Breaking Down the Silos of Dialysis Care

October 10, 2019

PARTNERS POPULATION HEALTH Confidential – do not copy or distribute 2

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Case StudyComplex patient, increased engagement, decreased utilization

Case: 70 y.o. male patient, degenerative neurological disease, anxiety, depression, impaired functional mobility, heart failure, hypertension

Background: Initiated dialysis in March 2018- Patient and wife extremely anxious- Complex polypharmacy- Multiple issues that impacted his dialysis treatment, including hypertension,

hypotension, severe constipation, immobility, spasms, cramping

Utilization: 20 months prior to enrollment (2016-2018)- 13 admissions

Case Study-TransplantComplex patient, increased engagement, transplant

Case: 67 yo male patient, history of diabetes, hypertension, CAD, ESRD on dialysisHD Initiated March 4, 2016

Background: Engaged by iCMP ESRD Care Coordinator March 15, 2016- Established interest in receiving a deceased donor transplanted kidney- Contacted Transplant Coordinator day of enrollment- Transplant evaluation April 25, 2016

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Biggest Challenge

Dialysis Center/Nephrologist PCP Practice Hospital Other-SNF/Pharmacy

Gaps in CareUncoordinated ESRD Care

• Patchwork of providers

• Absent or ineffective communication

• Redundant treatments

• Uneducated and overwhelmed patients

Missed Opportunities for Intervention

Poor Outcomes

• High cost and utilization of services

• Increase in readmissions

• High morbidity and mortality rate

• Frustrated and uneducated patient

National Data

• In the United States more than 726,000 people have ESRD.• 1% of the Medicare population but 7% annual expenditure- 35.4 billion dollars!

$71,889 annually for hemodialysis patients$53,327 annually for peritoneal dialysis patients$24,952 annually for transplanted patients

• Hospital admissions average 2 per year and ED visits have increased to 3 per year. • Inpatient treatment cost accounts for 33% total Medicare expenditures.• 1 in 3 discharges is followed by a readmission within thirty days. The annual

readmission rate is 37%.• Nearly 100,000 Americans are waiting to receive a kidney transplant.• Kidney Disease is the 9th leading cause of death in America.

• One in five patients who start dialysis will die within the first year.

Hhs.gov Usrds

Integrated Care Management Program OverviewWhat is iCMP ?iCMP is a primary care embedded, longitudinal care management program led by an RN Care Coordinator working collaboratively with the PCP and care team. • Key Elements:

• Access to specialized resources including behavioral health, community resource expertise, pharmacy, palliative care

• Involvement through continuum of care with home visits, telemonitoring, integration with post-acute and specialty services

• Promoting Patient self-management with health coaching and shared decision making

• IT enabled systems to improve care coordination leveraging real-time, automatic notification of admissions/discharges and EMR flags identifying iCMP patients

• Data driven analytics to support strategic decision-making and operations

• Intensive, on-going support and training for teams and staff (SIC, motivational interviewing)

• A payor-blind approach with initial attention to Medicare ACO, Medicaid ACO, and commercial risk contract patients

iCMP ESRD Care Coordination Program

Providing Care Coordination principles for disease specific specialty care

• Launched in February 2016 at Brigham and Women’s Hospital

• Implemented care coordinator face-to-face rounding at 4 dialysis unit locations

• Patients are based in PCP practices and identified as high risk for hospitalization

• Patients included in an accountable care organization (ACO) insurance program

• Coordinates care across all stakeholders, including dialysis units, PCPs, hospitals, transplant units, SNFs and others, and not just focused in the dialysis unit

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The Role of the ESRD Nurse

ESRD Care Coordination

iCMP Team

PCP

Patient Centered

Dialysis center

Other providers per

patients needs

• Face-to-face communication with the patient at dialysis units

• Monitoring of clinical parameters (dry weight, blood pressure, anemia, nutrition)

• Participation in patent centered care plan meetings• Identify HD/PD issues or modality changes (complicated

treatments, peritonitis, volume management)• Educate patient in self management strategies• Referral for transplant evaluation

• Medication/polypharmacy review and coordination

• Post-discharge assessments

• ED visit avoidance plan for non emergent issues

• Co-morbidity management and diabetic foot checks

• GI specialist affiliation for functional pain and diabetic

gastroparesis

• Continuous tracking of process and outcome metrics

• Serious illness conversations and palliative care referral

ESRD ICMP Care Coordinator Program

IT Infrastructure is essential

• Identification of patients who qualify for the program (iCMP, ACO)

• Data Collection/Process Metrics (hospitalizations, readmissions, transplants, contacts with patients, avoided encounters)

