WATCH ABOVE: The NDP released documents Saturday that claim budget cuts have compromised health care in Alberta. But as Eric Szeto reports, health officials say the changes that were made are safe, cost effective measures.

EDMONTON – The Alberta NDP says funding cuts to health care are having a serious impact on patient safety.

Edmonton-Calder NDP candidate David Eggen released a leaked AHS PowerPoint presentation Saturday which outlines changes to the Northern Alberta Renal Program, which provides hemodialysis treatments to patients.

The presentation, which Eggen said was given to him by a concerned AHS employee, outlines changes to the classification of dialysis waste from biomedical waste to regular waste. According to AHS, it costs about $15 to discard dialysis waste such as dialyzers and tubes in approved biomedical waste containers, compared to just a couple dollars in garbage bags.

“We know from workers, the people who leaked this information, this is compromising the level of safety of both patients and workers, and it’s a result of this choice by the PCs to deliver bargain bin medicine. Rather than looking for safety first, they’re looking for cuts first,” Eggen said Saturday.

Dialysis waste is considered general waste as long as there are no sharps attached or dripping blood, the AHS presentation states. A spokesperson with AHS says the procedure complies with CSA standards.

“Items that have come in contact with blood, but do not contain blood, can be disposed of in general waste. Any items containing blood continue to be disposed of in biomedical waste,” Shelly Willsey said in an email to Global News.

Willsey said the disposal of the dialysis system as biomedical waste costs more than four times as much as general waste disposal. She added that AHS continuously looks for ways to reduce spending while maintaining safe environments for patients.

Health Minister Stephen Mandel says Albertans expect the government to save money where possible and the health care system should make every effort to be as efficient as possible.

“If it’s proven to be clear and not any danger then we should do it the most effective and expeditious way,” said Mandel.

“Historically, I think that we’ve followed a process of being very cautious,” he added “We will never ever give direction on something that is not within the mandate of safety and security, nor will we give a mandate that would have any kind of implications to the environment.”

The president of the HSAA, the union that represents 25,000 paramedical technical, paramedical professional and general support employees, is extremely concerned with the system.

“In my experience, blood is considered a bio-hazard and should be disposed as such,” said Elisabeth Ballermann. “I showed this document and this waste to a member that I was with who is a lab technologist and her response was, ‘Oh my God.’ Her immediate concern was for the safety of anybody and everybody who might be handling this thing.”

Ballermann is worried that removing the sharps from the tubes may result in injury for staff members. She’s also concerned about the process of flushing the blood out of the tubes.

“They’re saying red is bad, pink is good,” she said. “Any normal saline that I’ve seen that they would flush the tube with has always been clear. That suggests that there’s still visible blood left in the lines… Viruses and bacteria aren’t usually visible to the naked eye.”

Eggen is calling for a review on the entire practice.

“This bargain bin medicine is the lowest possible safety standard. Front line workers are doing the best they can but they have no choice but to be getting rid of human biomedical waste in ‘robust’ garbage bags,” said Eggen.

With files from Eric Szeto, Global News. 

© Shaw Media, 2015

...

No one is more pleased to see the doors of the expanded Regional Nephrology Centre at Renfrew Victoria Hospital open than Ken McQuade.

McQuade was one of several patients who joined dignitaries and hospital officials to cut the ribbon on the new $12 million facility at a special event on Thursday, April 9 that drew a large crowd.

McQuade has been coming to RVH for the past five years for dialysis treatments.

He is thrilled with the new facility and was pleased to be at the official opening.

“This is great, it’s a beautiful spot. You couldn’t ask for better,” said McQuade, a retired auto shop owner who lives in Admaston-Bromley Township.

His dialysis consists of three trips to the centre each week for treatment that lasts four hours and 15 minutes each time. He’s there each morning at 7 a.m. and on dialysis days he goes home, has lunch and is tired out and usually naps. The days after each treatment are the good days when he feels stronger and has more energy to spend time with his family and on hobbies that include woodworking and boating.

“The next day I’m 100 per cent,” said McQuade.

The lifesaving dialysis that he gets so close to home means all the difference when it comes to enjoying his time with his wife Sharon and his children and grandchildren.

His kidney disease diagnosis meant big changes. “It’s quite a life change. Especially in your food and your diet,” he said.

