Jai Radhakrishnan, MDJai Radhakrishnan, MDColumbia University

1. The Patient-Centered Medical Home2. CKD Clinic as the paradigm for PCMH?3. Outcome data 4. The Columbia model5. Limitations6. Financial considerations

Scheduled appointment: (FU 99213: 15 mins) 75 year old patient with diabetes, R leg

amputation, CKD (eGFR 22ml.min)Hi BP i 200/100 3 d His BP is 200/100, 3+ edema

He has run out of medications, (does not remember nothing in the computer)remember, nothing in the computer)

You peep out in the waiting room You give him samples and call him back in 1 You give him samples and call him back in 1

month

RenalRenal OfficeOffice

Planned follow up visit for CKD Arrives with home attendant with BP and

blood sugar readings taken by VNSVi l i h l d b k d Vital signs have already been taken, meds updated by health tech.

CKD CDSS can be accessed online CKD-CDSS can be accessed online Epo and Influenza vaccine is prescribed-given

by NP in Room 2by NP in Room 2 Total visit 30 mins

Frequently, the acute symptoms and concerns of the patient crowd out the less urgent need to bring chronic illness under optimal managementmanagement

Bodenheimer..JAMA. 2002;288:1775-1779.

A physician-directed practice that provides care that is accessible, continuous,comprehensive and coordinated and delivered in the context of family anddelivered in the context of family and community.

The PCMH is a model of comprehensive health care delivery and payment reform that

emphasizes a central role for primary careemphasizes a central role for primary care

Health Aff (Millwood) 27 : 1219 –1230, 2008

Coordinated care by incorporation primary care model and disease management model:◦ reduced emergency department visits◦ fewer hospitalizations◦ fewer hospitalizations◦ less duplication and by incorporating increased use

of the electronic medical record with the chronic d l i l fcare model onto a primary care platform

Receive additional remuneration for coordinating allReceive additional remuneration for coordinating all of the patient's care, from diet to mental health to preventive measures.

Health Care O i ti Community

ResourcesOrganization

Self-management S pport

Delivery System Design SupportSystem Design

D i i S tDecision SupportClinical Information

S tSystemsBodenheimer..JAMA. 2002;288:1775-1779.

Primary care physician (PCP) societies American Medical Association American Association of Retired Persons Labor and consumer organizations Corporations, including IBM and Merck

Blue Cross/Blue Shield United Healthcare Aetna Centers for Medicare and Medicaid Services

(CMS) under Tax Relief and Health Care Act of 2006 to conduct a PCMH demonstrationof 2006 to conduct a PCMH demonstration project beginning in January 2010

1. CKD / ESRD is a growing problem 2. Late referral to nephrology is not goodate e e a to ep o ogy s ot good 3. Nephrologists might do a better job 4. CKD/ ESRD is expensivep

USRDS 2004

*

Adapted from Coresh J, Selvin E, Stevens LA, et al. Prevalence of chronic kidney disease in the United States. JAMA. Nov. 7, 2007;298:17.

>20 years old*

16

17

Medicare: period prevalent general Medicare patients age 65 & older, with Medicare as primary payor, & not enrolled in Medicare Advantage Medstat: period prevalent patients age 50 64 enrolled in a fee fornot enrolled in Medicare Advantage. Medstat: period prevalent patients age 50–64, enrolled in a fee-for-service plan. CHF, diabetes, & CKD determined from claims.

Early: > 12 months Intermediate: 4-12 months Late: <4 months

Kinchen KS….Ann Intern Med 2002 Sep 17;137(6):479-86

Effectiveness of a chronic kidney disease clinic in achieving K/DOQI guideline targets at initiation of dialysis--a single-

centre experience

Lee, W. et al. Nephrol. Dial. Transplant. 2006 0:gfl701v1-6; doi:10.1093/ndt/gfl701

Copyright restrictions may apply.

