EPIC Podcast: Kareecha Thomson

Join Yessi Cubillo, a Quality Insights ESRD Network 3 Patient Engagement Specialist, and Kareecha Thomson, a Social Worker with DaVita Perth Amboy, as they discuss the implementation of the "My Dialysis Plan" in patients' plans of care.

Learn more about Quality Insights End-Stage Renal Disease (ESRD) Network 3.

This material was prepared by Quality Insights Renal Network 3, an End Stage Renal Disease (ESRD) Network under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication No. ESRD3-101123-GK-C

Transcript

welcome to the third episode of the

empowering partners for improved care

epic podcast in each episode you're here

informative interviews about patients

family and staff engagement initiatives

including barriers Improvement practices

that may impact your own interventions

uh I yes it could be you

uh will be your host today I'm the

patient engagement specialist for ESRD

Network 3 and I have the honor today of

welcoming Our Guest karisha Thompson who

is a Sabrina social worker at the Rita

Perth Amboy uh together we're going to

talk a little bit about a facilities

implementation of the my dialysis plan

as an integral component of the plan of

care

hello karisha how are you thank you for

joining us today hello yesi good morning

I'm good

it is

to be here today and uh Javier as our

guest in in today's podcast so thank you

thank you so much for you know agreeing

to be a part of today's discussion and

I'm very very excited

um but karisha before we begin and we

start talking about all this craziness

that craziness that comes with uh

um a plan of care and my dialysis plan

and all of that uh can you tell me a

little bit about

um and tell the audience the the

listeners a little bit about your

experience as a real social worker

okay sure

um well I'm new to Davida I started

March 2021 right after the pandemic

prior to that I spent about five years

six years at Robert Wood Johnson in New

Brunswick

and I was working on the Nephrology

floor and then prior to that I had about

10 years experience in Brooklyn working

at three different dialysis clinics

throughout that 10-year span

um but I wanted to get back to my

dialysis Roots so I

um closer to the end of the pandemic I

said you know the hospital is is just

too much for me right now I want to get

back to dialysis and there was an

opening in DaVita close enough to my

home and so I said you know what let me

get back and I'm happy I did it awesome

awesome man I I know the the with you

know with everything that's going on

with Staffing shortages here and there

and it's very much appreciative to have

that drive that you want to go back to

you know being with patients in the

dialysis center

um so it is very much appreciated to to

have you you know doing that work

directly with patients so thank you

thank you so much and I'm very excited

actually it came up as uh you know I was

trying to identify a facility that had

been doing some of this work with my

daily analysis plan and the plan of care

and I I had a couple and then I kind of

reached out to you and the minute you

and I started talking it was like wait a

minute I wish I was recording this

already

this is like perfect for for our podcast

so I appreciate once again the fact that

you decided to to be a part of this and

and be a guest with us today so with

that being said today we're going to

cover three areas the first one is first

impressions of the my dialysis plan your

team's drives and actions to overcome

challenges with this tool and

implementation and the Lessons Learned

uh and what to avoid as a facility

adopted this to us you're a facility

adopted the tool so I I want to start

with the very first question and um and

and I want to I want you to be sincere

one just be honest how long has it been

since your facility was first introduced

to my dialysis plan to the my dialysis

plan and what was your teams as well as

the patient's first impression of the

plan and be honest if if you want me to

look around

really honest with this but you know I

wanna I wanna I want everyone to kind of

say wait a minute that's exactly what

I'm going through but that's exactly

what I went through uh and a lot of

people are gonna probably uh relate to

some of the things they have to say but

go ahead I I'll let you kind of share a

little bit about it okay speaking

candidly obviously we dialysis social

workers as well as the interdisciplinary

team we have a lot going on and um when

we first got the plan it was about fall

about this time last year I think

October or so we got the email and it

was just another email it's like oh no

there were many components

um the first email had like different

themes or different schools of practice

that

we would need to implement into our care

plan meetings and when we hear this it's

like oh not another one like how do we

do this now and it's the end of the year

and on top of every other projects that

we're working on it was uh it was it was

hard

it was hard

um but I volunteered to read through the

whole thing for the IDT and there were

different schools of thought as I was

saying and the one that resonated more

as a tool that we can Implement was

um the University of North Carolina at

Chapel Hill which is the one that you

guys ended up choosing on the website

that's now on your uh website and we

chose that one although it's not in

Spanish and 65 percent of our Perth

Amboy patients are Spanish only speaking

Spanish

um

we we thought that it was a little bit

more easier to implement they had all

the tools ready to go

