COORDINATED CARE AND DATA-DRIVEN MULTI-DISCIPLINARY RENAL DISEASE MANAGEMENTLooked at from a Data-Driven, Systems-Management-Structured and Outcomes-Responsive Perspective, How Can We Re-Design Kidney Care?

WHETHER IT WAS SAID BY EINSTEIN,

OR FRANKLIN,

OR FRED ZAMBERLETTI,

The statement: "The definition of

insanity is doing the same thing over and over and expecting it to come

out different”, is TRUE

KIDNEY DISEASE IS UBIQUITOUS• ~15% of Americans Across All Age Groups Have Some

Degree of Kidney Disease---that is >30 million• 7% are in CKD Stage 3 or worse (GFR<60mL/min) • By next year there will be 9 million Veterans 65+years• Prevalence of CKD is 25% in that group• At our VAMC, there are ~5000 Vets with GFR<60mL/min out of

~53,000 enrolled beneficiaries• Kidney Disease Arises From Multiple Illness States

– Metabolic causes predominate (>90%) • Diabetes/Obesity/Hyperfiltration• Hypertension

– Immunologic– Infectious– Neoplastic– Congenital– Age (Remember Cockcroft-Gault?)

LOCALLY FOR US IN EAST TENNESSEE, ESRD INCIDENCE IS HIGH:

AND ESRD CARE IS EXPENSIVE! Hemodialysis costs $65-90,000(avg $80K)/pt/year

Peritoneal Dialysis costs $55-60,000/pt/year

Kidney Transplant costs $120,000 the first year and $29-30,000 each succeeding year

The savings realized by deferring the need for ESRD care cumulate each year!

CUMULATIVE COST OF ESRD CARE BASED ON MODALITY FOR A SINGLE PATIENT OVER TIME

Year 1 2 3 4 5 6 7TreatmentHemodialysis $80,000 $160,000 $240,000 $320,000 $400,000 $480,000 $560,000 Peritoneal Dialysis $60,000 $120,000 $180,000 $240,000 $300,000 $360,000 $420,000 Renal Transplant $120,000 $150,000 $180,000 $210,000 $240,000 $270,000 $300,000

WE HAVEN’T DONE A GOOD JOB OF EDUCATING PATIENTS, EITHER

So, for decades, we have been doing basically the same things using the same processes to care for renal disease, and sure enough, we are not getting a different result!

SYSTEMS-BASED POPULATION HEALTH MANAGEMENT

Kidney disease is a process subject to systems-based analysis

To manage any system of disease, you must: Identify the patient population at-risk Identify the components of the process & how they link Identify the high-value / high-risk components Determine which of those components need better or

simplified management to improve overall performance Identify components amenable to prevention Gain control over those components using literature-

based methods

KIDNEY DISEASE PROGRESSION IS LARGELY PREDICTABLE Literature-supported progression risk factors: GFR<60mL/min dGFR/dt >3-5 mL/min/year Diabetes Hypertension Proteinuria Smoking Obesity (BMI >30) Hyperuricemia Metabolic Acidosis

CURRENT FRAGMENTATION OF CARE Components of care are delivered by different

Providers /clinics / hospitals Each tries to maximize its own financial position

independent of the whole. Medical care for those <65 years old is delivered by

independent competing insurers defining quality as least complications at lowest cost.

The average American changes health care plans every 3-5 years.

Over 65, the cost of ESRD care is covered by MEDICARE, a system with minimal effect on pre-ESRD prevention.

Result: No incentives exist for commercial insurers to spend current-year money on prevention, when the benefits of that investment will accrue to their competitors just as it is becoming effective.

THE DOG THAT DIDN’T BARK Everyone complains about the cost of

health care. However, because we are in an illness care

model depending on individual incidence-of-illness visits to unconnected clinics, and not a true health care model with prevention and cost linkages across Providers, nobody sees the potential savings from truly integrated care because outside the VHA, fiscal and data pockets do not connect

Therefore, nothing fundamental is done to fix it.

SO,RATIONAL TREATMENT REQUIRES

Recognizing the disease process as a disease system with identified risk factors

Prioritizing risk factors and recognizing which of them are most amenable to intervention

Recognizing which patients are most at-risk Recognizing the critical Providers’ interactions as

a system of care Creating a care system architecture that

optimizes overall system function and minimizes the total cost

Gaining control over the parts of the disease and care systems and their interactions

MULTI-DISCIPLINARY MEDICINE No one medical specialty practices in a vacuum.

