BC PROVINCIAL RENAL AGENCY

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The BC Provincial Renal Agency (BCPRA), a part of the Provincial Health Services Authority since 2002, is a virtual organization. We work with and for the renal community, particularly the health authorities and personnel delivering front-line care in order to ensure integrated high quality care for patients living with kidney disease in BC. By collaborating with multidisciplinary clinical and administrative teams in each health authority renal region, the BCPRA has demonstrated accountability and innovation in its approaches to improving access to care.

Our environment is changing and we are acutely aware of both the opportunities and challenges that lie ahead of the renal community and the BCPRA as a PHSA agency. The growing population of patients with kidney disease is clearly a challenge for limited human and financial resources, as are the increasing costs of technologies and drug therapies. Collaboration and integration with our partners and stakeholders will be essential to finding viable approaches and solutions to address these challenges.

With this document, the BCPRA has integrated clinical care, research and administrative responsibilities into a cohesive plan that maximizes resources and outcomes with minimal duplication of effort. Underlying all BCPRA activity is a focus on the continuum of care, from early identification to renal replacement therapy. Within that context, objectives have been identified for improving the effectiveness of care for those with kidney disease. To support the realization of those objectives the following key strategic goals will be pursued:

1. Facilitating the early identification and prevention of progression of kidney disease to reduce the burden of illness.

To this end, the BCPRA will pursue a provincial strategy for universal reporting of kidney function and educational strategies that target high-risk groups. This will require a substantial collaborative effort with a host of partners.1

2. Using new methods of independent care that deliver more dialysis therapy for similar or less cost overall than conventional methods.

Chronic disease groups have encouraged patient independence for some time. Earlier identification of patients will help them maintain their independence as will the management of co-morbid conditions such as diabetes and cardiovascular disease in patients with kidney disease. Independence will be encouraged prior to and when patients are on dialysis therapy, both of which will reduce overall health care costs.

1 Partners include: health authorities, Ministry of Health, Chronic Disease Management Group, BCMA Guidelines and Protocols Advisory Committee, BC Laboratory Medicine Physicians, primary care physicians, the Kidney Foundation, the Heart and Stroke Foundation and the Canadian Diabetes Association..

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3. Providing the cornerstone for integrated access to information for renal patients, caregivers and researchers throughout BC.

The BCPRA will continue to maintain and advance the patient record and outcome management information system (PROMIS), a unique database used to capture information on all BC patients known to nephrology teams. It provides the only information tool linking hospitals providing direct renal patient care, the University of BC (UBC), research organizations, financial groups and other organizations. PROMIS also enables improvements in clinical care, provides caregivers access to indicators of care, and supports research into both disease processes and evaluation of various treatment strategies.

4. Improving relationships with regional health authorities to mutually define service boundaries

The BCPRA will be in a position to enable a more streamlined approach to service delivery by improving relationships with regional health authorities. This will allow for a clearer understanding of funding responsibilities among the health authorities and for increased accountability to this end. The improved integration of services for kidney patients within each health authority can be achieved through an understanding of the linkages and interrelationships between acute care services, community services and primary health care. The BCPRA will play a key role in defining patient outcomes that rely on integrated services, and working with health authorities to ensure the best patient and health care system outcomes.

The BCPRA is also committed to encouraging research and education within the province that are aligned with the overall strategy outlined above, which will enhance care delivery either directly or through the expansion of knowledge.

Partnerships and collaborative efforts will be critical to implementing these strategies and realizing our objectives. Without the commitment of all members of the renal community including patient support groups, the functioning of the BCPRA would not be possible. Over the next five years, the renal community will face significant challenges; with this strategy we hope to be able to rise to those challenges, meet the needs of those requiring renal care, and improve patient outcomes.