McQuade is impressed with the expansion, which includes big windows and large rooms.

“I love the brightness and the space and the new chairs,” he said.

Plenty of parking right at the entrance of the centre is another feature he appreciates.

RVH is the only small hospital in Ontario that operates a regional dialysis program.

At the grand opening, medical director of the nephrology program Dr. Nicole Delbrouck said RVH was considering a regional program years before the rest of the province began to focus on regionalization.

Completion of the project brought to mind the Burl Ives song The Little Engine that Could, said Delbrouck.

“The Renfrew hospital is the little engine that could in this scenario,” she said.

“The other feature that is very important to emphasize is the will of this particular hospital to be hospitable to the needs of Renfrew county patients and in particular the renal population,” she said.

“The hospital undertook this program because the need was absolutely clear, we have the biggest county in Ontario, people were travelling huge distances,” said Delbrouck. “I did have people in their 80s who were doing this.”

At one time and for some patients, chronic kidney disease was a death sentence for patients unwilling to put their families and themselves through the ordeal of waking up in the middle of the night to drive hours several times each week for needed dialysis.

“Those people who were given the choice often declined,” said Delbrouck, because they couldn’t drive to Ottawa, couldn’t afford the frequent travel and weren’t prepared to bankrupt themselves or family members.

“The last person I knew that made that choice was someone who had been referred to us from the Ottawa program,” she said. The man was on a waiting list for the limited number of local beds that were available at the time. “He died in the process of waiting for a bed to become available. And I swore that would never happen again, that was absolutely unacceptable.”

Three local family doctors trained to be able to facilitate the local program, the only ones in Ontario and possibly the country to do that, she said. “We still enjoy tremendous support from our family physicians,” she said.

And from then on the engine has gathered steam, culminating in Thursday’s opening.

RVH works closely with and officials thanked the Champlain LHIN and Champlain LHIN Regional Renal Steering Committee, the Renal Administrative Leaders Network of Ontario (RALNO) and Ontario Renal Network (ORN) working groups and initiatives, and has links with The Ottawa Hospital Renal Program.

...

When social workers earn their Master’s degree, at least one thing is very clear: they have learned about the interplay of bio-psychosocial forces active in the life of every human being, and that these forces shape behavior.

Nephrology social workers see that dynamic in their patients with kidney failure each and every day. As they enter the world of integrated care, where they are invited into roles to improve quality while containing cost, it is no surprise that the master’s-level social worker feels right at home. From their seat at the integrated care table, they can help reach these goals by tailoring team care to the inner world of the patients being treated.

ACOs and renal disease

Integrated care has been a long time coming for the renal disease industry. Accountable care organizations, which spring from the goals of the Medicare Shared Savings Programs mandated by the Patient Protection and Affordable Care Act of 2010, bring together voluntary groups of hospitals, physicians, and health care teams that understand how Medicare and Medicaid beneficiaries with ESRD have significant and costly care needs. Medicare beneficiaries with ESRD constituted >1% of the Medicare population but consume a disproportionate 6.7% of the total Medicare budget, excluding Medicare Part D. ¹ Dialysis patients continue to experience frequent, lengthy, and costly hospitalizations. Such poor outcomes may be attributed in large part to high patient acuity and complexity and a fragmented care delivery system. ² The complex health needs of the ESRD patient often require beneficiaries to visit multiple providers and follow numerous care plans, which can be challenging for beneficiaries when care is not well coordinated.

Through enhanced care coordination, these beneficiaries can have a more person-centered care experience, which will ultimately improve health outcomes and beneficiary satisfaction. ³ If dialysis providers can contribute new and successful ways to reduce the cost of care under these new types of care models and other CMS initiatives––especially in the area of hospitalizations––they can receive a share of the cost savings to keep their business viable. Enter: Nephrology social workers with a mission to engage in onsite behavioral health care interventions that enhance patient adherence and adaptation to chronic illness.

