1. 1 Patient Assessment, Plan of Care, and Medical Records Kelly Frank, RN, BSN Health Facilities Surveyor

2. 2 Objectives For This Session Describe the required components of patient assessment and patient plan of care in the new ESRD CfCs Identify the expected timelines for completion of the patient assessment and patient plan of care Describe the medical record documentation for the patient assessment and plan of care

3. 3 We Are Playing Different Positions On the Same Team… And the Goal Is… Improving patients’ well-being through improved outcomes!

4. 4 Change in Focus: Patient Assessment & Patient Plan of Care From LTP/PCP to PA/POC Hard to talk about PA without talking about POC NOT about paper! About collaboration of the interdisciplinary team (IDT) About better outcomes for the patient: “attain and sustain”

5. 5 Outcomes Based on ESRD Clinical Practice Standards Developed by renal community workgroups & coalitions; e.g. National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) Guidelines National Quality Forum (NQF): Clinical Performance Measures (CPM) Address management of complications of ESRD

6. 6 Measures Assessment Tool (MAT) The MAT is a tool developed for ease of reference to these Clinical Practice Standards MAT was deliberately developed for ease in updating If an individual patient does not meet a goal on the MAT, the plan FOR THAT ASPECT of care must be revised

7. 7 Patient Assessment & Patient Plan of Care 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

8. 8 Patient Assessment and Plan of Care Best Friends Forever

9. 9 The New Conditions Place High Expectations on Facilities for Interdisciplinary approach for continually assessing individual patient’s care needs, and for planning and implementing the care. Outcome goals that meet current professionally-accepted clinical practice standards

10. 10 Interdisciplinary Care vs. Multidisciplinary Care InterdisciplinaryMultidisciplinary Work collaborativelyWork sequentially Communication by regular discussions about patient status & the evolving plan of care Medical record is the chief means of communication

11. 11 Interdisciplinary Team Collective vs. Individual Problem Solving

12. 12 Interdisciplinary Team (cont.) Includes at a minimum: The patient or his/her designee A registered nurse A physician treating the patient for ESRD A masters prepared social worker A registered dietitian Required for both patient assessment and plan of care

13. 13 Patient Assessment § 494.80 The interdisciplinary team (IDT) must collaborate to provide each patient an individualized comprehensive assessment 14 assessment “criteria” Most required sections do not specify “who” must conduct the assessment Reassessments required at defined frequencies “Unstable” = monthly “Stable” = annually

14. 14 Patient Plan of Care § 494.90 The IDT must develop & implement a written, individualized comprehensive patient plan of care (POC) Based upon the comprehensive assessment Addresses each patient’s care needs Outcome goals in accordance with clinical practice standards – MAT

15. 15 Stable / Unstable Stable patients: annual comprehensive interdisciplinary reassessment POC updated & implemented within 15 days Unstable patients: monthly comprehensive interdisciplinary reassessment POC updated & implemented within 15 days All patients: continuous monitoring of any aspect of care where the target is not met & revision of that aspect of POC

16. 16 Who Is “Unstable?” Includes but is not limited to: Extended (any stay >15 days) or frequent hospitalization (>3 hospitalizations in a month) Marked deterioration in health status Significant change in psychosocial needs Concurrent poor nutritional status, unmanaged anemia & inadequate dialysis

17. 17 In Between Assessments… Every patient must be continuously monitored. If a “stable” patient’s outcomes do not meet the care plan goals in an area, the facility must recognize and address that aspect by revising the plan of care for that aspect between comprehensive reassessments.

18. 18 Correlation of PA & POC PAPOC 1.Current health status (V502) 2.Lab profile (V505) 3.Medication/immunization history (V506) Incorporated into all POC tags 4.Appropriateness of dialysis prescription (V503) Adequate clearance (V544) 5.BP/fluid management needs (V504) Manage volume status (V543) 6.Assess anemia (V507)Manage anemia (V547) Home pt ESA (V548) ESA response (V549) 7.Assess renal bone disease (V508) Manage mineral metabolism (V546)

19. 19 Correlation of PA & POC PAPOC 8.Nutritional status (V509)Effective nutritional status (V545) 9.Psychosocial needs (V510) 10.Evaluate family support (V514) Psychosocial counseling/referrals/ assessment tool (V552) 11.Access type/maintenance (V511) VA monitor/referral (V550) Monitor/prevent failure (V551) 12.Evaluate for self/home care (V512) Home dialysis plan (V553) 13.Transplantation referral (V513)Transplantation status: plan or why not (V554) 14.Evaluate current physical activity level & voc/physical rehab (V515) Rehab status addressed (V555)

20. 20 For Each of the Care Areas IDT must assess each patient, develop & implement POC to achieve established targets Goals based on current clinical practice standards – MAT If expected outcomes are not achieved, in any area, IDT must recognize and address this aspect Must adjust the plan/implement the changes

