Ideas for better outcomes

[smartcookie]

My clinic is going through some changes and our numbers (lab values, catheter rates, etc) have been the lowest in the area despite staff education.  I am looking for some creative ideas that won't make the patients feel like children, but will encourage them to lower phosphorus, reduce fluid and gain some protein. 

I do have a program that is working for missed treatments right now, and have reduced our missed treatments to about 12% a month.  I put up a bulletin board in the lobby with a road on it marked in sections.  The first section is in red for missed treatments, the next is yellow for shortened treatments and the last is green for completed treatments.  I gave each patient a number and printed little jerseys with the number on it.  Each month, I put them into sections so they can visually see not only where they are, but clinic as a whole.  I put some tips to make treatment more comfortable (mostly ideas from here!) and a graph with the clinic numbers on it.  For the patients who completed all treatments without shortening, I put them in a drawing for a $10 Walmart gift card.  So far, it has worked pretty well and I haven't had any complaints. 

What sort of ideas do you have or things maybe your clinic has done to improve numbers?  My patients just seem so jaded and like they have heard it all before.  When I tell patients the dangers of calciphylaxis, I am told, "But I don't have that."  They don't listen to the part that you could in the future.  I am frustrated and looking for something new!

[kickingandscreaming]

Have you shown them photos of bones eaten away by excess phosph?  That's what did it for me.

I can't fault them for being jaded. Being a good doobie is tiresome.

[MooseMom]

Have you shown them photos of bones eaten away by excess phosph?  That's what did it for me.

Me, too.  A picture's worth a thousand words.  Print out all of the gory pics you can find.

[kristina]

What did it for me was my observing two dialysis-colleagues who let themselves go in a big way: they were constantly overstepping their liquid-limitations and they were also eating much more than was good for them ... and then ... all of a sudden ... they faded away ... very quickly ...  just like that ... 
Dialysis-treatments are "only" meant as a "rough" survival-treatment for people who would be dead without it, but since it is a harsh treatment, we also have to "pamper" our body to enable it to "put up" with it all.
For me it was most important to "put my body at ease" with an easy digestible vegetarian diet and the most successful way is to cook everything at home from scratch in order to avoid any salty food which would create problems by making one unnecessarily thirsty. Cooking everything myself at home enables me to really "stick" to my strict liquid-restrictions. It also helps me a lot to be a vegetarian ... 

[kristina]

... Another good idea for a better quality of dialysis-life is to go for regular walks in order to keep the body as fit as is possible...
... and ...  it also helps to "do" a few exercises i.e. arm-movements, careful little stretches, leg-exercises i.e. like cycling etc.
...  it all assists and also helps to feel a little less incapacitated by the dialysis-treatments ...
Good luck from Kristina.

[smartcookie]

Thank you for the ideas!!  We do have a calciphylaxis book.  The patients call it "the dirty pictures book."  All of our patients have seen it, and we added the most gruesome pictures we could.  I even have a patient who had calciphylaxis and beat it, but says that it wasn't her fault she got it.  She misses about three treatments a month and never takes binders.  I have educated her and thought I was making a difference, and she missed dialysis yesterday. 
My heart breaks for patients like her, because I know how much I would struggle if I had to be on dialysis.  She is a smart, capable woman.  She knows what to do, I just can't seem to encourage her to do it.  Dialysis sucks, and I cannot wait for those artificial kidneys to put me out of a job!! 

[cattlekid]

I am going to preface what I am about to write by saying that I realize what I am about to propose will increase your workload exponentially.  If you are like most social workers I have read about, you are stretched to the breaking point already so I am sure this is pie in the sky talk but I’m going to share it anyhow.

Here’s my idea from my time both in-center and doing home hemo:  for each patient, identify the top clinical goal. For Patient A, maybe it’s transitioning them from catheter to fistula.  For Patient B, maybe it’s getting their albumin to a reasonable level.  For Patient C, maybe it’s getting their phosphorus down.  Then have a discussion with each patient, letting them know what the benefits TO THEM would be for achieving the clinical goal.  Hopefully you can tie the benefits to a problem they are actually experiencing – make it real for them.  Then work TOGETHER to come up with 1-2 action items for the month.  Maybe for Patient A, an action item would be scheduling a vein mapping and then helping them get transportation to the doctor’s office to keep the appointment.  For Patient B, it might be asking them to add extra protein to breakfast each day and working with them to identify protein based foods they would like to include in their breakfasts.  Maybe for Patient C, it would be finding out what high-phos food or beverage they like and identifying accessible substitutes and where to find them locally.  Document the action items and both of you sign that the patient will work on the action item and you will be there to help them break down barriers to success. 