um they had an invitation that was a

little different from the current

invitation that we use

um offering the patient whether it's

chairside or on the phone in person

conference including them

um to offer a family member if they

wanted a caretaker to come by or be on

the phone with them we tweaked our

invitation towards that uh we also saw

where they had the brochure so it was

something we could print out and give to

them and say this is what a care plan is

my dialysis plan what do you want out of

this

um so that model or the University of

North Carolina Chapel Hill that one is

the one we decided so I took it to the

IDT meeting with my team and they were

like how are we gonna do this and I was

like guess what a binder we get another

binder

I mean we have so many partners guessing

it's a mess

um so we made a new binder

and in this binder we put all the

components the the brochure explaining

what's the care plan they had a script

for the staff how do you start this

conversation which I truncated and made

bullet points so it's easier for us to

use

um they had their own invitation which

we already had we tweaked it a little

bit

but then it was like uh how do we

tell the whole clinic now that this is

something new so we said let's do a

bulletin board

so we did a nice pretty bulletin board

and it was broken up into three I took a

picture I was so proud I put it on on my

book this is my big thick binder oh no

oh wow

right so I took a picture it was full so

it's got the fall leaves on it yes yes

and it's broken up into three and it's

you know on the left side keys to your

well-being this is the stuff that you

guys the network CMS what we want what

our staff and doctors look at so we want

the hemoglobin and we put the range

where do we want the hemoglobin and then

we have a nice little blood droplet

we say for the heart what do we want for

the heart what access the attendance we

want uh protein your albumin levels pth

and calcium and and uh phosphorus where

do we want your

um those lab levels and

on this side what's important to you I

want to spend more time with my

grandkids you know I want to travel I

want to transplant I want to walk the

dog I want to lose weight or gain weight

and then these are their conversation

Bubbles and then in the middle how do we

get there this is what we want this is

what you want where do we meet in the

middle right so it says let's create a

plan

I love this I mean like honestly this is

awesome

that's exactly that's exactly what the

plan aims to do but go ahead go ahead

keep telling us about so that's how and

it's in front of our scale so as you're

weighing you look up pretty colors here

we are what is this new board and then

of course for every patient that's due

that month we introduce the care plan we

give them that brochure

you know this is what a care plan is

this is what we want this is how we want

you to talk about it here's some things

you could think about is this important

to you or not and then we give them the

invitation when do you want this done

how do you want this done and at the end

of the month we meet with them and we go

over

each bullet point now granted in this

community a lot of people just come in

and go home they get their treatment

that's it

they don't care what happens in between

so it was hard and a lot of people did

not want to participate you know so that

was a little bit of a challenge but

that's how we decided we were going to

roll it out for our team

I I mean that that's exactly what what

um what I expected to hear first of all

because uh every facility has their

first impression when they see oh the

network is giving us another another

project another another thing another

thing we have to do like we got to

create another binder for another

project that we're doing when ultimately

and and I have this discussion with

facilities and I say to them this tool

is not additional work that we're given

to your facility this tool it's meant to

assist you in connecting exactly as you

did you envisioned exactly what we were

trying to convey this is what the my

dialysis team the into this

interdisciplinary team brings to the

table this is what we want you to

improve this is your outcomes and what

we discussed with you in my plan of care

and everyone from that team has a voice

the doctor the nurse The dietitian

Social Work everyone brings a little

piece to that component that left side

of the table as you may as you may say

now what is it that the patient wants to

to bring to the table and what what is

their voice saying to us and how can we

connect the two and give it a proper

follow-up even after the plan of care

has has taken place how can we give it

that proper follow-up and so that my

dialysis plan that's what I loved about

that tool that it kind of it connects it

all and it gives you those additional

tools that you've been using to to help

your team kind of guide that discussion

to guide the process that is not meant

to replace anything that you have but

it's meant to improve on what you're

already doing with your with your

facility which I clearly see that your

team has been able to do uh in this

scenario so I I I commend you guys for

such great work and and you know it

wasn't as bad as I thought it wasn't so

bad

but that's great and I love I had not

seen that picture you know for for those

listening I had not seen that picture

that you shared with the teams the

interdisciplinary teams goals on on one

side patience goals on the other side

and how with the my dialysis plan can we