Targeting high risks

As this new era of care advances, social work services that directly provide the coaching and counseling services to help patients manage the demands of treatment are under the spotlight. At Fresenius Medical Care, the Social Work Intensive Program (SWI), launched across the country in 2012 to serve patients at higher risk of hospitalization, is positioned strategically now in the Integrated Care Division. This social work program offers additional behavioral health tools when standard MSW interventions do not succeed in ameliorating psychosocial and quality of life barriers. The program has received the Modern Healthcare Spirit of Excellence Award for its ability to reduce the cost of care by improving patient adherence behavior. ⁴ Data presented at the American Society of Nephrology’s annual meeting in November 2014 confirmed the role of the program’s quality of life, depression, sleep and stress outcomes in reducing missed treatments, and fluid-related hospitalizations. ^5-7

Social work leaders are expanding their oversight of social work roles with patients at high risk of hospitalization and a new Director of Social Work in Integrated Care position has been created to drive the value of these behavioral health programs into a cost-sensitive future. “Nephrology social workers are uniquely equipped to assist the interdisciplinary team (IDT) in identifying underlying root causes of patient non treatment adherence as well as other psychosocial barriers that can be very complex and lead to frequent patient hospitalizations,” says Greg Garza, vice president of Integrated Care for Fresenius Health Partners. “Utilizing their full skill set of our social workers, we are able to find opportunities to improve their quality of life while reducing the overall cost of care to the delivery system.”

Social work programs such as the SWI launch social workers toward early screening of risk criteria. Low quality of life scores, non-adherent behavior, interpersonal stress and depressive symptoms are among the psychosocial variables that are known contributors to mortality and hospitalization. ^8-16 Early social work screening allows patients at higher psychosocial risk to be triaged into treatment programs as soon as they are identified. ¹⁴

Patient engagement has been exceptionally strong in this type of social work model, compared to models of the past 20 years where dialysis patients were referred to mental health providers not situated on the dialysis team. While only 36% of patients are willing to see an outside mental health provider and even fewer follow up on that referral, 86% of patients prefer to receive mental health services from their facility team social worker. ¹⁷ Only 5% of patients refuse the SWI program at FMCNA and the quality of life benefits it can offer them. These types of onsite social work treatment programs can be quickly tailored to each patient’s unique set of barriers, and interventions can be provided during treatment at times when patients feel their best. Since these services can be delivered during treatment by providers normally on the treatment floor, patients are able to maintain a feeling of privacy when they receive needed counseling services.

In early screening, if no psychosocial risk barriers are identified the patient is moved onto a social work usual care pathway. This type of triage methodology helps the nephrology social worker continually focus more of their time on the patients most at risk of hospitalization and poor outcomes.  Social workers work quickly, utilizing tools that improve mood, adjustment and coping. They deploy demonstrated interventions that restore quality of life and reduce social and interpersonal distress ^18,19 All interventions are tailored to address each patient’s specific risk area(s).

Symptom Targeted Intervention tools developed by Melissa McCool are also utilized in many cases to improve mood and overall psychosocial health. ²⁰ Following an eight-week period of intensive social work intervention, these high risk patients are then moved to maintenance for close oversight and support. Social workers are provided with additional time to serve this program by reducing their scope of service. Tasks that do not require a master’s trained social worker (travel placement, data entry, admission paperwork, etc.) are moved to other team members as the social worker takes the lead in the more skilled behavioral health interventions.

Hospitalization: Reducing the risk

In the integrated care environment, patient risk of hospitalization is a constant area of focus. During the course of the SWI program, the social worker is just one member of an interdisciplinary team (IDT) that stays in very close communication about all risk areas. There are more frequent informal team “huddle meetings” on any patient considered to be at higher risk of hospitalization. More formal calls are held on a routine basis with the full IDT to review progress and reassess risk on all levels. The social worker’s role in all meetings is to keep the team fully informed of any psychosocial risk areas presenting. All team members learn from the social worker how to best provide “real-time” support to reduce the psychosocial risk of hospitalization. The constant assessment and sharing of interdisciplinary perspectives on these calls, reaching out to pull in experts and team consultants as needed, and operating in a real-time environment are examples of effective integration of care. The more frequent intervals of oversight on patients screened to be of higher risk of hospitalization is yet another example. The nephrology social worker is a key player in each of these processes.

