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Social worker Wendy Dan, Fresenius Medical Care
Social worker Wendy Dan, left, used interventions to reduce phosphorus in a group of patients at Fresenius.

Spirit of Excellence Award for Team Winner: Fresenius Medical Care North America, Waltham, Mass.

Breaking the cycle: Holistic approach boosts dialysis compliance

By Modern Healthcare
Posted: December 15, 2012 - 12:01 am ET

The failure of dialysis patients to undergo treatments as often and as long as doctors recommend causes them to end up sicker and back in the hospital sooner, decreasing their quality of life and increasing healthcare costs. But the very process of going through dialysis brings on stress, pain, depression, sleeplessness and strained relationships—all of which work against compliance.

To break that cycle and improve patients' quality of life, Fresenius Medical Care North America is rolling out an improved intervention process, piloted starting in September 2011, to more than 2,000 clinics serving more than 165,000 dialysis patients.

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The pilot, which has earned Fresenius the 2012 Spirit of Excellence Award for Team, resulted in improved compliance within six months for 76% of 732 patients, in 400 of the company's clinics, who were struggling with nonadherence. Designed by social workers, the intervention addresses the root causes.

“Any time anybody starts dialysis, they are going through a whirlwind of change,” says Dr. Dylan Steer, a San Diego-based nephrologist and medical director at Fresenius Health Partners. “They oftentimes become depressed and shut down and withdrawn. It's a difficult time for them, but it's also a time of opportunity to engage them in their healthcare.”

But social workers are often consumed with administrative tasks, and no one in particular takes ownership when it comes to engaging patients. “We realized the social workers were being underutilized for their true skill set,” says Greg Garza, vice president of operations support for Fresenius' West Division. “Most of the time, when we had patients who weren't showing up regularly, it was put in a general context: Mr. Johnson shows up late because he's moody.”

The program, designed by lead social worker Stephanie Johnstone and her staff, built clinical interventions to help reorient and re-engage patients, scaffolding their resilience in the face of adversities they face. This included, for example, a class on “Getting a Good Night's Sleep,” as well as communication and problem-solving training to reduce stress.

“We were amazed at their capacity to change,” Johnstone says. “They needed hope, and they needed direction. Once we provided that, they received it beautifully. Once we saw that [reaction], the more we propelled it.”

The organization needed to gain buy-in at every level so that, for example, front-line managers understood why they were asking social workers to perform different duties than they had handled for decades in some cases, shifting those tasks to secretaries, Garza says. “We were making sure we answered that question of, 'Why does this make sense for us?' In some cases, we got ahead of ourselves and had to take a step back.” The initiative is cost-neutral, Johnstone adds, based on the reallocation of time among the same staff that clinics always have employed.

Now, medical directors in other divisions can't wait to get started, Steer says. “It's really a case of, success breeds success,” he says.

“I was impressed specifically by the fact that it was not just about how they can make their job easier, but also ties back into the patient and looks at it from a very holistic approach,” says category judge Linda Jimenez. “It's not just about a specific issue that the patient was having, but everything that compounded that issue and ultimately had an impact on their disease management.”

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