A Quality Improvement Project to Develop and Evaluate Systems of Care for Undocumented Immigrants with End-Stage Renal Disease in Southwest Idaho

In Southwest Idaho undocumented immigrants have, compared to legal residents, little to no access to, or funding for, preventative and maintenance care of ESRD. The disparity of care in the current delivery system for undocumented immigrants results in poorer outcomes, longer length of stay, and a significant financial impact to hospitals and providers. Literature review results show that undocumented immigrants are a vulnerable and growing population with worse outcomes and higher cost when treated for ESRD. Federal laws and payment policies contribute to the higher cost and poorer outcomes for the undocumented population. The objectives of the project were: 1) conduct a chart review looking at critical indicators for delivery of services to patients with ESRD; 2) complete an analysis comparing the process of care between undocumented immigrants and legal residents based on the critical indicators; 3) develop a care model based on available resources using principles of business and health policy for delivery of care for undocumented immigrants with ESRD; and, 4) submit findings and recommendations to key stakeholders. This project was implemented by developing a list of critical indicators to guide the chart review utilizing content experts to identify critical information. IRB approval was obtained for the chart review. Chart reviews occurred on records where the patient had dialysis initiated while in the inpatient setting at three area hospitals. Results were analyzed comparing care and processes for ESRD between undocumented immigrants and legal residents. A total of 69 records were reviewed with 38 meeting inclusion criteria for the review. All chart reviews were completed using electronic medical records at each facility. A few key findings from the review included: Undocumented immigrants were in the inpatient setting three times longer than the U.S. citizens; substance abuse was an issue nearly three times as often among the U.S. citizens as among the undocumented immigrants and legal residents; and 67% of the undocumented immigrants were employed when dialysis was initiated compared to only 4% of the U.S. citizens. Using the information from the chart review, comparison with national studies, and review of established care models a proposed care model for rural Southwest Idaho was developed. These results and proposed care model were presented to key stakeholder groups, which included hospitals, nephrologists, dialysis companies, immigration attorneys, and immigrant population advocates. Completion of the project objectives was evaluated by: critical indicators approved by content experts and the initial IRB approval; chart audit completion with results entered into RedCap; a written summary and interpretation of the chart audit information; a written care delivery proposal with options to address identified needs; and a presentation and discussion with key stakeholders regarding results and recommendation. This quality improvement project will set the stage for the implementation of care and possible payment and policy changes. Through assessing the disparities of care and addressing access and process issues in meeting the healthcare needs of an at-risk population, outcomes can be improved and costs reduced.