Abstract
Background: The Conditions for Coverage for End-Stage Renal Disease Facilities require that facilities evaluate each patient for referral to vocational rehabilitation (VR) services, assist the patient in achieving and sustaining an appropriate level of productive activity, and develop a plan that reflects individual patient preference. Though research shows that people on dialysis who keep working feel better, data collected in the 2008 USRDS Comprehensive Dialysis Study indicates that only half of dialysis patients continued to work after starting treatment.

Objectives: A review of the data and the reasons dialysis patients do not work provides an opportunity to identify resources and strategies to address barriers. FMQAI: The Florida ESRD Network (Network 7) initiated a quality improvement project in June 2008 to increase the percentage of Florida ESRD patients, aged 18 through 54, who were receiving VR services, attending school, or employed.

Methods: Using the 2007 ESRD Facility Survey (CMS-2744A) data as a baseline, Network 7 employed a two-pronged approach using both statewide spread efforts and focus group interventions with a targeted group of providers. All facilities identified in the focus group began the project with a baseline of 0% of patients ages 18-54 either engaged in VR, working, or in school. Quality improvement plan (QIP) workshops, conference calls, tracking tools, individualized facility data reports, educational materials, and technical assistance were utilized to improve VR rates in Florida.

Results: As of December 31, 2008, Network 7 increased their statewide results (patients aged 18-54 either engaged in VR services, attending school or working) by 2.5% over the 2007 baseline. For the focus group, as of June 30, 2009, results indicate that 40% of patients are either engaged in VR, working, or in school.
Recommendations: By including VR in facility quality assessment and performance improvement (QAPI) activities, facilities can demonstrate outcomes-driven practice and enhance the independence and quality of life for ESRD patients.

Disclaimer
This project was not supported by any grants. The work upon which this publication is based was performed under Contract Number HHSM-500-2006-NW007C entitled End-Stage Renal Disease Network Organization for the State of Florida, sponsored by the Centers for Medicare & Medicaid Services, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the government.

The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Centers for Medicare & Medicaid Services, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of this contractor. Ideas and contributions to the authors concerning experience in engaging with issues presented are welcomed.

Introduction
Research shows that people on dialysis who keep working feel better. They are more physically able, have less pain, and have better general health and energy.1 Better physical functioning predicts fewer and shorter hospital stays, and a longer life.2 People with CKD who work are also significantly more likely to have a health plan through work.3

The Conditions for Coverage for End-Stage Renal Disease Facilities require that dialysis clinics:

• evaluate each patient for referral to vocational and physical rehabilitation services.  
• assist the patient in achieving and sustaining an appropriate level of productive activity, as desired by the patient, including the educational needs of pediatric patients.
• make rehabilitation and vocational rehabilitation referrals as appropriate.4
  

Evidence of interdisciplinary assessment, education, assistance with barriers, and referral should be documented in an individualized plan that reflects each patient's preferences.

Barriers to rehabilitation
The 2008 U.S. Renal Data System Comprehensive Dialysis Study collected data on physical activity level, health-related quality of life, and work/disability. The data showed that while 50%-60% of people on dialysis under age 55 with a college degree worked prior to starting treatment, fewer than 25%-30% were still working after initiating dialysis.5

The Conditions for Coverage require social workers to assess and document reason(s) why dialysis patients are not interested in VR. Some commonly stated "reasons" and interventions to address these barriers are listed in Figure 1.



Other barriers the team can address include social isolation, transportation, lack of self-confidence, others' attitudes about work, fear that health will fail, lack of financial resources, unemployment rate, VR program budget cuts, etc. Education and resources can help to dispel real or perceived barriers, fears, and myths.

