A Workshop Facilitated by
Glenda M. Payne, RN, MS, CNN
ESRD Technical Advisor,
CMS Regions 4 & 6
Dallas, TX
First, let’s talk about:
The basic ESRD regulatory
requirements for patient
assessments and plan of care…
Every Patient Must Have
 Individualized Patient Assessment
 Individualized Plan of Care
 By Interdisciplinary Team
 Done Timely
 Implemented
 Reviewed and Updated as Indicated
Who Is Needs to Be Involved?
IDT includes at a minimum:
 The patient or their designee (if the
patient chooses)
 A registered nurse
 A physician treating the patient for
ESRD
 A social worker
 A dietitian
4
Multidisciplinary Care vs.
Interdisciplinary Care
Multidisciplinary
Interdisciplinary
Work sequentially
Work collaboratively
Medical record is the
chief means of
communication
Communication by
regular discussions
about patient status &
the evolving plan of
care
5
Timelines for Patient Assessments
 New admits:
 Initially: Latter of 30 days/13 treatments
 Reassessment: 90 days after initial assessment
 Transfers/transients:
 If they come with: use that for 3 months, then
reassess
 If they don’t come with: 30 days/13 treatments
 Stable patients: annually
 Unstable patients: monthly
Who Is “Unstable?”
Includes but is not limited to:
 Extended or frequent hospitalization (>15
days or >3 X a month)
 Marked deterioration in health status
 Significant change in psychosocial needs
 Concurrent poor nutritional status,
unmanaged anemia & inadequate dialysis
7
When Must POC Be Implemented?
 First assessment: within the same
timeframe as the assessment (latter of
30 days/13 treatments)
 Any reassessment: 15 days after
reassessment completed
What About Stable Patients?
 If a “stable” patient’s outcomes do not meet the
care plan goals in an area, the facility must
recognize and address that aspect and revise the
plan of care accordingly between annual
comprehensive reassessments
“Monitor, Recognize and Address”
9
Take It To the MAT
 Measures Assessment Tool
 Current, professionally accepted
clinical practice standards of care at
your fingertips
 Common understanding of expected
targets/goals
Let’s take a look at the MAT…
What Do You Need to Document?
 Process for patient assessment
 Patient plan of care development
 Goals
 Timelines
 Plan of care implementation
 Plan of care review/revision
11
Where Would This Work Be Documented?
 Assessments
 Plan of Care
 Orders for treatment
 Interdisciplinary
progress notes
 Lab results
 Dialysis treatment
records
 PD flow sheets
and clinic notes
 HD treatment
records-pre/post
assessments,
monitoring
during treatment
12
Dialysis treatment records?
Home patients:
 PD – look at 1-3 mo flowsheets ; HHD - 10-15 treatments:
 Is the patient following dialysis prescription?
In-center Hemo - look at 10-15 treatments:
 Staff following dialysis prescription?
 BFR,DFR, dialyzer, dialysate, heparin, Na/UF profile
 Medications administered as ordered?
 Anemia management
 Mineral/bone disorder management
 Immunizations, ABT, other meds
 BP/ Fluid management
13
Documenting Implementation
 Patient Plan of Care
 Interdisciplinary progress notes
 Nursing
interventions
 Social services interventions
 Dietary counseling/education
 Referrals for rehab, vascular access,
etc.
14
Documenting Implementation
Patient education
Modalities/self-care, home
dialysis, transplantation
Emergency procedures
Infection prevention,
immunizations, personal care,
vascular access care
Home training
15
CfC: PA and POC
Two interlocked Conditions:
§494.80 Condition: Patient Assessment
§494.90 Condition: Patient Plan of Care
Corresponding requirements
Patient Plan of Care “uses” Patient Assessment
Doing either in isolation will not accomplish the
intended goal: Individualized Care
Correlation of PA & POC
PA
POC
Current health status (V502)
Lab profile (V505)
Medication/immunization history
(V506)
Incorporated into all POC tags
Appropriateness of dialysis
prescription (V503)
Provide adequate clearance
(V544)
BP/fluid management needs
(V504)
Manage volume status (V543)
Assess anemia (V507)
Manage anemia (V547)
Home pt ESA (V548)
ESA response (V549)
Assess renal bone disease (V508)
Manage mineral metabolism
(V546)
17
Correlation of PA & POC
PA
POC
Nutritional status (V509)
Effective nutritional status (V545)
Psychosocial needs (V510)
Evaluate family support (V514)
Psychosocial counseling/referrals/
assessment tool (V552)
Access type/maintenance (V511)
VA monitor/referral (V550)
Monitor/prevent failure (V551)
Evaluate for self/home care
(V512)
Home dialysis plan (V553)
Transplantation referral (V513)
Transplantation status: plan or
why not (V554)
Evaluate current physical activity
level & voc/physical rehab (V515)
Rehab status addressed (V555)
18
ESRDSurvey@cms.hhs.gov
Now to Let You Do Some Work!
 In order for you to demonstrate knowledge of
the link between the patient assessment and
the plan of care for that specific patient, and
 To identify critical components of the POC for
specific patients,
 We have created several case studies for your
“IDT” to use in developing or updating POCs…
Pitfalls to Effective PA/POC
 Doing great assessments; not doing a plan of care
 Not using the information gathered in the assessment
to develop the POC
 Not implementing the plan
 Not reviewing the results to see if the plan is working
 Not updating the plan to change or refocus the goal(s)
 Not monitoring the individual’s progress after
interventions are implemented
Discussion…