Kidney disease and other chronic conditions can be some of the most difficult illnesses to manage. Patients are left to navigate a diffused health care system, juggling between their primary care physician and interprofessional team of specialists, often leading to inconsistent care and disengaged patients. In response, staff and physicians in Scarborough and Rouge Hospital’s (SRH) Regional Nephrology Program have redeveloped their model of care to improve haemodialysis patient care outcomes using a new case management approach to care.
The new Case Management Model assigns each haemodialysis patient to a dedicated registered nurse case manager who works directly with the patient to ensure all aspects of their care are coordinated and that others involved in the patient’s circle of care are appropriately involved.
“Many are mistaken in thinking that a patient’s circle of care is limited to health care professionals, but it also actively involves the patient and their family,” said Ethel Doyle, Patient Care Director, Nephrology.
“The Case Management Model defines the roles and responsibilities of all care team members so that, as an example, patients know that it’s their responsibility to alert others of their symptoms, just as much as it could be their family member’s responsibility to drive the patient to their appointment.”
Each case manager is assigned five to eight patients to meet individually on a six-week basis as part of their caseload. Together, case managers and patients review the patient’s chart and personalized progress card, which tracks health outcomes and measures such as weight gain and potassium levels, using red, yellow, and green stickers to easily show patients how they’re functioning within healthy parameters. During the discussion, case managers also assist their patients with setting self-management goals to address any concerns or challenges related to their health care, which are followed up on at the next meeting.
The previous Primary Care Model used to deliver patient care was ineffective. The model lacked continuity of care by assigning patients to nurses based on their daily workloads, which was extremely difficult and often impossible to manage due in large part to stretched resources and a growing patient population. This new Case Management Model provides patients with one point of contact to answer questions directly related to their kidney disease, as case managers are required to actively review their patient’s charts during the six-week cycle without needing to actually have the patient as part of the larger nursing team’s daily assignments. This ensures that all aspects of the patient’s care plan have been completed, tracked, and followed up on where appropriate.
The case manager/patient relationship has flourished through the new model of care leading to greater staff and patient satisfaction.
“Lisa, my case manager, is an excellent nurse. Not only does she provide superior care, but she helps me to identify areas that I need to work on to improve my health and well-being,” said Mr. Haniff Mohammed, a haemodialysis patient receiving care at SRH’s Yee Hong satellite dialysis site.
And Mr. Mohammed’s not the only one talking about the program.
“It has become a conversation piece among patients while they wait for their dialysis treatments,” recalls Serena Chan, Patient Care Manager, Nephrology. “I have heard them discussing how many green, yellow, and red stickers they’ve received on their reports, and it’s satisfying to know that we’re really making a positive impact and effectively engaging our patients in their care.”
The Case Management Model has seen tremendous results since SRH began implementing the program two years ago at the Yee Hong satellite dialysis site. In a recent patient engagement survey, 93 per cent of respondents felt they were more informed and motivated towards health care goal-setting and goal attainment since beginning the case management approach, and 89 per cent felt more knowledgeable about the influence and effect their involvement has in their health care. In fact, it was recently recognized as a leading best practice by Accreditation Canada.
SRH continues to expand the Case Management Model approach to haemodialysis care to all of the hospital’s sites and is scheduled to achieve full implementation throughout the haemodialysis program in Fall 2017.