New CMS Reporting Requirement for 2016: Clinical Depression Screening for Dialysis
Medicare wants to be sure that clinics assess dialyzors for clinical depression at least annually. Why should you care if your patient is depressed? Depression can lead to behaviors that affect dialysis outcomes, including skipping and shortening dialysis, fluid overload, forgetting to take medications, and substance abuse. While research has shown that depression increases the risk of hospitalization and death, it is still underdiagnosed and undertreated in people on dialysis.
Dialysis clinics must screen eligible dialyzors age 12 or older and those who have been on dialysis at least 90 days for clinical depression (both as of October 31, 2016 before February 1, 2017) using a standardized screener once between January 1, 2016 and before February 1, 2017. There are several standardized screeners, but two that are validated for all ages include the PRIME MD PHQ-2 and the CES-D. Facilities that opened before July 1, 2016 and those that treat more than 11 dialyzors will get a score for depression screening and follow-up that will be used with other QIP measures to determine the facility’s payment for 2018.
To comply with this new requirement, dialysis clinics will report in CROWNWeb one of these conditions for each eligible dialyzor at least once between January 1, 2016 and before February 1, 2017:
- Screening for clinical depression is documented as positive, and a follow-up plan is documented.
- Screening for clinical depression is documented as positive, a follow-up plan is not documented, and the facility has documentation stating that the patient is not eligible.
- Screening for clinical depression is documented as positive, the facility has no documentation of a follow-up plan, and no reason is given.
- Screening for clinical depression is documented as negative, and a follow-up plan is not required.
- Screening for clinical depression not documented, but the facility has documentation stating that the patient is not eligible
- Clinical depression screening is not documented, and no reason is given.
In # 2 and 5 above, examples of patients who are “not eligible” could include those who already have a diagnosis of depression or bipolar disorder or limited functional capacity that would invalidate the results, patients with urgent or emergency need that any treatment delay could risk their health, or those who refused to complete the survey.
So far as the plan for a positive screening for depression, a CMS presentation suggested such things as “additional evaluation for depression, suicide risk assessment, referral to a practitioner who is qualified to diagnose and treat depression, pharmacological interventions, other interventions or follow-up for the diagnosis or treatment of depression.”
The medical record should indicate the depression treatment:
- Goal - e.g., reduce depression as indicated by score on depression screener.
- Plan - e.g., provide counseling or refer for counseling.
- Timeline - e.g., reassess in x months.
- Outcome - e.g., score on depression screener shows improvement and patient reports improved mood, etc.
If a patient screened positive for depression but there is no plan to treat, the dialysis staff should document why not, (e.g., treatment is not appropriate, treatment is medically contraindicated, etc.) If there was a plan and the goal was not achieved, the IDT, including the patient, should revise the plan to address barriers.
Speaking of barriers, research has shown that most people on standard in-center HD who are referred to outside mental health providers choose not to go. Why would they? They’re already spending 3 days a week at dialysis or recovering from dialysis. Adding another appointment with a person they have to establish a relationship with and tell their whole “story” seems too overwhelming. They may have a hard time finding someone who accepts Medicare, and if they don’t they worry that they may have one more bill to add to their stress, which could be contributing to depression. They may worry about how having a diagnosis of depression in their medical record and how that will affect their future, transplant listing, jobs, etc. And those concerns don’t even count having to deal with society that stigmatizes depression and other mental illness as “weakness.”
There may be another way. What about making sure that people with kidney failure are using the treatment option and setting that allows them to enjoy the highest quality of life?
- The dialysis social worker should be able to provide brief supportive counseling to address depression at no additional charge, or can refer to a community mental health provider.
- Dialysis facilities should make sure the social worker’s license includes counseling and give social workers sufficient time to provide it.
- The nephrologist and team can review patients’ symptoms and make appropriate changes in diet, medications, and the dialysis prescription that might improve symptom management and reduce depression.
Depression is one of those areas where “it takes a village.” The social worker or any other individual team member can’t do it alone.