Strategies for successful VR outcomes
Providing more treatment options may improve employment. Research published in 2008 analyzed factors that predicted employment among working age dialysis patients associated the following with higher employment:

• Availability of evening dialysis shifts
• Home dialysis (peritoneal dialysis or home hemodialysis) training
• More frequent dialysis6
  

Support patients' pursuit of rehabilitation goals by:

• Assessing each patient's current status and expectations regarding:
• Productive activity
  
• Employment
• Education/job training
• Treatment modality

Documenting a rehabilitation plan to:

• Provide education, training, and referral
• Help set personal goals for rehabilitation that reflect the patient's preferences
  

Following up by:

• Asking patients to inform you about VR activities, barriers, progress, and need for help (e.g.communication with counselors, current or potential employers, care coordination)
  

Collaborate with community resource groups:

• Contact and build a relationship with VR counselors
• Meet with VR counselors in their office or in the dialysis facility
  
• Educate VR counselors about kidney failure and patients' ability to work
• Hold "VR Days" for patients and families with successfully rehabilitated patients and VR counselors
• Provide facility staff and physicians with education on vocational rehabilitation 
• Post VR materials and profiles of consenting rehabilitated patients in facilities' public areas 
• Advocate at the facility for home dialysis referrals and prioritizing treatment around patients' work schedules
  

Take advantage of work incentive programs. SSI/Medicaid recipients can benefit from a long-standing work incentive program called Section 1619. Under Section 1619a, individuals can work and keep their SSI check with a sliding scale reduction based on earnings. The publication Understanding Supplementary Security income / SSI Work Incentives explains how this works (http://www.socialsecurity.gov/ssi/text-work-ussi.htm). Under Section 1619b, individuals can keep Medicaid at a much higher income than someone who is not working (http://www.socialsecurity.gov/disabilityresearch/wi/1619b.htm).

The Red Book-A Guide to Work Incentives explains many work incentives that could benefit patients, including the Plan to Achieve Self-Support (PASS) program (http://www.socialsecurity.gov/redbook). A 2007 report on the Ticket to Work program provides data on how many of those eligible had heard of and used specific work incentives (www.socialsecurity.gov/disabilityresearch/ttw3/ttw_report3.pdf). Of the 17,696 SSI recipients surveyed, 13% have heard of PASS and only 0.6% had used it as of 2004 nationally. A PASS allows SSI (and some SSDI) recipients to designate income or resources to pursue a work goal while Social Security continues to pay their full check. A PASS can be used for such things as tuition, books, uniforms, and even a car if public transportation is not available for school or work.

Network 7's VR Quality Improvement Project
The ESRD Facility Survey (CMS-2744A) collects data on patients ages 18 through 54 who are receiving VR services, attending school full/part time and/or employed full/part time.

FMQAI (the Florida ESRD Network) analyzed 2007 VR Annual Survey data, and found that, in Florida, only 25% of patients aged 18 through 54 were receiving VR services, attending school or employed. To improve VR rates in Florida, Network 7 collaborated with the Vocational Rehabilitation Advisory Committee (VRAC) to initiate a quality improvement project, "Vocational Rehabilitation: Getting Back on Track," during June 2008.

Goal for improvement
The VR project goal is to increase the percentage of Florida ESRD patients, ages 18 through 54, who are receiving VR services, attending school, or employed. The objectives include:

• promoting VR awareness.
• engaging facilities in conducting CQI.
• demonstrating outcomes-driven social work practice.
• enhancing independence and quality of life for ESRD patients.
  

Using the 2007 VR Annual Survey data as a baseline, the Network set a statewide goal of 30% (a 5% increase over the baseline), by December 2009. The Network set a stretch goal of 35.7% of patients receiving VR services, working or employed (based on the top 25% of facilities during 2007).

A separate goal was set for the focus group (a group of facilities with the greatest need for improvement.) The goal for the focus group participants was to achieve 18.7%, which represented a 75% gap reduction between the facility baseline (0% in 2007) and the Network rate for 2007.

Methods/activities
Network 7 employed a two-pronged approach using statewide efforts and focus group interventions with a targeted group of providers.

Statewide Spread. Data were extracted from the SIMS database to identify the top 10% facility performers for each of the six Florida VR regions. Forty-three top performers were identified. A conference call was conducted to collect best practices and brainstorm ideas. Best practices were incorporated into Network 7 VR education activities, including:

• holding a statewide conference callwith social workers about Social Security work incentives and VR.
• sharing articles from patient and provider newsletters. 
• sending educational fax-blasts on VR to all Florida providers.
• posting new VR educational materials online.
• distributing the VR Annual Toolkit Material to all Florida providers.
• providing handouts on VR to medical directors during Network onsite visits.
  

