2001 OPTIMA award Developing an On-Site Dialysis Treatment Center.

Adapted from the submission by the Glengariff Health Care Center, Glen Cove, New York; written by Robert Mackreth, Consultant Social Worker

Beginning in 1995, our skilled nursing facility, which has provided long-term care since 1971, began admitting patients requiring subacute services. Most required intensive rehabilitation or treatment of medically complex conditions. Among the patients accepted into the subacute program were those discharged from hospitals in need of restorative rehabilitative services who also had a secondary diagnosis of end-stage renal disease, requiring chronic hemodialysis treatment.

These dual- or multiple-diagnosis patients, requiring close and continuing supervision, were transported a minimum of three days a week to outlying dialysis centers, usually the hospital or center of origin, for treatment of 3 to 4 hours' duration. Some of these centers were as distant as 25 miles from the facility. This meant that the patients, spending an average of 1 to 2 hours traveling by ambulette (longer in heavy traffic or inclement weather), in addition to the time in treatment, often missed their physical, occupational or speech/language therapy sessions or were too tired to participate in them upon returning. This interrupted therapy schedule added to these patients' length of stay, which averaged 30.78 days in 1998, and delayed their reaching rehabilitative goals before discharge.

Because the patients undergoing dialysis would not be in the facility for their noonday nourishment, bag lunches were provided, thus reducing the number of hot meals available to them and compromising the staffs ability to measure their consumption. Family visiting was more difficult, and the patients had limited opportunity to participate in therapeutic recreation, religious services and other aspects of facility life. Moreover, the increased lengths of stay and need for transportation resulted in additional costs being incurred by Medicare, Medicaid, insurance and private-pay.

Patient and family concerns and frustrations, as expressed in customer satisfaction surveys, further heightened our determination to find an alternative treatment arrangement.

Inasmuch as there were no known models upon which to pattern an on-site dialysis program, we consulted with nephrologists and hospital personnel, reviewed the medical literature and spoke with our own physicians. Following these initial explorations, formal planning began.

Planning

The Governing Body, with input from the Quality Improvement Committee, medical staff, and all professional disciplines and supportive services involved, sought to develop one or more alternative proposals to meet the special needs of our dialysis patients, consistent with the organization's overall quality improvement objectives and mission.

This effort led to our reaching out to a voluntary teaching hospital in the facility's service area, a federally certified provider of chronic dialysis services. After extensive discussions between joint administrative and medical staffs, Glengariff initiated, in April 1998, bed-side dialysis treatment in our facility provided by the hospital.

To administer dialysis at bedside required us to convert dedicated rooms and install five dialysis machines, along with all the necessary plumbing and drains. Treatment was to be performed and supervised by hospital renal nursing staff.

Initial Results

We saw some encouraging early results. Transportation time was, of course, eliminated; rehabilitative therapy scheduling and participation improved; and the average length of stay for these patients was reduced.

Nevertheless, problems arose. While a maximum of 15 patients could be accommodated, bed utilization was inconsistent, nursing staff had to move from room to room to monitor treatment and, overall, the bedside program was not cost-effective.

Any choice as to whether to continue this service as initially structured was lost when the agency then known as the Health Care Financing Administration (HCFA) determined that no Medicare Part B reimbursement could be made to certified providers of chronic dialysis services for care rendered in a skilled nursing facility. This brought the initiative back to our Governing Body, administration and Quality Improvement Committee in January 2000. It also provided an opportunity, drawing upon the experience we had already acquired, to refine performance measurement criteria, gather significant data and plan performance improvement actions.

What emerged, slowly but with increasing clarity, was the possibility of Glengariff's establishing its own on-site chronic hemodialysis treatment center. The quality improvement goals identified at that point were to:

* enable dialysis patients to receive optimum, time-effective benefit from rehabilitative services, further reducing, if possible, their length of stay in the facility. It was projected that this average, then (in 1999) 28.9 days, could be reduced by perhaps 5 days.

* increase customer satisfaction, as measured by ongoing patient, family and staff surveys.

* enable and encourage patients to assume a greater role in planning their treatment.

Each department was asked to submit its recommendations, including what it could contribute to such a program and what additional resources might be needed. Opinions and suggestions also were sought from patients (and their families) who had been receiving dialysis at off-site treatment centers or at bedside. The outline of the project was presented to and discussed at two successive Resident Council meetings. In addition, hospital-based care managers, citing the absence of any other facility's offering such a program, were very supportive in encouraging its establishment.

Implementation

After additional study, consideration of options and negotiations with the hospital, Glengariff entered into a cooperative venture with the hospital to establish an on-site dialysis center at the facility, where dialysis services could be rendered both to inpatients and, space permitting, individuals referred from the community. To make this possible, the facility undertook major construction to provide and equip a ground floor, handicapped-accessible, 900 sq. ft. area. The plans included a six-bed treatment unit, nurses' station, medication dispensing station, reverse osmosis machine, chemical storage space and a waste removal station.

