Presentation about involuntary discharges from the dialysis units Given at ESRD Network 15 Medical Review Board

1. Involuntary
Discharges From The
Dialysis Unit
CHRISTOS ARGYROPOULOS MD PHD FASN
ESRD NETWORK 15 CONFERENCE CALL MAY 13TH 2019

2. Instead of an introduction …
https://www.kevinmd.com/blog/2017/01/involuntary-discharge-dialysis-health-care-practice-like-no.html

3. Overview
1.Involuntary discharges (IVD) in the
Conditions for Coverage (CfC)
2.Non-adherence and Involuntary
Discharges
3.Preventing IVDs

4. Involuntary
Discharges and the
CfC

5. Some old data about involuntary discharges

6. Involuntary Discharge (IVD) at a Glance
Should be the last resort in managing difficult patient situations
Even when it is done, it is not always appropriate
Appropriate situations are recognized in the Conditions for coverage §
494.180 (f)
Requires appropriate documentation and intervention before it is
implemented
It is the Medical Director’s responsibility to oversee all IVDs
The Network can help in managing difficult patient situations
before they escalate to IV

7. Patient rights and the IVD
Be informed of the facility’s policies for transfer, routine or
involuntary discharge, and discontinuation of services to
patients
If this does not happen the facility will be cited
Receive written notice 30 days in advance of an involuntary
discharge, after the facility follows the involuntary discharge
procedures
In the case of immediate threats to the health and safety of
others, an abbreviated discharge procedure may be allowed.

8. IVDs recognized in the Conditions for
Coverage
The patient or payer no longer reimburses the facility for the ordered
services;
The facility ceases to operate;
The transfer is necessary for the patient’s welfare because the facility can
no longer meet the patient’s documented medical needs; or
The facility has reassessed the patient and determined that the patient’s
behavior is disruptive and abusive to the extent that the delivery of care to
the patient or the ability of the facility to operate effectively is seriously
impaired
Failure to comply with instructions of a facility staff does not qualify as a
reason

9. The IVD Process
The IVD starts with the Medical Director who ensures that the interdisciplinary team:
1. Documents the reassessments, ongoing problem(s), and efforts made to resolve the
problem(s) in the medical record
2. Provides the patient and the local ESRD Network with a 30-day notice of the planned
discharge
3. Obtains a written physician’s order that must be signed by both the medical director
and the patient’s attending physician concurring with the patient’s discharge or
transfer from the facility
4. Contacts another facility, attempts to place the patient there, and documents that
effort
5. Notifies the State survey agency of the involuntary transfer or discharge.

10. Abbreviated IVD Process without a
30 day notice: serious threats only
Each facility should have a procedure for abbreviated involuntary discharge that
indicates:
1. Behaviors and/or actions will result in an abbreviated discharge (less than 30 days)
2. Notification of patient in writing regarding the decision to discharge
3. Placement assistance will be provided to the patient by the facility
4. Provision of a listing of hospitals providing acute dialysis care for interim dialysis care
until placement can be arranged
5. Efforts to be made to provide the necessary security at the facility (including those
made to provide ongoing dialysis care while placement efforts are undertaken)
6. Notification of the Network prior to discharge (discharge is not official until written
notification of discharge is provided to patient)

11. When a nephrologist discharges a
patient …
1. If the facility can find an adequate replacement, then the patient cannot
be IVDed
2. If the facility cannot find another nephrologist who will care for the
patient in the facility, the patient must be discharged or transferred to
another facility
3. In these situations the clinician who refused to provide care must avoid
medical abandonment
 Inform the patient they will no longer provide care after a “reasonable” period
 Make a “reasonable” attempt to place the patient into another clinician’s care
 “Reasonable” behavior standard : what a “reasonable person” would do under the
circumstances

12. Preventing IDs – the role of the
MSW/ IDT
Patients are to be assessed at least monthly when they exhibit
significant changes in
psychosocial needs
patterns of disruptive behavior (abusive language, physical
harms or threats of harm, brings weapons or illicit drugs in the
dialysis unit)
Patterns of non-adherence to recommendations which is highly
likely to lead to conflict with staff and disruptive behavior

13. Involuntary
Discharges and Non-
Adherence

14. Concepts for understanding non-
adherence
1. Patient has the right to refuse treatment (ethical principle of autonomy)
2. The provider has no statutory authority to deny treatment to non-
adherent patients
Legal cases related to non-adherence and IVD:
1. Payton vs Weaver (1982)
2. Brown vs Bower (1987)
 Both cases characterized by significant disruptive behaviors towards other
patients, facility staff and physician in addition to non-adherence
 Both patients were IVD for disruptive behaviors not for their non-adherence

15. Non-adherence and IVD
Failure to comply with instructions of the dialysis staff does not qualify as
disruptive behavior
Nonadherence may signify changes in needs that should be used as red
flags to devote resources/investigate the needs of patients
Grievances
Painful treatment
Adult care schedule conflicts
Work schedule conflicts
Travel problems
Inadequate understanding of consequences (need for education)
Cultural context for the behavior

16. Examples of non-adherence that
qualify or not for IVD
QUALIFIES
Shortened treatment times/missed
treatments only when it impacts other
patients’ schedules
Even in this circumstance the facility must
document that they tried to work around
the issue
DOES NOT QUALIFY
Failure to reach facility set goals (cannot
discharge patient for “screwing up
stats”)
Eating during dialysis
Not taking meds
Shortened treatment times/skipped
treatments when it does not impact
other patients’ schedules
https://www.cms.gov/Medicare/Provider-
Enrollment-and-
Certification/GuidanceforLawsAndRegulation
s/downloads/esrdpgmguidance.pdf

17. Preventing IVDs

18. Useful things to consider in your
facility to prevent IVDs
1. Acute/”unstable” care plan meetings when behavioral red flags
are detected
2. Behavioral agreements (‘contracts’)
3. Mental Health Services referrals
4. Pay attention to simple stuff: dialysis time/shift, changing
transportation arrangements, social security checks, assistance
with copays
5. Implementing the Decreasing Patient – Provider Conflict toolkit
6. Talk to the Network!!