I always worry that too many dialyzors identify themselves as being a “dialysis patient” rather than being “someone who needs dialysis to live a full life.” How many isolate themselves when they could be out and about with friends or family, working even part-time, volunteering, or doing anything to build their self-esteem? What barriers prevent them from doing things that could counter depression? Can the dialysis team help dialyzors identify and overcome those barriers? It’s important to help dialyzors to see themselves as survivors, not victims. I’ve said before that people live up or down to our expectations. Yet too many staff view dialyzors as dependent, helpless, and worthy of pity. How would that make anyone feel?
Want to know more? Read the technical specifications for all the measures for performance year 2016 including the reporting measure for Screening for Clinical Depression and Follow-Up, look at the Federal Register describing this new measure, watch the CMS presentation, and search PubMed for research articles on depression in dialysis. When I looked, there were over 1900 articles.
Comments
Robin Franzi
Mar 09, 2016 11:04 PM
I sat in a dank room for weeks on end and re-lived each horrible moment. I forced myself to go to session when I probably should have rested, as my sense of responsibility is strong. I feared being labeled non compliant. I was told to meditate, to pray, to come to a group and tell the story one more time. The advice had not changed in decades. All that was offered was this re-living of the trauma. Little focus was on coping skills or moving forward in any productive way – identifying peers, finding hidden skills, challenging one’s self, etc. were never concepts offered by counselors, I am pursuing them for myself.
Here is yet a perfect example of another industry lacking evolution as well as an ample supply of qualified workers. It took a toll, going to treatment then repeating the experience over and over again, while in the throws of fighting for my life, as any dialysis patient will convey. My life went from including an active career, hobbies and friends to dialysis, doctors and depression.
And the drugs! Of course, I was told I would be non-compliant if I did not take debilitating SSRIs. I had to "prove" that these were of ill effect; my word was not sufficient for these gatekeepers. We are not adults here. Time of my life, lost work opportunity, declining health – proving myself to these people. Well-meaning, but ill prepared people who were less than qualified to truly be of help in this situation with this archaic model of psychiatry. I truly believe and fear that, coercing and intimidating patients who are in that initial transition and dealing with the subsequent emotional fallout may be subjected to – and inappropriately – this brand of psychiatry with its’ dysfunctional drugs and junk science. I fear a patient may worsen under this model, as it is ineffective. I fear more well-meaning intentions will translate to more harm than good under the current model in the U.S. There is plenty of literature to support the idea that conventional psychiatry can indeed be harmful in this very way - particularly in more recent times.
And, while the above proposals are well intended and even welcomed, perhaps as a functioning adult until ESRD, I have had and still have a full plate of activities to pursue without having a social agenda selected for me? Perhaps I would prefer to use my dialysis time researching my disease, corresponding around the world, catching up on a bi-coastal phone call, or in some other way than repeating the genealogy project I conducted a decade ago or any other chosen craft or social activity? We choose activities for children in society. Generally, adults have a choice.
Perhaps, as someone whose mortality looms daily, it would be of benefit to me to focus on my health and energy (stable hemoglobin management, agreement on adequate dialysis schedules, understanding the alchemy of dialysis and the relationship to my lifestyle and dietary choices, or correct medical information and support that is available and accountable.....) so that I exist tomorrow to greet the day I am working so hard to meet? All of this dribble is of no use if my organs are being systematically damaged by less than stellar treatment and any hopes and plans for the future are negated by declining health?
The dialysis industry is so focused on looking for a band-aid to fix the horror show that this assembly line model has turned into for its patients, that it forgot that it was in the business of health care to begin with - a business that has traditionally carried a higher ethical standard and consideration for the patient. This has changed since the inception of the hippocratic oath, and patients are now seen as either profit centers or guinea pigs rather than thinking adults who have choices to be respected. As in many areas of life, our individual rights are under assault here.
Personally, while I applaud ANY positive attempt at change, I as a patient do not need a community center, a genealogy class, or a social network supplied for me. While I do not oppose the idea of a community center or any resources that could help someone, I fear the cart is being placed before the horse. I am a thinking, functioning adult who prefers to choose how to spend her own precious remaining time on this planet in her own way. And just because I am tethered to a dialysis chair does not make me a lab rat. That time and my mind are still my own, on or off the chair.