The dialysis center opened on June 30, 2000, after a New York State Department of Health survey and its approval. Under a contractual arrangement, Glengariff Health Care Center leases space to the hospital and accepts landlord obligations, and the hospital provides equipment, staffing and administrative services. Under the terms of the contract, the facility retains responsibility for admissions, discharges and overall patient care. Both organizations have developed center-specific administrative and departmental polices and procedures.

Dialysis treatment records are maintained in triplicate, with one copy entered into the facility's medical record, thus facilitating communication and coordination between the two entities responsible for patient care.

The center operates six days a week, from 7:00 a.m. to 6:00 p.m. The maximum number of patients who can be served weekly is 36. When another shift is added, as is anticipated, the maximum will be increased to 48.

Hospital personnel assigned to the center include an RN supervisor, an LPN for every four patients and, on a weekly and as-needed basis, a dietitian and social worker. Patients are seen at least weekly by a hospital nephrologist but remain under the care of their attending physicians. Before the center opened, both the hospital and facility provided mandatory in-service training to their respective staffs. New employees receive orientation upon assignment to the center.

All disciplines, departments and support services were involved in the planning for the unit, as they are in its operation. This includes attending physicians, one of whom is both an internist and a nephrologist.

Some anxiety was experienced in both the planning and early operational stages with respect to possible impediments to the center's effective functioning and the unequivocal need for a coordinated team approach. Indeed, several problems--both major and minor--did emerge. All have been resolved.

One example of a minor problem was the need to substitute a weight scale provided by the hospital with one that could accommodate patients in geri-chairs--a need not anticipated by hospital staff accustomed to caring for ambulatory patients in an outpatient setting. Another involved repositioning patient television sets, suspending them from the ceiling rather than attaching them to the wall where they would interfere with access to the chairs.

More serious initial problems centered around "territorial" issues--e.g., nursing staff were uncomfortable with sharing patients and environment with "outside" staff, and physicians were reluctant to yield part of their autonomy to the nephrology group assigned by the hospital. In turn, hospital personnel, accustomed to focusing on their area of skill and concern, needed to be helped to understand that the facility is responsible for treating the whole person and not just a specific need.

These issues were successfully addressed through joint discussions, delineation of respective responsibilities and, perhaps most effectively, through the common satisfaction found in making this new venture work. All hospital nephrologists have become privileged and credentialed at the facility and have the opportunity to attend medical staff meetings.

Certain adjustments to staff and operational schedules were needed, such as earlier preparation of breakfast trays to accommodate patients at the beginning of the treatment schedule, changes in certified nursing assistant assignments and hours, and more frequent collection and disposal of medical waste. After a short break-in and adjustment period, the operation has run smoothly.

Evaluation

Performance measurements, designed to assess the functioning and value of the on-site dialysis center and to identify possible areas needing improvement or greater efficiency, were developed organization-wide, with each involved discipline and department participating, and with coordination and integration provided by the Quality Improvement Committee.

Quality indicators and performance objectives were established, based upon the literature, professional standards and practice guidelines, previous experience with both off-site and bedside models, and the pooling of suggestions from both facility and hospital staff. All were consistent with the organization's mission and commitment to quality care.

Data collected systematically through instruments already in use or developed specifically for this purpose have now been incorporated into the facility's ongoing quality improvement program. The size of the dialysis patient population made it possible to obtain data for the entire cohort, rather than employing a random or statistical sample.

With 1998 used as a baseline, data were assembled to reflect changes that occurred during the six months of the center's operation in the year 2000. Data reports were made on a monthly basis and submitted to the Quality Improvement Committee. This made it possible to consider and, if indicated, implement changes or improvements in a timely manner.

Data sources, intended to highlight sentinel events (such as hospital transfers), included admission and discharge records, medical records, patient care plans, rehabilitation schedules, dietary records, incident reports, cost reports, staff schedules, surveys and activity reports.

In terms of cost-effectiveness and management of resources, this program's results have been dramatic. The average length of stay fell from 30.78 days in 1998 to 19.7 days in 2000, achieving more than twice the 5-day reduction projected at the project's onset. An actual reduction of 36% was achieved (Figure 1). Continuing this trend, the average length of stay for the month of April 2001, the latest month studied, was 16.1 days.

Primarily because the cost of transportation to outlying dialysis treatment centers has been eliminated, the total cost of a stay for dialysis patients has dropped from an average of $12,800 in 1998 to $8,147 in 2000, representing a cost savings of more than 36% (Figure 2).

While these benefits have been sufficient to justify the development and operation of the on-site treatment center, perhaps the most important advantage has been the patients' improved quality of life. For example:

* Shorter lengths of stay have meant that patients have been able to complete their rehabilitative program more quickly and return home sooner. Cooperative discharge planning has facilitated better continuity of care.

