Week 3 Discussion Post

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Dec 6, 2023

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DDHA 8051 Diefenderfer Week 3 Discussion Meet Pam. She is a middle-class working patient with a high school education residing in Wichita, Kansas. She has commercial insurance through her employer and has her family on the plan too. Pam started experiencing shortness of breath and edema in her legs and landed in the ER. She was found to have a history of type II diabetes and after lab work in the ER, it was noted her Creatinine was 6.5. She was diagnosed with End-Stage Renal Disease requiring hemodialysis three times a week. The emergently placed a CVC line to start dialysis and remove fluid on her heart and lungs. ESRD is not a disease that you can recover from. The kidneys no longer function properly or at all therefore the patient requires hemodialysis to clean the blood and remove toxins. The only possible way to partially recover is a kidney transplant, which is a long journey in itself with a 7-year average waitlist if you are approved after the workup. Even after the transplant, post-care and medication are required and they are not guaranteed to last a lifetime. This indicator shows the percentage of Medicare beneficiaries who were treated for chronic kidney disease in Kansas through 2018 (Kansas Health Matters, 2022). As you can see, it is trending upward over time. Now that Pam has been diagnosed with ESRD, she will require multiple providers to follow her care along with outpatient services and procedures. First, Pam will need to find a nephrologist to care for her kidneys as well as an endocrinologist to monitor her diabetes. The hospital is responsible for setting up outpatient dialysis services for Pam, so they will admit and assign her to a chronic DaVita clinic in her area near her home. Pam will have to attend her dialysis sessions at the facility three to four times a week. She will also need to go to the vascular access center to get vein mapping completed so they can then schedule a procedure for a fistula or graft placement. This shows the complexity of healthcare and more specifically ESRD (Shi, L., & Singh, D. A. (2019). There are several different types of dialysis modalities. Some are more beneficial for patients who are still employed. There is the outpatient dialysis setting in a chronic center, Home Hemodialysis and Peritoneal Dialysis. The dialysis outpatient centers are responsible for educating each new patient and all patients annually on modality options per CMS requirements (DaVita, 2022). Since Pam is an employed patient, she may choose to do the Home Hemo or PD dialysis at home in her convenience. Medicare is the federal health insurance program for persons aged 65 years or older, persons under age 65 years with certain disabilities, and persons of any age with end-stage renal disease (ESRD). (Kansas Health Matters, 2022). One of the eligibility requirements for Medicare Part A & B coverage is End Stage Renal Disease (ESRD). Once a patient is diagnosed with ESRD, they become eligible for Medicare coverage. Pam’s dialysis center Social Worker will help her start the process for the coverage. The center is required to completed a Medicare form called 2728 to inform CMS the patient has started on dialysis and they begin the coverage process which back dates to the first day of dialysis for the patient. Her commercial insurance will still be primary until 180 work quarters have been covered. There are assistance programs like the American Kidney Fund that help pay insurance premiums for ESRD patients and assist with other financial measures. The American Kidney Fund fights kidney disease on all fronts as the nation's leading kidney nonprofit. AKF works on behalf of the 37 million Americans living with kidney disease, and the millions more at risk, with an unmatched scope of programs that support people wherever they are in their fight against kidney disease — from prevention through post- transplant living (American Kidney Fund, 2022).
It will be difficult, if not impossible, to deliver patient-centered care without taking time to listen to our patients and build relationships with them. Upholding who they are will sometimes challenge us to move beyond our narrow role as specialists and re-imagine what constitutes good care. Putting these practices to work in the complex, fragmented, technologically focused health care environments in which many of us operate will not be easy, but in my opinion has real potential to improve the experiences of patients and providers (O’hare, 2018). The IDT team plays a big role in timely and patient centered cared too. Challenges : transportation, work/life schedule References: Institute for Healthcare Improvement (IHI). (2019a). Across the chasm: Six aims for changing the health care system. Retrieved from http://www.ihi.org/resources/Pages/ImprovementStories/AcrosstheChasmSixAimsforChangingth eHealthCareSystem.aspx Join us in fighting kidney disease on all fronts. American Kidney Fund. (2022, March 23). Retrieved March 26, 2022, from https://www.kidneyfund.org/ Kansas Health Matters, K. H. (n.d.). Chronic kidney disease: Medicare population . Kansas. Retrieved March 23, 2022, from https://www.kansashealthmatters.org/indicators/index/view? indicatorId=2056&localeId=19 Kidney disease and dialysis information . DaVita. (n.d.). Retrieved March 26, 2022, from https://www.davita.com/ O’Hare, A. M. (2018). Patient-centered care in renal medicine: Five strategies to meet the Challenge. American Journal of Kidney Diseases, 71(5), 732–736. https://doi.org/10.1053/j.ajkd.2017.11.022 Shi, L., & Singh, D. A. (2019). Delivering health care in America: A systems approach (7th ed.). Burlington, MA: Jones & Bartlett. Describe one organization/agency that would be involved in care delivery for your hypothetical patient. Provide specific details related to: o Types of patients typically treated at this facility o Administration o Departments
o Payment sources the organization accepts o Performance improvement efforts Briefly identify other organizations/agencies with which your selected organization is likely to coordinate in order to provide optimal care.
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