Involuntary Patient Discharge:

1. Involuntary Patient Discharge: Looking Back & Moving Forward Mark A. Meier, MSW, LICSW

2. My Disclaimer • I talk far too much • I sometimes swear…so I will offer up a “prepology” now • I get a little fired up at times • I still have hero’s

4. “What do we live for if not to make life less difficult for each other?” Roger Bannister

5. I Appreciate That… • Time is an issue • Duties are constantly changing • The patient situations can be difficult • You are frequently asked to do more with less

6. But Also… • We are the professionals • We are guided by ethics, federal guidelines, and professional responsibilities • The patients you serve need your oversight now more than ever!

7. What Patients Tell Me “You don’t understand how hard it is to complain about the people who care for you” “What do you think will happen to me if I make a complaint, they will throw me out” “Nobody will do anything about my concerns anyway”

8. Sample - 71% of U.S. patients and providers 94% survey return rate 458 discharges reported (0.2%) CMS/OMB approved Involuntary Patient Discharge Survey - 2003

9. Participating Networks 1 11 4 3 12 9/10 5 18 6 8 14

10. Top Reasons for Discharge (N=458) 117 (25.5%) 39 (8.5%) 35 (7.6%) 24 (5.2%) 23 (5.0%) Noncompliance Verbal Threat Lack of Payment Verbal Abuse VA, VT, PT

11. All Reasons for Discharge (n=458) 223 176 175 102 58 53 36 15 Non- compliance Verbal Threat Verbal Abuse Physical Threat Lack of Payment Physical Harm Property Damage/ Theft Other

12. What Is It About Patient Adherence That Makes Us So Crazy?

15. Just 2 Weeks Ago… “If they don’t care about themselves enough to come to treatment why should I care.” “They are adults and there is no room for noncompliance in kidney disease.” “They (nonadherent pt’s) are a waste of time and supplies.” “They deserve to be kicked out”

16. Nonadherence “It is unethical for patients to be left without treatment based solely upon non-adherent behaviors that are a risk only to themselves.” Ethical, Legal, Regulatory Subcommittee DPC Task Force 2005

17. “Nonadherent behavior that is not harmful to others does not justify involuntary discharge from a dialysis unit.” Hashmi and Moss 2008 www.nature.com/clinicalpractice/neph

18. 2008 Conditions For Dialysis Coverage

19. Subpart D- Administration 494.180 Governance (f) Involuntary discharge and transfer policies and procedures

20. 494.180 Governance Involuntary Discharge The governing body must ensure that all staff follow the facility’s patient discharge and transfer policies and procedures. The medical director ensures that no patient is discharged or transferred from the facility unless- • The patient or payer no longer reimburses the facility for the ordered services; • The facility ceases to operate;

21. 494.180 Governance Involuntary Discharge • The transfer is necessary for the patient’s welfare because the facility can no longer meet the patient’s documented medical needs; • The facility has reassessed the patient and determined that the patient’s behavior is disruptive and abusive to the extent that the delivery of care to the patient or the ability of the facility to operate effectively is seriously impaired, in which case the medical director ensures that the patient’s interdisciplinary team-

22. Interpretive Guideline Involuntary discharge or transfer should be rare and preceded by demonstrated effort on the part of the interdisciplinary team to address the problem in a mutually beneficial way. The facility must have and follow written policies and procedures for involuntary discharge and transfer.

23. Standard-Nonpayment Interpretive Guideline: If a facility involuntarily discharges or transfers a patient for nonpayment of fees, there must be evidence in the patient’s medical record that the facility staff (e.g., billing personnel, financial counselor, social worker) made good faith efforts to help the patient resolve nonpayment issues.

24. Standard-Facility Closure Interpretive Guideline: In the event a facility ceases to operate, the governing body must notify CMS, the State survey agency, and the applicable ESRD Network. The facility’s interdisciplinary team must assist patients to obtain dialysis in other facilities.

25. Standard-Disruptive and Abusive Interpretive Guideline: Patients should not be discharged for failure to comply with facility policy unless the violation adversely affects clinic operations (e.g., violating facility rules for eating during dialysis should not warrant involuntary discharge).