While this might seem daunting, what I am trying to describe is two-fold:  individualizing the goals by person (not something that is clinic-wide that is too generic to make a difference) and having the conversation be private and adult.

[MooseMom]

I am going to preface what I am about to write by saying that I realize what I am about to propose will increase your workload exponentially.  If you are like most social workers I have read about, you are stretched to the breaking point already so I am sure this is pie in the sky talk but I’m going to share it anyhow.

Here’s my idea from my time both in-center and doing home hemo:  for each patient, identify the top clinical goal. For Patient A, maybe it’s transitioning them from catheter to fistula.  For Patient B, maybe it’s getting their albumin to a reasonable level.  For Patient C, maybe it’s getting their phosphorus down.  Then have a discussion with each patient, letting them know what the benefits TO THEM would be for achieving the clinical goal.  Hopefully you can tie the benefits to a problem they are actually experiencing – make it real for them.  Then work TOGETHER to come up with 1-2 action items for the month.  Maybe for Patient A, an action item would be scheduling a vein mapping and then helping them get transportation to the doctor’s office to keep the appointment.  For Patient B, it might be asking them to add extra protein to breakfast each day and working with them to identify protein based foods they would like to include in their breakfasts.  Maybe for Patient C, it would be finding out what high-phos food or beverage they like and identifying accessible substitutes and where to find them locally.  Document the action items and both of you sign that the patient will work on the action item and you will be there to help them break down barriers to success. 

While this might seem daunting, what I am trying to describe is two-fold:  individualizing the goals by person (not something that is clinic-wide that is too generic to make a difference) and having the conversation be private and adult.

This is a brilliant idea.  Most people like to be thought of as "special" in some way, and dialysis has a way of making one feel like they're just another small and insignificant cog on a titanic size machine.  Having one on one talks with each patient to identify their particular obstacles to their particular goals may go a long way to making them feel more included in their own treatment.

[iolaire]

My DaVita dietitian gives everyone handouts with the lab values each month and the dietitian talks over the values.  But that being said I doubt that motivates the unmotivated.  Unfortunately I really don't know how you reach those people and I'm sure that's what makes your job very hard.  I'd suggest something like a personal morbidity forecast showing how getting X under control increase your odds of surviving by X years, but I'm sure that would offend the unmotivated.

[smartcookie]

We do initial, 90 day and yearly assessment and care plans, but I love the idea of having each patient to commit to something they can change, Cattlekid!  Maybe we can do a lobby day doing that and ask each patient to write it down.  We have a program call "Support a Patient" where techs are assigned patients to check with twice a month to address concerns and make sure patients are happy with their care.  That could be something we incorporate in that program.  I am going to bring that up with management and see what we can do!  Thanks for all the ideas!

Iolaire, you are so right.  Motivation is a hard thing.  I have to answer for missed and shortened treatments in the clinic, and it is always uncomfortable to ask a patient why he/she missed.  It makes me feel like I am scolding a child.  I have now started coming up to patients I know have missed and saying, "Hey, so and so!  I missed you a couple treatments ago!  Is everything okay?"  I am also trying to end conversations with patients with "It is always a pleasure talking to you."  Patients' faces light up when I say that, and it is true!  I enjoy talking with my patients and what I do. 

[cattlekid]

Question:  Why does it have to be a lobby day?  To me, that still isn't individualized enough.  To really move the needle, I think it has to be a targeted one on one conversation where you and the patient can really dig into the weeds of what the barriers are to meeting a goal and brainstorming actionable changes.  Not something that can be done in a lobby day. 

We do initial, 90 day and yearly assessment and care plans, but I love the idea of having each patient to commit to something they can change, Cattlekid!  Maybe we can do a lobby day doing that and ask each patient to write it down.  We have a program call "Support a Patient" where techs are assigned patients to check with twice a month to address concerns and make sure patients are happy with their care.  That could be something we incorporate in that program.  I am going to bring that up with management and see what we can do!  Thanks for all the ideas!

[smartcookie]

True.  Support a Patient might be a better way to keep it individualized and identify the correct staff member to help them. 

