Personal visits help CMs establish rapport
Personal visits help CMs establish rapport
Home assessment helps identify family dynamics
Face-to-face contact is an essential part of managing the care of patients with end-stage renal disease, says Cristina Walter, MS, RN-BC, CCM, CCP, regional operations director, DaVita VillageHealth.
"It takes a lot of time and face-to-face contact to build up the rapport with patients and to get a full picture of their individual situation and needs. The case managers establish a close relationship so the patients feel comfortable telling them when they need help. Then we bring in social work to help identify resources to meet the patient's needs," she says.
By gaining the trust of their patients, the case managers have been able to find out that their patients didn't take their medications because they couldn't afford them or that they didn't understand how to read the labels.
The case managers work with the patients to sign them up with a pharmacy drug program if they are eligible and are constantly on the lookout for other psycho-social issues, she adds.
VillageHealth case managers also conduct home visits to assess any psycho-social issues the patient may be having and to get a first-hand look at conditions in the home.
When they go into the home, the case managers assess the home environment to get an understanding of living conditions, the patients' support systems, and family dynamics.
"Case managers are the eyes and ears of the rest of the treatment team. Sometimes the dialysis center staff have no idea what else is going on with the patient. It's the case manager's job to add clarification," she says.
Depending on the rapport she has established with the member, the case manager may ask to see the kitchen and bathrooms.
"They're looking at the food situation and how clean the home is. A lot of times patients have to choose to purchase food over medicine but they are too proud to tell us they need medication assistance," she says.
If appropriate, the case manager can call in a social worker to help get the patients established with community resources that can help with their needs.
During the home visit, the case manager asks the patients to bring out all of the medications they are taking and goes over each with them.
"Dialysis patients are on multiple medications and often need help in understanding which one to take at what time," she says. "Medication adherence is so important, especially with a population that is dealing with so many comorbidities."
Often patients were taking one medication when they were hospitalized and received a prescription for a similar medication while in the hospital and continue to take both, she says.
One patient brought out two shoeboxes full of medication dating back to 2003. Another, who was supposed to take 10 pills a day filled up a pickle jar with pills and randomly picked 10 to take each day.
In the case of patients whose confusion leads to major medication adherence problems, the DaVita VillageHealth case managers go to the homes once a week and put the medication in pill boxes to make it easy for the patients to become adherent.
"Dialysis patients often don't understand the complexity of their medications. We work with patients who are on as many as 16 medications, which are taken at different intervals, some with food and some on an empty stomach," she says.
In the case of the patient who took 10 pills a day at random, her albumin levels were off the scale and she had anemia, along with other problems. The situation had been going on for a long time but until the case manager visited the home, no one had noticeed, Walter says.
"Nobody had stopped to listen and hear what the patient was saying. Our case managers know that it's so much more important to listen than to speak. When the case managers stop and listen to what their patients are telling them, they can do a much better job of managing their care," she says.
Face-to-face contact is an essential part of managing the care of patients with end-stage renal disease, says Cristina Walter, MS, RN-BC, CCM, CCP, regional operations director, DaVita VillageHealth.Subscribe Now for Access
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