merged it to I love love that idea so

thank you so much for sharing that

um and you mentioned the other thing is

you mentioned patients take on this

um a lot of the things that I also hear

is patients just want to come in they

get their dialysis and then go home like

you know they don't want to spend extra

time with the plan of care they don't

want to spend extra time listening but

then you also have on the other hand a

group of patients who is very much

interested in being part of that care a

group of patients who who want to be

more informed informed as to what is

happening with their care and what and

how they can impact their own care and

so I think those patients may even help

in the future help drive that same

attention with other peers in their in

the dialysis center and we we aim to do

that with other projects that we are

implementing but

um that that idea that that now you have

a tool that is is my tool the dialysis

plan is mine it's not the dialysis

facilities it's not the social workers

it's not the dietitian the doctors is my

tool that my team is giving me feedback

on and we have established a process

that we can follow or plan that we can

follow on after my plan of care meeting

so I I love that that's great

um and you talked about you know how you

guys overcame some of those barriers and

and one of the things you identify was

assigning that one person but not just

the sign in and kind of forgetting about

it because as we I always highlight

facilities it's not a uh your job and

then that's that and no one else is out

of my radar because you're responsible

for doing that but no you were

responsible to kind of bring in the

information to the team and together

being informed as a team and making a

decision how to proceed forward to make

it Implement and then follow up on

outcomes afterwards which I think is a

very very good way of kind of uh of

doing that of following up with

everything that you're doing at the

facilities not just one person because I

always say in my office in our office if

anything were to happen to me I would

like my teammates to know exactly what's

going on and how they can pick up on the

work that I've been doing and so we make

it all available to our teammates so

they can be able to

um to be able to get that information

out and continue the work so I I like

that and having binders I mean although

it another binder another one it does

provide follow through so that way to

happen and you're no longer able to

provide that follicle with the patients

now you have a process established that

the next person that comes in to cover

for you will be able to continue with

that process so I love that that's

that's great

um and then you talked oh I do want to

highlight you mentioned that initially

in the fall of last year when you

started implementing the tool not not

many of the the documents from the my

dialysis plan were available in Spanish

we actually work with our our pfac our

patient and family advisory Council from

Puerto Rico and they translated every

single tool I thought I thought and I

was very appreciative because my copy

was a hot mess I I had the brochure and

then in Spanish below the English and I

had to squeeze it in on the Adobe tool

yeah it wasn't pretty yeah yeah and I'm

sorry I try to get that as soon as

possible I had to know because it's not

our tour yeah that was helpful I work

hand in hand with the University of

North Carolina to get their permission

and and and I figured that because I was

like oh this is the one that and it's on

that site like I was I was excited about

that when I saw the Spanish versions pop

up yeah so I gave credit to our our

patient representatives from Puerto Rico

for making that happen and yeah thank

you they really did a nice job together

with us on that

um so let's talk a little bit in regards

to in addition to you promoting with the

bulletin board you share that

um you you talk about the the medical

outcomes of the patient and things to

the nature or if the patient's interest

is I want to spend more time with my

family spend more time doing this I also

get examples of of patients who say I

want to be able to get a transplant I

want to go to home dialysis I I want to

be able to improve my clinical outcomes

and things to that nature how do you

guys connect and that's other projects

that we as a network are kind of

promoting work in that kind of we are

working thoroughly with each dialysis

center to improve in those outcomes

could you share a little bit of of how

your team is using the my dialysis plan

and those feedback the feedback that the

patient is giving you to improve or

address some of those areas

of course so if for instance when we are

having our care plan we print out for

them a summary sheet and with the Vita

we changed over our program so halfway

through the year in July we had to

figure out which is the new summary

sheet

um and right now I'm using the IDT

worksheet and that prints out a nice

pretty summary for the patients it gives

them a look back of their labs for the

past couple months their treatments

whether they're completing their full

treatment time or cutting it short their

blood pressures their weights and from

that pretty bulletin board I created a

keys worksheet so these are the keys to

your well-being right we give them the

summer Richie we give them the keys to

their well-being worksheet and I have

the

the my dialysis tool there's a there's a

plan when we actually sit down there's a

care plan sheet that we would sit down

and say okay what's important to you