[Michael Murphy]

I try too be as compliant as I can, in 4 years I have never missed a treatment, never gotten off sooner and have usually good lab results.  And when my lab work shows a problem I start making changes to improve them.  Why it's not that I like being compliant but because I like to live.  Emory University has a app that calculates the mortality rate for dialysis patients..  Currentlly my mortality rate is 1 in 5 with a cadaver transplant its 3 in 100 with a live donor its 1 in 50.
These odds ain't good, however if you are compliant your personal odds go up.  Early in my treatment I was in a very rural center where in the waiting  room I heard patients arguing who missed the most treatments then and ther I understood the odds.  Miss and die, too mush fluid die,  high or low levels of phospherous or potassium die, compliance seems to be the narrow path that keeps you alive despite the odds.  This disease kills to many too soon with out helping it kill through noncompliance.  We are all involved in a fight for our lives and need every advantage to survive.  When the odds of winning are against us follow James T. Kirk cheat, the way to beat ESRD is to cheat by being compliant.

[Simon Dog]

With US standards for in-center, compliance assures you get "minimal", not "optimal" treatment.   3 days rather that qod is good for finances; bad for the patient.  Ditto for the FMC restrictions on the larger filter sizes.  Remember, CMS says you have a right to "adequate" treatment, not "optimal" or "best" treatment.

[Xplantdad]

Simon Dog...agreed...which is one of the reasons why we started home hemo.

It gave us dialysis that acted more like the kidney would (instead of one day on, one day off...one day on two days off...the whole yo yo effect of clean blood then dirty blood... and it being convenient for the dialysis center and not the patient). If we wanted to do 7 days in a row we could (and had the okay from the nephrologist) or if we wanted to skip a day ...we could as well. Since my wife has great insurance, the center was paid really well for us to do the dialysis.

As far as improving patients numbers , it's pretty much personal responsibility of the patient/caregiver of the patient to follow through..as long as adequate dialysis is being done in center and the techs are doing their jobs to the best of their ability 

[PrimeTimer]

According to what my husband hears at his clinic, some patients are just absolutely in denial and refuse to think that any of the "rules" apply to them. For instance, a woman who comes in 5 kilos over her dry weight refuses to believe that it has anything to do with fluid and that she doesn't need to limit her intake...and she says this while slugging down more coffee from her thermos and then yells at the techs when they tell her they can't remove 5 kilos in one treatment unless she wants to be there for 5 hours. Another believed that it felt far better to have high blood sugar than low blood sugar so he refused to take insulin and watch his sugar intake. He didn't survive long after his second leg amputation.

Meanwhile, I am willing to bet that many patients lack the support they need at home. Do they have someone willing to shop and cook healthy meals for them? When you feel sick and weak, it is very hard to even get yourself to a store much less come home and cook. Add children or other members to the household and it would be overwhelming to deal with your own illness while looking out for all of them too. Maybe some patients are the only one in the home who require a special diet and don't want anyone to fuss over them. Maybe a lot of them have already lost a great deal of their independence by having to live with other family members. They may not want to ask for any special meals to be prepared for them, already feeling a burden on their loved ones. And sadly, no doubt that some people are alone and have no one that can help them with chores, the grocery shopping and cooking but maybe have one friend who is willing to pick them up a cheeseburger and fries on their way over to visit. Applaud those who are compliant, dig a little deeper with those who are not. Everyone has a story. One-on-one conversations would probably help bring their story to light.

[smartcookie]

Definitely good advice, PrimeTimer.  I have a patient who misses and shortens her treatment a lot, but it turns out she has an elementary age child.  She has no one to meet him coming off the bus, so I put her on the waiting list for an earlier time.  Another patient has a bad relationship with his wife.  Even though she was working at the time, she required him to pay all the household bills, including his medicine, out of his disability check and thus he wasn't getting his medicine.  I had a patient who told me he was great all the time, but his labs were terrible.  A couple months go by and he is in my office crying saying he is actually homeless and living out of his car.  You really do have to dig.  Sometimes you have to wait on the patient to come to you when he/she is ready.  Other times you do everything but physically fix them meals and put the pills in their mouth, and the patients still have terrible labs and sign off treatments.  One of my biggest reasons I hear for signing off or not coming to treatment is diarrhea.  Can't say I blame them on that one...

[iolaire]

So I decided I should not post this on this tread so it could have its own discussion area, but a I started a new post Planning for the future – We need an advertising program focusing on the risks of over consumption

[Michael Murphy]

The homeless guy need to contact a lawyer and start divorce proceedings then his miserly wife would have to pay alimony, plus if they own a house he may be intitled to half its value. 

[PrimeTimer]

smartcookie: I applaud your commitment AND your efforts!  Your patients are surely glad you are there for them. You seem to look at your place in the clinic as more than just a "job". I love that in people!