Current literature supports the belief that hemodialysis (HD) services delivery is fragmented and redundant in the facilitation of the overall quality, co-ordination and continuity of patient care (Curtis, 2013 & Terra, 2007). It is also widely acknowledged that the lack of integrated frameworks and systematic approaches to patient care delivery have resulted in inconsistent care in many organizations.

In order to improve patient outcomes, hemodialysis programs need processes and patient care delivery models that reflect patient and family engagement through self-management, care continuity and collaborative partnerships. Given the chronic nature and multiple comorbidities of the HD patient population, follow-through and continuity of care remains an issue for many programs.  Many HD units struggle to keep track of the ongoing management of complex patient care needs. Most literature suggests the adoption of a “triad-concept” which addresses structures (how care is organized), process (how care is delivered and documented) and outcomes (how care helped the patient).

The Case Management (CM) approach to patient care delivery is a systematic approach to mitigate a negative patient experience. The overall goals of the model are to:
• Improve patient engagement and partnerships
• Maintain care continuity along the care continuum
• Improve staff accountability for patient care through inter-professional collaboration
• Leverage the concept of patient goal-setting and self-management

A dedicated case manager is assigned to each HD patient. The case manager ensures that care is coordinated and directed to those within the patient’s circle of care. The model involves standard work processes that: 1- Defines care tem members roles and responsibilities and  2- Outlines the repeatable steps and best approach to complete a task by defining “who does what, when and how” in order to reduce variation in care.

Each case manager’s is assigned to 5-8 patients. At the end of each patient’s six-weekly blood work assessment, each case manager reviews each patient’s hardcopy chart and completes the “Case Manager’s Checklist” and “Summary Sheet” tools in their electronic file. After each item of the checklist has been completed, the CM summarizes the patient’s experience over the 6 week period in their e-document.

The CM model was implemented over 2 years ago within the Hemodialysis Satellite Units. In the beginning, some staff were resistant; however by leveraging educational opportunities and highlighting patient care safety incidences and coordination of care experiences, staff now see the value in the process.

Contact Information:

Title: Patient Care Director – Nephrology and Diabetes; Patient Care Manager Nephrology; Clinical Resource Leader Nephrology

Contact information: edoyle@tsh.to; schan@tsh.to; jblack@tsh.to

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