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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