I don't need to be managed or monitored, I need to be respected and heard. For example, currently I am in need of an alternative or treatment to provide relief from a common allergy. I have been pursuing help for literally years. If we can't treat a straightforward allergy and so many other issues with implementing what we currently have, it is useless to add more programs when the existing infrastructure is completely broken. As I have continuously heard, at least in this country – yes, that’s a great idea, but – where’s the money coming from?
• Until the patient's well being is considered in the equation of kt/v's and reimbursement schedules;
• Until the patient is HEARD (as it is, after all, his or her body);
• Until doctor's financial incentives for income don't directly oppose a patient's health interest(s);
• Until patients are treated with dignity and respect and we return our system to one of reason and humanity --- none of these other things will yield lasting, tangible results – if that’s what we’re after.
I have come to realize that, sitting in a dank office and re-living the horror that Henning so aptly referred to was fueling my depression rather than alleviating it. I have since released the counselor and joined a co-op garden, so that I can move my stiff muscles, breathe fresh air, get outside and grow healthy food. I dropped the poisonous anti-depressants long ago. Whether you call the depression situational or clinical, when someone is yanked from the prime of his or her life and tossed into a dialysis chair for the foreseeable future, it’s going to be a difficult adjustment.
Physicians and providers can be overly cavalier about the emotional toll the chair takes. How about, instead of bells and whistles, dog and pony shows, lobbyists and trade shows, propaganda and jargon - we start to consider being accountable for a standard of care that provides the possibility of a return to a quality of life? The remedy for depression is not in a pill or a checkbox, folks. It is in the form of another four-letter word. HOPE. Hope comes in many forms, including being able to trust that when you see your doctor or nurse, that they have your best interests at heart and aren’t distracted counting pennies and germinating social activities. Could dialysis centers be more pleasant? Yes! But, as I wither away and evaporate from inadequate or poor dialysis, these efforts will mean little to me in the end.
Wayne Renn
Feb 25, 2016 5:05 PM
As others have posted, the literature is replete with studies that have found depression to be significantly more prevalent among incident chronic kidney disease patients that have initiated in center dialysis treatment than in the general population. However, as with assessment of any medical or mental health disorder, it is essential that the evaluation include some consideration of differential diagnosis in order to design an effective course of treatment. More specifically, its important to determine whether dialysis patients are presenting symptoms of clinical depression or what is now defined as adjustment disorder/stress response syndrome more informally referred to as situational depression.
Having only reviewed several of the 1900 articles mentioned, I'm by no means well informed of the conclusions drawn by each of the studies. However, my anecdotal experience working with dialysis patients and some amount of intuitive sense, lead me to believe that a large percentage of patients presenting with symptoms associated with a depressive disorder are more likely to meet the diagnostic criteria of adjust disorder/stress response syndrome rather than clinical depression. Indeed, types of stress known to trigger such a syndrome include developing a serious illness (yourself or a loved one) and undergoing a major life change, both of which easily describe the event of loss of kidney function and the need to start dialysis in a treatment facility.
I wholeheartedly agree with others that requiring the use of well validated screeners to determine the likelihood of situational depression in dialysis patients is not necessary. In my opinion, its not much different than screening cancer patients for the presence of mood problems. In both cases, its likely that you would be just as accurate in assessing the likelihood of situational depression by simply asking a person if they are on dialysis or if they have cancer. My guess is that the false negative rate would be relatively low.
Back to Ms. Angelou. Perhaps the analogy of changing the situation for in center dialysis patients would include the option of home therapy as suggested by Mr. Rosenbloom. I'm reminded of the recently retired male patient admitted to the in-center dialysis clinic presenting a text book set of situational depression symptoms, clearly discouraged and feeling hopeless. He was evaluated for Home Hemodialysis Therapy and found to be a suitable candidate. Within 24 hours of initiating training, most, if not all of his depressive symptoms lessened and were virtually gone by the time he completed his training. Of course this is only one case and a change to home treatment can be, in itself, a stressful event for many patients. I do believe, however, that each of us can recite similar experiences where a change from in-center to home treatment resulted in positive mood changes.
