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 staff's 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.
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, bedside 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.
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 accomodated, 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.