Evaluating self-care

In addition to more attention on psychosocial risk, “usual care” models that serve the psychosocial needs of all patients (even those not considered at higher risk of hospitalization) are continuing to progress. Early assessment of patient self-care behaviors will allow the team to tailor interventions that advance patient engagement. These newer patient activation approaches, which have been shown to reduce cost of care in chronic illnesses such as diabetes, are likely to play key roles in working with incident patients who drive up considerable cost in the first 120 days of their admission to an outpatient dialysis center. ^21-23 Working with the new patient, a nephrology social worker can ladder patients into feelings of confidence and mastery over their self-care while stabilizing their quality of life. The interrelationship of these forces (confidence, mastery and health related quality of life) is powerful in creating positive outcomes and there is, perhaps, no team member more skilled than the systems-trained social worker to mobilize those forces. Trained to help others maximize their life functioning, adapt to challenges and solve problems, the nephrology social worker is well positioned to steady the course for a patient, their family system, and the social systems around them. All patients benefit from this inoculation of life skills during their first 120 days of treatment and refresher support throughout the trajectory of their life with ESRD.

Accountable care in social work

The integration of care has also driven the field of nephrology social work into more accountability. Social workers are relying more than ever on the use of metrics, ensuring that psychosocial health is restoring at all times in those at risk and having a positive impact on treatment adherence and hospitalizations. In addition to tracking actual risks identified (such as depressive symptoms, sleep quality, HRQOL), they will be monitoring the efficiency of the interventions they are using, and improving intervention processes using that data. They will be tracking referral processes and case management activities to continually improve their care navigation activities. With access to resource data, social workers can also improve their advocacy efforts where community resource gaps exist.

In the integrated care environment, social workers will constantly identify population issues and address them with pathways that serve those population needs. Social work pathways focus on periods of the care continuum where psychosocial stressors are often magnified and might present more risk of hospitalization. Table 1 demonstrates some of the high-risk periods of hospitalization for all ESRD patients throughout their continuum of care. Social work pathways will focus and guide the patient more intensively during these periods to bridge additional support to the patient. Treatment planning is more intensive and outcomes are monitored heavily during these high-risk periods. Notice the interplay of bio-psychosocial forces in the risk periods displayed in Table 1 and the role of the MSW to help navigate those forces to maximize patient and family functioning and reduce risk of hospitalization.

Summary

Integrated care has brought changes to the field of nephrology social work. In turn, nephrology social work has brought innovative contributions to the field of integrated care. The new social work service delivery systems described in this article are sure to help the industry reach its goals to keep care patient-centered while maintaining quality and reducing the costs of treating end stage renal disease. Social workers are called to serve the needs of the client, the family, the community and the society at large. Nephrology social workers are right where they belong in the ESRD integrated care environment. They feel right at home.

References

1.     US Renal Data System USRDS 2011 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Vol 2. Bethesda, Md.: National Institutes of Health, National Institutes of Diabetes and Digestive and Kidney Diseases; 2011: e208, e282.

2.     Nissenson AR, Maddux FW, Velez RL et al. Accountable Care Organizations and ESRD: The time has come. Am J Kidney Dis. 2012; 59 (5): 724-733.

3.     Centers for Medicare and Medicaid Services Comprehensive ESRD Care Model Fact Sheet.Released:Tuesday, April 15, 2014. http://www.cms.gov/Newsroom/Newsroom-Center.html

4.     Spirit of Excellence Award for team. Breaking the cycle: Holistic approach boosts dialysis compliance. Modern Healthcare, Dec 17, 2012

5.     Oral presentation:  Johnstone S, Li NC, Maddux FW, et al. A social worker-initiated program to reduce fluid overload in hemodialysis patients. American Society of Nephrology, 2014. Philadelphia, Pa.

6.     Oral presentation: Johnstone S, Dombro L, Garza G. et al. Declines in hemodialysis patient physical and mental component scores before death. American Society of Nephrology, 2014. Philadelphia, Pa.

7.     Poster: Johnstone S, Li NC, Maddux FW, et al. Reducing hemodialysis therapy non-adherence: A social-worker initiated program. American Society of Nephrology Meeting, November 2014, Philadelphia Pa.

8.     Lopes AA, Bragg J, Young EW, et al. Depression as a predictor of hospitalization among hemodialysis patients in the United States and Europe. Kidney International 62: 199-207, 2002.