21. 21 Current Health Status & Medication History Assessment Medical & nursing histories & physical exams Must include etiology of kidney disease & listing of co-morbid conditions Initial review of current medications & allergies Ongoing assessment of home medications Plan of care for these aspects is addressed in other care areas

22. 22 Immunization Assessment: evaluate the patient for Immunization history/status for hepatitis, influenza, pneumococcal pneumonia HBV, tuberculosis screening Must know HBV status on admission or tx as positive Plan of Care: offer the patient Influenza & pneumococcal vaccines HBV vaccine for all susceptible patients Retest vaccinated patients for response

23. 23 Blood Pressure & Fluid Management Assessment: Patient’s B/P on & off dialysis Interdialytic weight gains Target weight & intradialytic symptoms Plan of Care: Achieve targets in fluid/weight management – MAT Symptomatic drops in BP or continued hypertension during dialysis require plan revision

24. 24 Anemia Management Assessment: evaluate the patient’s: Laboratory values for Hgb, Hct, serum ferritin, transferrin saturation Associated co-morbid conditions Appropriateness for ESA &/or iron therapy Plan of Care: provide care aimed at Achieving established targets in anemia management – MAT Adjusting medications as indicated (may use algorithms/ESA protocols)

25. 25 Nutritional Status Assessment by dietitian: see list at V509 Albumin Body weight Plan of Care: provide care & counseling aimed to: Achieve & sustain effective nutritional status (V545) - MAT

26. 26 CKD Mineral Bone Disorder Assessment: evaluate the patient’s: Laboratory values for calcium, phosphorus, iPTH Relevant dietary factors Need for medications: phosphate binders, vitamin D analogs, calcimimetic agents Plan of Care: provide care aimed to: Achieve established targets (calcium, phosphorus, iPTH) in CKD-MBD management – MAT Adjust medications as indicated; may use guidelines/algorithms Provide dietary education/counseling as indicated

27. 27 Dialysis Adequacy Assessment: required for every patient: HD: initial & monthly Kt/V (or equivalent measure, URR) PD: initial & at least every 4 months Kt/V (or equivalent measure, none currently) Plan of Care: Prescribe treatment aimed at achieving HD spKt/V of at least 1.2 (3 tx/week); PD Kt/V of 1.7; or Modify the dialysis prescription; or Provide a rationale for not achieving the expected target

28. 28 Dialysis Access: Assessment Assessment for most appropriate access for that patient: AVF, AVG, CVC, PD catheter Consider co-morbid conditions/risk factors, patient preference Evaluation for/of HD access: Communicate with radiologist, interventionist, vascular surgeon Do venous mapping, place new access as indicated Evaluation of PD access Absence of infection: exit site/tunnel, peritonitis Patency & function

29. 29 Dialysis Access: Plan of Care Patient evaluation as candidate for AVF If CVC >90 days, action plan for a more permanent vascular access or rationale for continued use Vascular access monitoring: To ensure capacity to achieve & sustain adequate dialysis treatments For early detection of failure & Timely referrals for interventions

30. 30 Psychosocial, Functional Status & Modality Needs: Assessment Evaluation by SW: see list at V510 Abilities, interests, preferences, goals for participation in care, modality & setting Family & other support systems Physical activity level Referral for vocational & physical rehab Suitability for transplant referral based on area transplant center criteria

31. 31 Psychosocial, Functional Status & Modality Needs: Plan of Care Counseling and referral as indicated Address physical & mental functioning & rehab needs Home care plan (or why not) Transplantation referral (or why not )

32. 32 Timelines: All Began 10/14/08 Initial comprehensive interdisciplinary assessments for new patients: PA = 30 days/13 treatments whichever is later POC implemented within this same timeline Comprehensive reassessment for new patients: 3 months after initial assessment completed POC updated & implemented within 15 days of reassessment

33. 33 What About Current Patients on October 14, 2008? Need a plan to implement this new system Complete some assessments/POCs each month until all are done All current patients should be included in the new system by 10/14/09 Three month reassessments for current patients are NOT expected Any aspect of care that does not meet targets must have an updated POC

34. 34 What’s Wrong With These Pictures?

35. 35 The ESRD Medical Record Format - Electronic, manual, combination Content - Consents - Histories/medical exams - Progress notes - Labs - Treatment orders - Dialysis treatment records - Patient education

36. 36 Medical Record Documentation Patient assessment Patient plan of care development/revision Plan of care implementation May be found in multiple parts of the record Use of the Mat

37. 37 Quality Patient Care Is About the Process…Not the Paper Patient Assessment Plan of Care

38. 38 ESRDSurvey@cms.hhs.gov