Is a Patient-Centered Dialysis Behavior Contract Possible?
Sometimes I read posts from social workers on the National Kidney Foundation’s (NKF) Council of Nephrology Social Workers (CNSW) listserv asking for a template of a “behavior contract.” Social workers want to know how to motivate patients to behave differently. Some dialysis clinics ask patients who exhibit challenging behaviors to sign a contract to avoid consequences. Examples of challenging behaviors include but are not limited to swearing or yelling out, arguing with staff or patients, skipping or shortening in-center or home dialysis treatments, not attending home dialysis clinics as scheduled, and not providing home records as often as requested. Establishing a contract implies that both the clinic and the patient will get something of value—the clinic will see a behavior change or if the behavior doesn’t change, there will be consequences for the patient and the patient will get dialysis. Some clinics threaten discharge and others have discharged patients for infractions that are not allowed reasons for involuntary discharge. If the clinic follows through on discharge, the patient may file a grievance with the ESRD Network and/or a complaint with the state survey agency, either of which could bring additional investigation of patient behaviors and clinic actions.
Staff need to understand that the Conditions for Patients’ Rights in the ESRD Conditions for Coverage (CfC) at 42 CFR 494.70(a) grants multiple rights. Among these are the right to participate as fully as desired in their care, to refuse or discontinue treatment, to be informed of ALL treatment options and settings, to receive services in their plan of care, to be informed of the clinic’s rules and expectations for behavior, to file an internal and/or external grievance without fear of reprisal or denial of services. Dialysis staff should recognize how hard it is for patients to file a complaint or grievance out of fear of being labeled as a “difficult patient.” Instead of viewing a patient’s complaint or grievance negatively, it could be helpful to listen to patients’ complaints and viewing grievances as opportunities for improvement.
The ESRD CfC also requires patients to be informed about policies for routine or involuntary transfer/discharge and to receive a 30-day notice of involuntary discharge unless he/she presents an “immediate severe threat.” The Interpretive Guidance, which helps ESRD surveyors determine the dialysis facility’s compliance with the regulations, describes what behavior rises to that level.
The Condition for Governance at 42 CFR 494.180(f) provides only four reasons to involuntarily discharge a patient and requires that the medical director “ensures that no patient is discharged on transferred unless--
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, in which case the medical director ensures that the patient’s interdisciplinary team—
In the case of immediate severe threats to the health and safety of others, the facility may utilize an abbreviated involuntary discharge procedure.”
(i) Documents the reassessments, ongoing problems(s), and efforts made to resolve the problem(s), and enters this documentation into the patient’s medical record;
(ii) Provides the patient and the local ESRD Network with a 30-day notice of the planned discharge;
(iii) 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;
(iv) Contacts another facility, attempts to place the patient there, and documents that effort; and
(v) Notifies the State survey agency of the involuntary transfer or discharge.
In most cases, the ESRD regulation above along with the American Medical Association’s Principles of Medical Ethics Section 1.1.5, effectively eliminates transfer or discharge as a consequence. Other consequences for challenging behaviors that dialysis clinics have used include shortening treatments, changing shift days or times, and requiring home patients to change from home to in-center dialysis. When these actions are taken without assessing contributing factors, it can lead to fractured patient-staff relationships, greater miscommunication, and worse outcomes.
Recently, several social workers have posted on the CNSW listserv that they, like me, believe behavioral contracts are not worth the paper they were written on. Some have suggested more patient-centered or less paternalistic punitive approaches to assuring both staff and patients follow rules. They believe developing an agreement that addresses goals and responsibilities helps make communication effective, respectful behavior possible, and desired outcomes achievable.
ESRD Networks have staff who are charged with helping to address challenging situations. Some ESRD Networks have posted documents including:
ESRD National Coordinating Center’s Decreasing Dialysis Patient-Provider Conflict Provider Manual, Tips on Cultural Awareness and Building Bridges
The Heartland Kidney Network’s Guide to Care Agreements: An Effective Way to Address Challenging Situations for the Renal Community
The Renal Network’s Health Care Team Agreements
Here’s an example of an agreement that dialysis clinics could use with new dialysis patients. We welcome your thoughts about ways to improve this draft, including when is the best time to present it to a patient and how to position it to get the most buy-in.
Download a copy of this agreement.