this is where the patient will tell us

so the three things that they want out

of this if it is transplant we discuss

okay have you chosen a hospital where

are you in the process and I usually

have my transplant book as well so I'm

going through and I already know where

they are

um and then we create step by step what

is the next step now if you've already

called you've already done this test do

you have the other test scheduled would

you like me to call and make that

appointment because I can you know do

you have a specialist if they say you

need clearance from this doctor or the

next you don't know if your insurance

um covers this that's where I come in

and I try and make those phone calls I

find on their website whatever it may be

Horizon United Healthcare

in-network Providers that are

specialists in whatever field it is that

they require if it is they need to lose

weight That's The dietitian she takes

over she starts talking about meal plans

and if you know because this is all

about them if they choose to participate

and say you know what I'm ready to

commit I I this is going to be my meal

plan they start with a diary what do you

eat on a day-to-day basis and she starts

pinpointing and this is where our

follow-up comes in because we can't see

what they're eating right away

we follow them for about two or three

days write down your diary and then

she'll come back on the fourth day or

fifth day and say all right these are

some things that you can tweak or you

can change you know so if it's weight

loss or weight gain this is what she

will work on if it's energy I I need

more energy I go to work every day but I

feel wiped out we look at that summary

sheet so let's see how you're adhering

to your dialysis is it working for you

or do we need to tweak something do you

need more fluid removal so you need to

be mindful of it or do we need to

prescribe you know talk to the doctor

and prescribe your Dialysis in a

different way uh what about would you be

okay with an extra treatment or sitting

on for 30 minutes more if that's your

concern

um how are your blood pressures are you

taking your meds on time any difficulty

getting them or

um they're depending on what it is they

want we try and sit there and talk it

through and write it down on the plan so

the follow-up depending on whatever it

is will be according to their need

it's it's involved it is and and that is

something you guys are already doing and

we're already doing with your patients

talking about these topics addressing

those topics with the plan of care now

you're half as I mentioned earlier it's

you have a tool that the patient owns

the my dialysis planter is a tool that

they own they take it they take it it's

their tool and when you do that

follow-up with the patient you're able

to document in their tool you're able to

document what that follow-up is a lot of

people are more visual than they are if

you just give them information or say to

them this this and that and they walk

away and the next day they're like wait

what I don't know what yeah yeah I mean

just ask me if I have to go to the

supermarket and I have to get a list of

things don't tell me what I need to get

write it down for me because I need to

know what that list of things is before

I go there or otherwise I'll get to the

supermarket and I get one thing like

there was something else there was

something else I can't remember what was

it and then you get home or you're like

wait a minute that was like five of the

things I forgot to get and you know but

very true it is it is it is good to have

things written down so that the patient

you're not only holding the team

accountable for that plan that was

developed for the patient but the

patient is also being held accountable

for their own actions now for their own

follow-through with what they said on

that plan of care meeting that this is

what I'm going to do to be able to

achieve that goal that we set together

as a team and and he's not just a verbal

kind of yeah I'm gonna do this no you

you said it it's here on your plan this

is what we talked about and you agree

that this is what you wanted to do

because this was your goal and what you

wanted to achieve so I I think that's

great now going back a little bit I want

to take a step back now we're talking

about the patient engagement and I know

that um we mentioned how patients are

not not every patient is sold on you

know being a part of the plan of care

meeting or using the tool do you can you

share a little maybe a best practice or

lesson learned that you've had from how

you can get a patient maybe who was not

interested in being a part of my diet of

my pla the plan of care or using the my

dialysis plan and maybe how they were

able not suede it into maybe oh this is

something that benefits me and kind of

using that have you had Addison error

similar to that you know what it is

honestly the first couple of months it

was no but the consistency okay they see

us with the same exact tool going around

and it's for for New Jersey we do our

semi-annual assessment so it's every six

months it's not every month

um it's not even every quarter right

which I'm not asking for please don't

um

but we go around with the same

invitation the same brochure and now

that we're go it's one year later I'm

asking them do you remember this you

know and this is where we talk about how

to make you feel your best and we want

to hear from you but that first three

months or so they were like okay care

plan all right that's fine they listen

to the the labs they listen to where

