia
– Withdrawal from dialysis
– Vascular Access Cx
– Infection
• Vascular Access
• Pneumonia
– Hyperkalemia
– Fracture
Time-series curves for death
A:Modifiable factors
B: Fixed factors
Chan K E et al. CJASN 2011;6:2642-2649
©2011 by American Society of Nephrology
Change in adjusted all-cause & causespecific hospitalization rates, by modality
Figure 3.1 (Volume 2)
Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; ref: ESRD patients, 2005.
Incident HD pts (n = 303,289),
A: relative risk of death B: Hospitalization
Relative risk of A: death and B : Hospitalization at each 1week interval compared with a reference group of patients
who survived the first year of dialysis
Chan K E et al. CJASN 2011;6:2642-2649
©2011 by American Society of Nephrology
Access events & complications in prevalent dialysis patients
(CPM data; rate per patient year)
Table 2.c (Volume 2)
Catheter, fistula, graft: prevalent hemodialysis patients age 20 & older, ESRD CPM & claims data.
Peritoneal dialysis device: prevalent peritoneal dialysis patients age 20 & older.
Access use at first outpatient hemodialysis, by preESRD nephrology care, 2009
Incident hemodialysis patients, 2009.
HR for Mortality in First 90 days
Catheters
DAYS
1-30
31-60
61-90
0
2
4
6
8
10
12
14
Referent Group: AVF
Adjusted for age, sex, race, case of ESRD and Vintage
16
HR for Mortality in First 90 Days
AV Grafts
DAYS
0-30
31-60
61-90
0
2
4
6
Referent Group: AVF
Adjusted for age, sex, race, case of ESRD and Vintage
8
Associations of pneumococcal vaccination
& Mortality and Hospitalization
Gilbertson D T et al. Nephrol. Dial. Transplant.
2011;26:2934-2939
© The Author 2011. Published by Oxford University Press on behalf of ERA-EDTA. All rights
reserved. For Permissions, please e-mail: [email protected]
Cause-specific rehospitalization rates in the 30 days following
live hospital discharge, by age, 2009
Figure 3.4 (cont.; Volume 2)
Period prevalent hemodialysis patients age 20 & older, 2009; unadjusted.
Includes live hospital discharges from January 1 to December 31, 2009.
Medical Errors
& ESRD
• Poly-pharmacy
• Multiple providers
• Multiple handoffs
Cumulative number of medications in
Part D-enrolled ESRD patients, by race/ethnicity
& low income subsidy (LIS) status, 2008
)
Point prevalent Medicare enrollees alive on January 1, with Part
D enrollment, October 1–December 31, 2007 & 2008.
The Bundle & ESRD Medications
• Presently the dialysis units bundle the cost of
outpatient dialysis related injectables as part
of the “Bundle”
• In 2014, the outpatient dialysis facility will
dispense all outpatient meds associated with
dialysis
Top 25 drugs used by Part D-enrolled dialysis patients
by frequency & net cost, 2008
Part D claims for all dialysis
patients, 2008.
ESRD Discharge
• Multiple handoffs, because of:
– Multiple co-morbidities
– Poly-pharmacy
– Multiple providers
– Multiple levels of care
Unforeseen consequences
• Reduction in trainee work hours did not result
in the expected decrease in medical errors
• Reduction in trainee work hours had resulted
in an increased # of hand-offs:
Rates of All Harms, Preventable Harms, and High-Severity Harms per 1000 Patient-Days, Identified Rates of All
Harms, Preventable Harms, and High-Severity Harms per 1000 Patient-Days, Identified by Internal and External
Reviewers, According to Year.
by Internal and External Reviewers, According to Year.
Landrigan CP et al. N Engl J Med 2010;363:2124-2134.
Hand/Offs
• Considerations:
– What is the most effective H/O?
• Telephone, email, text, EMS
– How do we teach H/O?
– Who is responsible for H/O?
• Trainee, nurse navigator, attending
– Identify patients at increased risk for medical error
at H/O
Inter facility Transfer form
Transitional Care Models:
Decreasing LOS & Hospital Days
• Disappointing results with reducing hospital
admission & readmission rates
• Among CKD patients initiating dialysis, those
enrolled in a multidisciplinary CKD care model
had a significantly lower mean hospital days
compared to controls
OBJECTIVES
• Review Epidemiology of ESRD
– Mortality/Hospitalization in ESRD
• Transitions of care in ESRD:
– Discharge Handoffs
• Future Collaborations
– Communication at transfer
– Nurse navigator
Future Directions
– Promoting communication at transitions of care
– Improving Handoffs: Bidirectional
– Health care navigators: DCI CMS Innovation Grant
Collaboration in Transitions of Care in
ESRD
• Hypothesis: Collaboration between Hospitalist
& Renal services utilizing Nurse navigators will
decrease LOS & total hospital days
Collaboration in Transitions of Care in
ESRD
• Specific Aim 1: Identify the 20% ESRD pts with
frequent re-admissions to UNMH. Randomize
50/50 to usual care vs Nurse navigator
• Specific Aim 2: Compare Missed HD
treatments, ER utilization , hospital admission,
readmission, LOS, total hospital days between
groups