* Dialysis patients have been able to attend therapy sessions more consistently, participate more actively and achieve their treatment goals faster.

* Choice in the scheduling of treatment sessions has strengthened patient autonomy.

* Patients receiving dialysis on-site can participate more fully in facility activities.

* Family visiting has been made easier.

* A decrease in the number of dialysis patients transferred to hospitals has meant fewer disruptions in care. (Previously, patients being treated at off-site centers had been admitted directly from the centers to acute care for conditions that could have been handled in the facility.)

* Patients' nutrition has improved and desirable weights maintained.

Customer satisfaction surveys have long been conducted by the facility and their results incorporated into the facility's Quality Improvement Program. In May 2000, the month prior to the opening of the on-site dialysis program, a focused survey was performed, involving patients then being treated in outlying centers or at bedside, and their family members. Participants were invited to add personal comments in their survey responses (see sidebar, "Comments From Patients and Family Members").

Six key issues registering satisfaction were identified:

1. Comfort in scheduling and attending dialysis treatment appointments;

2. Avoidance of conflict in participating in both dialysis and rehabilitative therapy sessions;

3. Amount of time required to achieve rehabilitative goals prior to discharge;

4. Ability to maintain family contact while in the facility and undergoing treatment;

5. Opportunity to participate in scheduled recreational therapy activities; and

6. Relationship with treatment personnel, including physicians and nurses.

This survey was repeated in September 2000, three months after the on-site center began operation, and again in December 2000 and March 2001. Results are found in Figures 3 and 4. The areas of most marked improvement in satisfaction, for both patients and families, were treatment scheduling, shortened lengths of stay and the ability to receive dialysis and attend rehabilitative therapy concurrently. The high satisfaction levels have continued since the last survey. For those patients who previously had to be transported to off-site treatment centers, the overall increase in satisfaction was, as might have been expected, especially pronounced. Greater ease in maintaining family contact and support was cited as an important factor in satisfaction by both patients and family members.

Regarding satisfaction with patient's opportunity to participate in scheduled recreational therapy activities, it should be noted that the physical depletion caused by dialysis and the demands of rehabilitative therapy limit patients' energy for engaging in other activities. Nevertheless, some positive change in this measurement was noted; but it was not apparent whether providing dialysis in the facility where patients reside facilitated that increase.

Of particular interest in the survey was the level of comfort and confidence patients expressed regarding receiving dialysis in familiar surroundings, attended by familiar staff.

Conclusion

Seeking to improve the care Glengariff Health Care Center was providing to a particularly vulnerable patient population, the facility undertook a major quality improvement initiative that has now been in operation, under continuing assessment, for almost a year.

The material and personnel resources required for this program proved to be a worthwhile investment. The evidence to date demonstrates the success of this collaboration between Glengariff Health Care Center and its hospital partner in taking a team approach to meeting patients needs while utilizing the special skills and experience of each. This win-win effort has dramatically reduced lengths of stay, lowered costs, developed new ways of rendering service and, most important, improved the quality of patient care.

Because of these documented improvements and the satisfaction expressed by both patients and their families, Glengariff intends to continue this program.

Figure 1. Average length
of stay for dialysis
patients.
YEAR
1998  30.78
1999   28.9
2000   19.7
Note: Table made from
line graph.
Figure 2. Total cost per dialysis patient.
1999  $12,800
2000   $8,147
Note: Table made from line graph

[Graph omitted]

[Graph omitted]

Comments From Patients and Family Members

From patients:

"The drivers were very nice but the trips were very tiring. Now I can go downstairs to have my [dialysis] treatment, and I don't have to get used to new people."

"I like the flexibility of the new system. I have rehab in the morning and again in the afternoon, with dialysis in between. If I'm too tired or something else comes up, I can switch the appointment around."

"My worship service is scheduled for Wednesdays. I used to miss it because I had to go out for treatment. Now I'm right here and I don't have to miss something that is very important to me."

"I was discharged about two weeks ago, sooner than I expected. This made me a little anxious, but the social worker hooked me up with an outpatient treatment center and my dialysis has continued without missing a beat. Thanks."

From family members:

"It was frustrating to visit my mom, expecting that she'd be back from her dialysis appointment, only to find that she'd be delayed an hour or so. When we visit now we know that she'll be here waiting for us."

"When my father was discharged from the hospital, he was very weak and we thought he would need at least a couple of months of rehab before he'd be ready to come home. Instead, he completed the program in less than half that time (thanks to your excellent therapists). He's doing well at home and is still on dialysis, but don't be surprised if he comes to visit."

"Being dependent on dialysis is bad enough without having to go out for treatment three times a week and come back exhausted. My sister and I are grateful for all that you're doing for our mother."

"When my wife, who has a kidney condition, needed a hip replacement and then physical therapy, the social worker at the hospital assured me that I'd be very happy with the care she would get at your facility. She was right."