their blood pressures are or what they

need to work on take this med don't take

this med whatever it is and they're like

okay

it goes right over their head with this

we have to ask them questions what's

important to you they don't even think

about that you know in the beginning

they had no clue but now as we are going

into a year of using this tool those who

were kind of like dismissive have opened

up more you see that we are here to help

you you know they see that it's not just

about the numbers but about you as a

person and what happens outside you come

here for your treatment this is to help

maintain you so you can manage outside

can you what do you want to do are you

working do you want to start working you

just want to be able to sit on your

stool you know to have enough energy and

not be sleepy all the time sure we can

try and help and these are the steps

we're going to take and that consistency

that follow-up that follow-through had I

think it opens up their eyes so they

those who I know were very dismissive

are now a little bit more open a little

bit they're trying they're trying to

open up that shell so I think they see

that we're here for them you know

whereas before it may not have seemed

that way but we didn't care yeah yeah

yeah no and I agree because you're like

you said it's the expectation is we're

just going to talk numbers we're going

to talk outcomes and you're gonna give

me all this information and then let's

move on and that maybe that sometimes

that's what they don't want to hear more

about it but now if you make it personal

to that patient to that person you make

it about them it's like wait a minute

take a step back uh this is mine this is

about me uh I need to take a little more

accountability with this and I like what

you said it's the the consistency of

being able to if one year they said no

the next year I'll try again and now

they see that other patients are using

the tool or if they hear about the tool

they see a bulletin board about the tool

or if they see a promotional thing

something about the tool they're going

to start kind of being like it's like

planting that seed and letting that seed

kind of grow a little by little uh until

they kind of now are curious about it

and want to be a part of of what's going

on with the with the tool so I think

that's that's great feedback and and and

and I really appreciate that I have to

tell you in all of this as I hear you

talk and I hear you talk about the

patients I worked a couple of years in

Perth Amboy before coming to the network

so I do have a special place in Perth

Amboy uh my heart and I spend a lot of

time working with the community like

families within the community the

activities that they do so I know

there's a lot of activities in the

community that that patients are part of

that not just patients like families are

a part of and and being a part of this

community and being a part of of being

more not just uh going to dialysis and

going home there is additional things

that they are a part of

um having that communication with your

team to make your outcomes better to

make your health better I think it's

something they're appreciated including

the family in those discussions is very

important too so that's great well I I I

I mean we could stay here karisha for

hours and hours and I know you and I can

talk for for a whole day if need be but

um any final words of wisdom that you

want to share with the audience anything

in addition that you think

um may help either to patients or to

staff themselves any final words of

wisdom

I mean wholeheartedly we're here for the

patients and if we sit with them they

appreciate that little two minutes three

minutes and just to let them know that

you do care following up with that care

plan tool

um it it Bridges the Gap it really does

and it allows them to see that there is

more than just dialysis this is not the

end-all be-all you can do more

um and we're here to help them and to

trust us that what we keep saying oh

take these meds eat this food don't eat

that it's all for our purpose and it's

for their health it's for them to live

longer healthier lives

um and not to be defeated by dialysis

but uh understand that this is just an

extra step

um that they have to take and we're here

to guide them along that path

that's great thank you so much karisha

and and thank you for joining us and

sharing such valuable information

um I always appreciate the opportunity

of having patience and having staff to

share their unique experiences and I

learn a lot from it like I just learned

some good stuff from you and I hope our

audience also as well learned some some

great initiatives I do foresee you being

in one of our future podcasts as well I

I I will dig deeper into other topics

and things that you're working on but I

really appreciate you being being here

with us today and to our listeners if

you have a specific topic of interest

that you would like to hear more about

and if you want karisha back with us let

me know uh submit your your questions

below below this video that you're

watching

um or audio if you're if you're gonna if

you listen to the audio uh and let me

know if you would also like to be a

guest in our podcast let me know send me

an email at why could be your

qualityinsights.org and um I'll be in

touch with you guys and I'll be looking

out for those uh feedbacks and thank you

again karisha thank you so much and

thank you to our listeners for listening

to our epic podcast stay tuned for

future episodes and thank you bye