• Monitoring of patient population

• Initial, monthly and post discharge assessments

-specific to the ESRD population

• Review of clinical indicators, vascular access, ACP,Immunizations, palliative care referrals, polypharmacy reviews

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IT InfrastructureDocumentation of Care Management Program and Care Coordination Note in EMR

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Case StudyComplex patient, increased engagement, decreased utilization

Case: 70 y.o. male patient, degenerative neurological disease, anxiety, depression, impaired functional mobility, heart failure, hypertension

Background: Initiated dialysis in March 2018- Patient and wife extremely anxious- Complex polypharmacy- Multiple issues that impacted his dialysis treatment

Utilization: 20 months prior to enrollment (2016-2018)- 13 admissions

Case Study continued

Interventions: - Engaged by iCMP ESRD Care Coordinator in March 2018- Face to face biweekly visits at the dialysis unit- Patient and family education regarding renal disease, ED utilization, and

medication management for hypo and hypertension- PharmD evaluation for pill burden relief- iCBT and Palliative Care involvement

Utilization: 17 months post-enrollment- One ED visit at outside hospital (Jan 2019) for HF due to change in dialysis schedule, shortened treatments and volume indiscretion(daughter’s wedding)

Case Study-TransplantComplex patient, increased engagement, transplant

Case: 67 yo male patient, history of diabetes, hypertension, CAD, ESRD on dialysisHD Initiated March 4 2016

Background: Engaged by iCMP ESRD Care Coordinator March 15, 2016- Established interest in receiving a deceased donor transplanted kidney- Contacted Transplant Coordinator day of enrollment- Transplant evaluation April 25, 2016

Case Study Continued

Interventions:- Continuous collaboration with transplant team to complete evaluation process

- Cardiac clearance 12/2017 –intensive correspondence with cardiology and patient to obtain clearance

- Active status 3/6/18- GI Clearance-patient admitted 8/7/2018 with GIB and H Pylori –inactive transplant status until

antibiotics completed and repeat H Pylori test/GI follow up. Frequent correspondence with patient until completed GI workup

- Active list 12/2018- Reevaluated in May 2019 by transplant surgeon

Utilization: Three years and 3 months iCMP ESRD Care Manager engagement- 4 inpatient admissions• - 1 Successful Transplant June 12,2019

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Currently Tracked Metrics

Process Metric Patient Count

Total patients enrolled as of July 31,2019 145

# of deceased patients 23# of patients transplanted 9

# of patients moved/opted out/transferred/disenrolled 19Current active patients as of July 31,2019 51Contacts with patients March 2016 through August 2019 3,729

Face-to-face encounters 2,265

Care coordination encounters 898

Post-discharge assessments 323

Other encounter types: avoided encounter, discharge coordination, family meetings, patient education, team meetings

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Outcome Metrics Patient CountsHospital Readmission Rate 28.8% 26 patients

35% nationallyPatients referred for transplant evaluation within 1 year 32% (31 patients)

24% nationallyTransplanted- deceased donor 6 per 100 dialysis patient-years

(9 patients)2.5 per 100 dialysis patient-years

Active patients with polypharmacy medication reviews completed 100% of patients

Serious illness conversations completed 44

Patient referred to palliative care 24.5% (25 patients)13% nationally

Patients with catheter use 9% (5 patients)20% nationally

Ambulance Transport 4 Patients

Annualized ED visit rate

USRDS 2016

1.42.5-2.9 nationally

Outcomes Compared to National Benchmarks –EHR based Metrics

Main Findings

• All-cause and dialysis-specific readmission rates are lower than national average

• Transplantation rates are higher than national average

• Catheter utilization rates are lower than national average

• All patients have an automatic polypharmacy review performed within 30 days of enrollment and then quarterly or whenever the need exists

• Palliative Care Referrals are above the national average

Future Directions

President Trump Policy Changes as Executive Order released July 10, 2019

Goal 1: 25% decrease in ESRD by 2030

Goal 2: 80% of new ESRD patients on home dialysis or receiving a transplant

Goal 3: Increase Access to Kidney Transplants – double available kidneys by 2030

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Overview

• Approach for ESRD

• Improve access to and quality of person-centered treatment options , i.ehome dialysis

• Increase utilization of available deceased organs by increasing organ recovery and reducing organ discard rate

• Increase living donation by removing financial disincentives • New value-based kidney disease payment models that align provider

incentives with patient preferences and improve quality of life – dialysis units will be randomized and held accountable for metrics such as increase in home dialysis and transplants

Diane Goodwin ESRD iCMP RN Care CoordinatorBrigham and Women’s Hospital75 Francis StBoston, MA 02115

Questions ?

Thank you