9.     Lacson E, Bruce L, Li NC et al. Depressive affect and hospitalization risk in incident hemodialysis patients. CJASN 9 (10) 1713-1719, October 2014

10.  Lacson E, Li NC, Guerra-Dean S, et al. Depressive symptoms associate with high mortality risk and dialysis withdrawal in incident hemodialysis patients. Dial Transplant (2012) 0: 1-8.

11.  Untas A, Thumma J, Rascle N, et al. The associations of social support and other psychosocial factors with mortality and quality of life in the Dialysis Outcomes and Practice Patterns Study. CJASN. 6:142–152, 2011.

12.  Mapes DL, Bragg-Gresham JL, Bommer J, et al. Health-related quality of life in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis.Nov 44(5 Suppl 2):54-60.

13.  Elder SJ, Pisoni RL, Akizawa T, Fissell R, Andreucci VE, Fukuhara S, Kurokawa K, Rayner HC, Furniss AL, Port FK, Saran R. Sleep quality in hemodialysis patients: Results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant 2008; 23: 998-1004

14.  Boulware LE, Liu Y, Fink NE, et al. Temporal relation among depression symptoms, cardiovascular disease events, and mortality in end-stage renal disease: contribution of reverse causality. Clin J Am Soc Nephrol 2006; 1:496-504.

15.  Fan L, Sarnak MJ, Tighiouart H,et al. Depression and all-cause mortality in hemodialysis patients. Am J Nephrol 2014;40:12-18

16.  Johnstone S.  Depression management for hemodialysis patients: Using DOPPS data to further guide nephrology social work intervention. Journal of Nephrology Social Work, 26 (5), 18-31, 2007.

17.  Roberts J and Johnstone S. Screening and treating depression: Patient preferences and implications for social workers. Nephrology News and Issues, 20 (13): 43, 47-49, 2006.

18.  Johnstone S. Helping patients manage treatment recommendations: Start with quality of life!  Renal Business Today 8 (7): 16, 18.

19.  Johnstone S, Li NC, and Demaline J. The expansion of a social work behavioral health program: Helping dialysis patients manage fluid craving. Neph News Issues, 29:1, pgs. 30-35, 2015

20.  McCool M, Johnstone S, Sledge R, et al. The promise of symptom-targeted intervention to manage depression in dialysis patients. Neph News and Issues 25 (6): 32-37

21.  ParchmanML, Zeber JE, PalmerRF. Participatory decision making, patient activation, medication adherence, and intermediate clinical outcomes in Type 2 diabetes: A STARNet Study. Ann Fam Med. Sep 2010; 8(5): 410–417.

22.  Remmers C, et al. Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes? Jrnl of Ambul Care Manag2009; 32:320-7

23.  United States Renal Data System Annual Data Report 2012. ESRD Chapter 1: Incidence Prevalence, Patient Characteristics and Mortality. http://www.usrds.org/2012/view/v2_01.aspx.

...

Poor patients undergoing dialysis at the State-run Institute of Nephro-Urology will have to shell out 25 per cent more from now on.

Patients with BPL cards, who were earlier paying Rs. 250 per dialysis, now have to shell out Rs. 310. Those under the APL category, who were paying Rs. 500 per dialysis, now have to pay Rs. 625.

The hospital authorities said that this was not unreasonable since the charges had remained stagnant since 2007, while maintenance charges had gone up.

However, this increase has come as a shock to many. “I bring my 13-year-old son Naveen from K.R. Puram for dialysis thrice a week to the institute and have to spend quite a sum on conveyance. I am a daily wager and have to miss work on dialysis days as I have to accompany my son. How can I afford to pay the increased charges?” asked Srinivas M.

Narsimha Murthy (29), who comes from Konanakunte Cross, said the “patients had no other go but to pay and get dialysed as they cannot afford dialysis in a private hospital.”

C.S. Rathkal, who retired as the Institute Director last week, said the proposal to increase the charges had been approved by the Institute’s Finance Committee on August 12 last year.

“We have increased the charges as the prices of all consumables have gone up. We had placed the proposal before the Governing Council on February 2 and got it approved,” he said.

When contacted, Medical Education Minister Sharanprakash R. Patil promised that he would get the institute to “put the revised charges on hold.”

...