19. The nuance of contracts
1. Can be used to formalize an agreement with consequences
to both sides in the event of failure
2. Provides a written record of a mutually agreed-upon solution
3. Cannot and should not be used as a prelude to IVD
 CMS & the ESRD Networks will promptly discount the value of the
contract
 It will not protect the facility from negative legal or regulatory
consequences

20. Decreasing Patient – Provider
Conflict Toolkit
1. Developed with funding from CMS
2. Based on collaborative efforts by content experts,
work groups and ESRD networks
3. Material designed for all levels of dialysis staff
4. Composed of tools and resources regarding
professionalism and conflict resolution
http://esrdnetworks.org/resources/special-projects/decreasing-patient-provider-conflict-dpc

21. “CONFLICT” Resolution Model
(DPC)
C -Create a Calm Environment
O-Open Yourself to Understanding
N -Need A Nonjudgmental
Approach
F-Focus on the Issue
L-Look for Solutions
I- Implement Change
C-Continue to Communicate
T-Take Another Look

23. DPC Glossary- Definitions
1. Nonadherence
2. Verbal/Written Abuse
3. Verbal/Written Threat
4. Physical Threat
5. Physical Harm
6. Property Damage/theft
7. Lack of Payment

24. DPC Taxonomy
“At Risk” Categories
Risk To Self Risk To Others Risk To Facility
Both Patients & Staff can do things that are a risk to themselves, others and the facility

25. DPC Glossary
1. Nonadherence: Noncompliance with or nonconforming to
medical advice, facility policies and procedures, professional
standards of practice, laws and/or socially accepted behavior
toward others (Golden Rule).
2. Verbal/written abuse: Any words (written or spoken) with an
intent to demean, insult, belittle or degrade facility or medical
staff, their representatives, patients, families or others.
.

26. DPC Glossary
3. Verbal/written threat: Any words (written or spoken)
expressing an intent to harm, abuse or commit violence
directed toward facility or medical staff, their representatives,
patients, families or others.
4. Physical threat: Gestures or actions expressing intent to harm,
abuse or commit violence toward facility or medical staff, their
representatives, patients, families or others.
.

27. DPC Glossary
5. Physical harm: Any bodily harm or injury, or attack upon facility or
medical staff , their representatives, patients, families or others.
6. Property damage/ theft: Theft or damage to property on premises of
ESRD facility.
7. Lack of payment: Refusal to maintain or apply for coverage or
misrepresentation coverage.

28. Algorithm for
resolving
disruptive
behavior.
Edward R. Jones, and Richard S. Goldman CJASN
2015;10:1470-1475

29. Bibliography
Emerging Trends in Discharging Disruptive Dialysis Patients: A Case
Study https://www.kidney.org/sites/default/files/v37b_a2.pdf
Difficult patient behavior in Dialysis Facilities
https://www.karger.com/Article/Pdf/494592
Managing Disruptive Behavior by Patients and Physicians: A
Responsibility of the Dialysis Facility Medical Director
https://cjasn.asnjournals.org/content/10/8/1470

30. Backup
THE DPC CONFLICT MODEL

31. Create A Calm Environment
“In order to effectively address a
conflict, you need to be aware of the
physical surroundings, as well as the
thoughts and feelings you are
experiencing because of the conflict”

32. Open Yourself to Understanding Others
“When addressing a
conflict, it is important
to acknowledge the
perspective and
feelings of the other
individual(s) involved”

33. Need A Nonjudgmental Approach
“As a dialysis professional, it is important
for you to maintain an objective and
professional approach as you address
the conflict. Keep in mind that words
exchanged in the heat of an argument
are often not intended as personal
attacks.”

34. Focus On The Issue
“When conflict occurs, there is a tendency
to lose sight of the issue that started the
disagreement. What starts out as a concern
about starting dialysis on time can quickly
become a disagreement about the facility
staff, the clinic operations, or the physician
care.”

35. Look For Solutions
“Not all conflicts can be resolved nor
are all conflicts based on valid
complaints. But working in
collaboration with the patient will
improve the likelihood of a positive
outcome.”

36. Implement Agreement
“If you take the time to
work through the conflict,
it is likely that you will
reach a stage of
agreement when changes
will need to be put into
action.”

37. Continue To Communicate
“Effective resolution of a conflict
requires follow up communication. This
allows you to monitor the progress being
made. And demonstrates to the patient
your commitment to resolving the
conflict.”

38. Take Another Look
“Handling a conflict, like successfully performing
dialysis related tasks, requires practice, understanding,
education, and monitoring. Regardless of whether a
conflict is minor or major, reviewing the steps used in
addressing the conflict will be beneficial.”