Focus Groups. The Network identified 28 low-performing facilities representing each of the six Florida VR Regions as the focus group. In addition to including the facility social workers, administrators were also included in the focus group to engage them in reinforcing utilization of VR tools. Focus group activities included:

• a conference call to introduce the project goals, objectives, activities, and timelines.
• an in-person workshop hosted by the Network and VRAC to help each focus group facility develop its own facility-specific quality improvement plan (QIP) to improve its overall VR rate.
• quarterly conference calls to allow for facilities to report on QIP activities and data on patients receiving VR services, working, or in school using a new user-friendly Network-developed tracking tool.
• technical assistance between quarterly calls via fax-blasts, emails, and sharing of lessons learned.
  

Statewide results
As of December 31, 2008, 27.5% of Network 7 patients aged 18 through 54 were receiving VR services, attending school, or working, an increase of 2.5% over the 2007 baseline (see Figure 2).



Focus group results
VR outcomes data for October/December 2008 indicated that:

• 79% of focus group facilities met the 18.7% project goal.
• 55% of focus group facilities met the 35.7% project goal.
• overall, 40% of patients in the focus group were receiving VR services, employed, or attending school full/part time.
  

Due to this initial success, the following changes were made to the project goals:

• The previous stretch goal (35.7%) is now the project goal, and the new stretch goal is now 48%. How this goal was determined:
• The top performing 10% of facilities statewide were at 57%
• The top performing 25% of statewide facilities were at 38.4% 
• The average of these two points is 48%
  

As of June 30, focus group facilities were continuing to make impressive improvements, such as:

• 54% of Focus Group facilities have met the 35.7% project goal.
• 46% of Focus Group facilities have met the 48% stretch goal.
• overall, 40% of patients in focus group facilities are receiving VR services, employed or attending school full/part time.
  

A post-evaluation survey of the QI workshop was conducted. One hundred percent of facility respondents said that the workshop was effective and 85% indicated they had implemented or revised processes in their facility as a result of what they learned.

Next steps
One of the primary lessons learned with this project is that many facilities provided inaccurate data (that is, 0% of patients, aged 18 through 54 receiving VR services, working. or attending school) on the 2007 VR annual survey. On the 2008 VR annual survey, 60 facilities (18%) reported 0% of their patients 18 through 54 are receiving VR services, working or in school. The Network provided VR tracking tools/instructions to these facilities. Use of the user-friendly tracking tool that allows easy monitoring of patients receiving VR services, working or in school will be promoted through a statewide conference call, Network Web site, and fax-blast. Using the tool enables facilities to easily review their outcomes in Quality Assessment and Performance Improvement (meetings and adjust team VR goals, activities, and interventions.

Summary
Promotion of vocational rehabilitation not only improves facility and statewide outcomes, but ultimately makes a difference in the quality of life for kidney patients. The diagnosis of CKD is life changing. Evaluation, education, referral, and continued active involvement by the interdisciplinary team can serve to reduce the impact of kidney disease on patient lifestyle, income, and overall adjustment to care. Encouraging patients to take an active role in setting and working toward goals can provide a win-win situation for all.  

References
1. Blake C, Dodd MB, Cassidy A, O'Meara YM. Physical function, employment and quality of life in end-stage renal disease. J Nephrol; 13(2): 142-9, 2000

2. Lowrie EG, Curtin RB, LePain N, Schatell D. Medical outcomes study short form-36: a consistent and powerful predictor of morbidity and mortality in dialysis patient. Am J Kidney Dis;42(6): 1286-92, 2003

3. U.S. Renal Data System special data request, May 20, 2003

4. Conditions for Coverage for End-Stage Renal Disease Facilities, Final Rule. 42 CFR Parts 405, 410 et al. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Section 494.90

5. Chapter 9, Special Studies, U.S. Renal Data System, USRDS 2008 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md., 2008

6. Kutner N, Bowles T, Shang R, Huang, Y, Pastan S. Dialysis facility characteristics and variation in employment rates: a national study. Clin J Am Soc Nephrol. 2008; 3(1): 111-116

7. Chapter 9, Special Studies, U.S. Renal Data System, USRDS 2009 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md., 2009

Ms. Hall is the Community Services Coordinator at FMQAI: The Florida ESRD Network (Network 7) and Ms. Gore is Network 7's Special Projects Coordinator. Ms. Witten is a consultant with The Medical Education Institute, Madison, Wisc.