As for changing the way we thing about dialysis treatment, the previous bloggers provide an excellent description of how shifting our thinking towards creating a more therapeutic sense of community and committing considerable resources aimed at developing a "positive social experience" would be crucial steps for providers to take in truly having an impact on reducing situational depression in patients and there families.
Beth Witten
Feb 26, 2016 8:42 PM
Many patients I worked with tried to hide their feelings and act as if they were feeling OK. Staff accepted what they saw at face value and questioned my assessment when I reported that patients appeared to be depressed. Screening and identifying a patient as being depressed, even mildly depressed, can provide the evidence the team may need to get everyone on board to address the suffering that patients may feel.
One thing about situational depression in people on dialysis or those with CKD is that if the trigger (chronic illness, need for regular treatment) can't be changed, learning new coping skills can help. That said, it doesn't let the doctor and/or dialysis staff off the hook to prescribe the best treatment possible that's individualized to the person and to offer dialysis in the safest and most pleasant environment (home if possible).
In my opinion, people generally live up or down to our expectations. We cannot allow low expectations to keep us from doing what we can to help more patients feel less depressed and more hopeful. Ways to do that must be individualized to the person, which means that staff need to take the time to know their patients. Sadly, in US dialysis facilities time is at a premium. But the payoff from taking the time is HUGE.
Henning Sondergaard
Feb 15, 2016 9:31 PM
I live in a country that traditionally lived on pig farming and we have an old adage that goes something like this: You don't fatten the pig by weighing it constantly. And that is what I feel on this issue. It's not going to help a single dialysis user one bit that CMS require staff to measure depression. What we need to look at is why depression is so prevalent in our dialysis population. And I think it's safe to say it's the environment. Depression is like the canary that miners took into the mine so they knew to get out as soon as the canary croaked. It's a sign that the way we do this kind of treatment is unhealthy and wrong.
We need to turn the "business of dialysis" upside down. Start by asking what it is people with stage 5 kidney disease (not ESRD) want out of life and what they are willing to do to get it. Then we need to make units into something pleasant and not houses of horror. We need a whole new approach to treatment where people actually feel better - also in between their treatments - that might mean they have to dialyze as long as it requires for them to feel better (remember, what do people want and what are they willing to do to get it?) We need to send all the people home that are able to go home so only the most infirm are in the clinic ever.
So forget about measuring depression. We know it's there. And we know there's a good reason for it to be there. I would go so far as to say, those in a center who are NOT depressed probably need a check-up from the neck-up.
John Agar
Feb 16, 2016 11:48 AM
But, your sentence " ... we need to make units into something pleasant and not houses of horror" caught my eye. We, briefly, tried to do that (and with huge success) back in about 1991. Indeed Rosemary Heintz, one of our senior dialysis nurses, presented it for us as an accepted abstract here at the RSA in Oz but, to my shame, there was no follow-up paper. We had a retired professor - a charismatic teacher with the University of the 3rd Age - visit twice a week to teach/educate/enthuse/taunt/encourage/interest our patients during dialysis about things geneaological ... showing how to trace family histories ... setting homework ... engaging and leading patients to explore their roots.
It was magical. Reams of data began to accumulate. Patients almost seemed keen to come in to the unit for the dialysis - which almost became secondary - as they tumbled over each other to tell what they had discovered in their dialysis down-time. OK ... perhaps I exaggerate a little ... but you get my drift. The mood change was palpable.
Sadly, he fell ill himself, could no longer attend, and the program fell into disuse as we were (at the time) unable to replace him. I always regret not re-kindling that program ... but there is just so much each of us can do.
Perhaps the money that might go to the 1901st and 1902nd study could better be spent on small stipends - across the country - to support similar charismatic teachers to start similar activity programs to (1) pass the dialysis time (2) enthuse the dialysis patients with something other than 'their house of horror'.
Just a thought.
David Rosenbloom
Feb 14, 2016 2:07 AM