Lee, W. et al. Nephrol. Dial. Transplant. 2006 0:gfl701v1 6; doi:10.1093/ndt/gfl701

Effectiveness of a chronic kidney disease clinic in achieving K/DOQI guideline targets at initiation of dialysis--a single-

centre experience

PHYSICIANN C lt•New Consults

•Follow up consults with active issues•Return from NP if active

NURSE PRACTITIONERS

FELLOWS3 SECRETARIES1 BILLER

PRACTITIONERS•Straight CKD•Chronic Stable GN•Chronic Stable

Patient Volunteer

Dedicated Vascular Surgeon•Transplant

•Hypertension

Surgeon

Dedicated Interventional Nephrologist

Extensive use of online and paper diet sheets Extensive use of online and paper diet sheets Patient helpline for drug assistance programs Patient volunteer and front desk staff are very Patient volunteer and front desk staff are very

efficient.

43%50%

Column1

23%20%30%40%

7%2%

0%10%20%

AVF PLACED AVF REFERRED PD FAILED ACCESS

Health Care O i ti Community

ResourcesOrganization

Self-management S pport

Delivery System Design SupportSystem Design

D i i S tDecision SupportClinical Information

S tSystemsBodenheimer..JAMA. 2002;288:1775-1779.

Patient with CKD

Identify patients with CKD

CKD-CDSS

Provider

Note in EHR

CDSSMonitors notes for

CKD documentation

Informs provider of CKD ifInforms provider of CKD if documentation is lacking

JAMIA 2010 17: 588-594

EHREHR

This is the first admission for a 74 year

Date Test Value

“Structured” data “Unstructured” dataCDS

admission for a 74 year old man admitted with chronic renal insufficiency and shortness of breath…

1/23/09 Creatinine 1.6

12/2/09 Creatinine 1.7 CKD

29

CDSS Promoting Early Recognition and Optimal Management of CKD

Patient CKD Report

Provider CKD Report

Feedback [2]

CKD Diagnosis

pRenal Function

Anemia

Mineral Metabolism...A

Provider

CDSS

Patient CKD ReportRenal Function

Anemia

Mi l M t b li

Note in EHR [1]

Patient CKD ReportRenal Function

Anemia

CDSS

Notification [1]

Mineral Metabolism...

E

Anemia

Mineral Metabolism...

Guideline-based reportsRecommendations [2]

R

Guidelines

PMost recent

Patient CKD

Parameter recentValue

creatinine 2.3 mg/dleGFR,

l/ i / 2 40ReportRenal FunctionAnemia

ml/min/m2

U alb/creat No valueUrine protein 3+CKD e a

Mineral MetabolismCardiovascular

Parameter Most recentValue

Ca, mg/dl 8.6

CardiovascularNutrition

phos, mg/dl 5.4

PTH, IU 325

Vitamin D No value

ICD 9 Office Visit Billing Codes

CKD Stage 1 (GFR > 90) – 585.1 CKD Stage 2 (GFR 60 89) 585 2 CKD Stage 2 (GFR 60-89) – 585.2 CKD Stage 3 (GFR 30-59) – 585.3 CKD Stage 4 (GFR 15-29) – 585.4g ( ) CKD Stage 5 (GFR<15) – 585.5

Office Visit Reimbursement

Commercial Insurances reimburse NPs at f100% of MD charges

Medicare only reimburses NPs at 80% of MD hcharges

Medicare and a secondary insurance reimburses NPs at 100% of MD chargesreimburses NPs at 100% of MD charges

Office Visit Reimbursement

Commercial Insurances reimburse NPs at f100% of MD charges

Medicare only reimburses NPs at 80% of MD h if t i d d tlcharges if pt independently seen

Medicare and a secondary insurance reimburses NPs at 100% of MD chargesreimburses NPs at 100% of MD charges

CPT ESA Billing Codes

Epoetin alfa – J0885 (Standard unit 1,000 units)

Darbepoetin alfa - J0881 (Standard unit 1 )mcg)

Injection – 96372HemoCue Lab 85018QW HemoCue Lab – 85018QW

Multilingual communications Comprehensive electronic data systems Detailed case management Coordination of care Performance and satisfaction reporting

C t l i Cost analysis Proactive patient care self-initiatives Preventive care measures Preventive care measures Ongoing continuous quality improvement

Nephrologists would usually not wish to be designated as the medical homedesignated as the medical home.

Exceptions: dialysis or transplant recipients Exceptions: dialysis or transplant recipients.

The financial and logistic burden of CKD/ESRD patients continue to increase

CKD clinics with physician extenders are a logical next step.

The PCMH model is probably an optimal one but needs to be “customized”one, but needs to be customized .