26. Standard-Disruptive and Abusive Interpretive Guideline: Patients should not be discharged for shortened or missed treatments unless this behavior has a significant adverse affect on other patients’ treatment schedules. A facility may evaluate the patient (who shortens or misses treatments) for any psychosocial factors that may contribute to shortening or missing treatments; for home dialysis; or, as a last resort to avoid inconveniencing other patients, may alter the patient’s treatment schedule or shorten treatment times for patients who persistently arrive late

27. Standard-Disruptive and Abusive Interpretive Guideline: Patients should not be discharged for failure to reach facility-set goals for clinical outcomes.Facilities are not penalized if a patient or patients do not reach the expected targets if the plan of care developed by the IDT is individualized, addresses barriers to meeting the targets, and has been implemented and revised as indicated.

28. Interpretive Guideline An "immediate severe threat" is considered to be a threat of physical harm. For example, if a patient has a gun or a knife or is making credible threats of physical harm, this would be considered an "immediate severe threat." An angry verbal outburst or verbal abuse is not considered to be an immediate severe threat.

29. Practice Issues And Involuntary Patient Discharge

30. What Do We Know? “….69% of survey respondents indicated that their dialysis facilities had witnessed an increase in difficult/disruptive patient situations within the past 5 years.” “The Frequency and Significance of the Difficult Patient: The Nephrology Community’s Perceptions “ King, K & Moss, A; Advances in Chronic Kidney Disease, 2004

31. And… • 51% of staff indicate they lacked adequate training to deal with difficult/disruptive patient situations • 77% of staff report that their facilities did not offer regular education on how to deal with difficult/disruptive patient situations King, K & Moss, A; Advances in Chronic Kidney Disease, 2004

32. Remember This? • Conference Calls • Interviews • All stakeholders perspectives • Summer 2003 • Final Report with recommendations

34. Interpretive Guideline (Tag# V767) “At the time of publication of these rules, each facility had received a copy of an interactive program developed by the ESRD Networks on Decreasing Dialysis Patient Provider Conflict (DPC) that addresses proactive techniques to resolve such issues before progression to involuntary discharge.”

35. DPC Toolbox

36. DPC • Who is monitoring to insure training? • Is the toolbox available to providers? • How can the patient organizations (RSN, DPC, AAKP, etc.) be leveraged to help with this initiative • Does CMS embrace that conflict is at the root of many wasted hours and resources in the dialysis clinic

37. Addressing Nonadherence

38. Standard-Disruptive and Abusive Interpretive Guideline: Patients should not be discharged for shortened or missed treatmentsunless this behavior has a significant adverse affect on other patients’ treatment schedules. A facility may evaluate the patient (who shortens or misses treatments) for any psychosocial factors that may contribute to shortening or missing treatments; for home dialysis; or, as a last resort to avoid inconveniencing other patients, may alter the patient’s treatment schedule or shorten treatment times for patients who persistently arrive late

39. Standard-Disruptive and Abusive Interpretive Guideline: Patients should not be discharged for failure to reach facility-set goals for clinical outcomes.Facilities are not penalized if a patient or patients do not reach the expected targets if the plan of care developed by the IDT is individualized, addresses barriers to meeting the targets, and has been implemented and revised as indicated.

41. The Scope of the Problem? “About 20-30% of dialysis patients present with depression” Tossani, Cassano, Fava; Seminars in Dialysis, Volume 18, No. 2 (March-April) 2005

42. And… “Our results suggesting that almost half (44%) the patients with ESRD starting dialysis therapy were depressed….” Watnick, Kirwin, Mahnensmith, and Concato. The Prevalence and Treatment of Depression Among Patients Starting Dialysis. AJKD 41(1), 2003: pp 105-110

43. Also… “This (Depression) may be one of the last modifiable risk factors for poor outcomes we as nephrologists and mental health care workers can address.” Kimmel P, Peterson R. Clinical Journal Depression in Patients with End Stage Renal Disease Treated with Dialysis: Has the Time to Treat Arrived?American Society of Nephrology 1:349-352, 2006

44. Prevalence of Physician Diagnosis of Depression and CES-D > 10, by Country

45. Antidepressant medication use (%), by indication of depression/symptoms and country

46. Concluding Thoughts • The conditions on their own will not adequately address these issues • Patient discharge is still occurring and likely more problematic is patient refusal • Depression and conflict resolution training are key leverage points. • If Fistula First worked…so can DPC First and Depression First

47. Thank You markm@equalicare.com Or 612.789.9897