To deliver effective, timely care, you must: Identify the critical disciplines involved in care Link their participation to permit effective,

timely care Determine how each discipline is paid and whether

failure of one component impacts the others in ways that create incentives for improved linkage

Develop algorithms for them to work together smoothly

Have an outcomes-measurement system to recognize what works and what doesn’t

THE CRITICAL COMPONENTS Identify patients at-risk through an adequate EMR

database Prioritize the patients for intervention based on risk factors Determine what Primary/PACT Providers can do versus

Nephrologists, Nurses, Dieticians, Social Workers, Educators and Pharmacists

Engage patients in the care process through EDUCATION Pro-actively prepare for ESRD when it is inevitable

Predict CKD Progression and ESRD onset from dGFR/dt Arrange for dialysis access (fistula/graft or PD catheter) early

Facilitate early renal transplantation referral Pro-actively screen for transplant candidacy at

GFR<20mL/min

MULTI-DISCIPLINARY, SYSTEMS-BASED CARE HAS BEEN TRIED, AND IT WORKS!

In the Chen, et al study all patients with eGFR <45 Ml/Min Per 1.73 M2 were requested to join the program. “Multidisciplinary Care Program for Advanced Chronic Kidney Disease: Reduces Renal Replacement and Medical Costs: Ping, et al; The American Journal of Medicine (2015) 128, 68-76” http://www.amjmed.com/article/S0002-9343(14)00687-1/pdf

A qualified Nurse or NP conducted a detailed initial interview, assessed their basic knowledge of chronic kidney disease, lifestyle modification, clarified risk factors, and stage of CKD / risk of ESRD.

They achieved more efficient staff utilization through tele-health clinics for education.

Dietician consultation was conducted initially, and is repeated routinely.

The participants returned to the clinic every 1-3 months, according to the judgments of Nephrologists based on eGFR and dGFR/dt

Once patients entered Chronic Kidney Disease Stage 5, they were invited to visit the dialysis center to receive dialysis education regarding the modalities of renal replacement therapy.

Preparation of the hemodialysis vascular access or peritoneal dialysis catheter was encouraged when timely for patients deemed suitable for each modality.

RESULTS OF THE CHEN INTERVENTION“Patients in a multidisciplinary care program had the benefit of risk reduction of 33.6% renal replacement therapy compared with patients not receiving this program. Patients receiving a multidisciplinary care program had lesser chance of admission or emergent dialysis. A multidisciplinary care program is cost effective.”

THE VA AS A SINGLE-PAYER SYSTEM

All care in the VHA from PCP to Dialysis is paid for by the same enterprise budget. So, every Veteran going on Dialysis costs the

system $60,000-$80,000 per year Every year dialysis is postponed saves the system

$60,000-$80,000 per patient, and it’s cumulative! In that respect, the VA is like Canada, Taiwan,

and Italy, where multi-disciplinary care has been validated in the literature.

In this care system, ESRD becomes the cost of failed prevention and can drive innovation.

HERE’S WHAT WE PROPOSE TO DO Use CPRS/VistA/DSS to identify and prioritize the

patients at-risk and continually track their status. Put Nephrology and a Renal PCP, Nurse

Education, Clinical Pharmacy, Nutritional Medicine, Social Work, and a Data-Manager/Transplant Coordinator all together in one clinic.

Walk-in access for patients to the specialists. Enhanced collaboration with Vascular and

General Surgery for timely, standardized access. Locate this multi-disciplinary clinic near dialysis,

as a reminder to the patients of the cost of failing to collaborate meaningfully in their care.

OUR PROPOSED SCHEME TO ACCOMPLISH THIS:

THE POTENTIAL COST SAVINGS ARE ENORMOUS

Quoting Dr.David Shulkin,M.D.N Engl J Med 2016; 374:1003-1005 March 17, 2016

Few other systems enroll patients in areas where they have no facilities for delivering care. Fewer still provide comprehensive medical, behavioral, and social services to a defined population of patients, establishing lifelong relationships with them. These realities, combined with the wait-time crisis, have led the VA to reexamine its approach to care delivery.

I believe that addressing veterans’ needs requires a new model of care.

Our “whole health” model of care is a key component of the VA’s proposed future delivery system. This model incorporates physical care with psychosocial care focused on the veteran’s personal health and life goals, aiming to provide personalized, proactive, patient-driven care through multidisciplinary teams of health professionals. The VA will also maintain care registries, crisis lines, and centers-of-excellence programs in services for veterans that are not available in many communities.

Data-Driven

Systems-Based

Outcomes-Responsive