Developed 27 months ago in collaboration with the BC renal care community, this strategic plan continues to provide solid direction and guidance to BCPRA as we move forward on various initiatives and strategies. An environment scan did not raise any previously unrecognized risks/opportunities that would require significant alterations to our overall strategic direction. Dr. Adeera Levin Provincial Executive Director BC Provincial Renal Agency

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Table of Contents The BCPRA – Who We Are and What We Do 5 Committees and Working Groups 7 BCPRA Achievements at a Glance 8 Events and Initiatives 12 Looking Forward: Opportunities and Pressures 15 Our Strategic Directions 17

Improve the continuum of kidney care 17 Cost efficient and cost effective care 17 Integrated access to information 18 Improve relationships with regional health authorities 18

Strategic Action Items 19 Appendix 1: BC Renal Networks 20

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The BCPRA – Who We Are and What We Do The BCPRA was created in 1997 to provide cohesive and integrated planning for a group of patients requiring life support therapy in the form of dialysis treatments. Philosophically, the BCPRA was created to ensure cohesiveness, collaboration and co-ordination of costly services to a diffuse and large group of patients receiving expensive care. Since its inception, the BCPRA has operated as a virtual organization with a centralized secretariat and decentralized care delivery model.

The BCPRA has recognized the need for innovation in care of patients receiving dialysis and the need for improved patient care prior to dialysis. Using clinical evidence, the BCPRA determined that costs of comprehensive multidisciplinary care prior to dialysis should be part of the provincial mandate of renal services. By adopting this approach, the focus of the renal community has shifted from reacting to patient needs as they arise to proactive care, and the development of integrated professional and paraprofessional clinical teams and processes to ensure best care for patients. The focus of change in the renal community has been to improve patient outcomes. The cornerstone of the BCPRA’s activities is the development and maintenance of a unique database (PROMIS) that leads the country with respect to using data to develop evidence-based benchmarks with input from the community, and supports all aspects of renal care delivery and planning. This sophisticated tool provides real-time, accurate data supporting a broad range of functions, all focused on two key outcomes – better health for people with kidney disease, and the best use of healthcare resources. With data collected from BC’s 35 renal units, PROMIS supports: individual patient management; renal unit management; continuous quality improvement and research; outcomes-based planning. In 2006, the Canadian Council on Health Services Accreditation (CCHSA) recognized PROMIS as a “leading practice” in its annual Canadian Health Accreditation Report. CCHSA defines leading practices as “innovative and creative practices or processes that offer an idea or approach that other organizations can replicate.” See Appendix 1 for BC Renal Networks diagram.

Mission

To promote and improve the health of British Columbians of all ages through the development, ongoing monitoring, and dissemination of comprehensive and integrated investigative and treatment programs for patients with chronic kidney disease.

The BCPRA: • Ensures the delivery of province-wide services. • Sets directions and develops province-wide standards and

guidelines. • Develops financial models and allocations to support

optimal health outcomes. • Measures, monitors, and reports on outcomes of both

patients and the system. • Engages in evaluation and continuous improvement

initiatives. • Fosters the creation of knowledge and innovation through

research and teaching.

What we do

The BCPRA plans and co-ordinates the care of patients with kidney disease throughout the province. As part of the quality improvement initiatives lead by the BCPRA, the renal agency is

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engaged in continuous evaluation and modification, followed by re-evaluation with respect to both patient and system outcomes. Clinical/service programs include: pre-dialysis clinics (to be renamed chronic kidney disease clinics to more accurately reflect the patient group and function), peritoneal dialysis, home hemodialysis, in-hospital hemodialysis, and community hemodialysis.

The BCPRA facilitates the delivery of services through 11 hospitals and more than 24 community dialysis centres throughout the province.

FRASER HEALTH AUTHORITY Greater Fraser Valley Renal Region

Royal Columbian Hospital Surrey Memorial Hospital Abbotsford Limited Care Dialysis Unit Newton Community Care Dialysis Unit Tri-Cities Community Dialysis Unit

INTERIOR HEALTH AUTHORITY Okanagan/Similkameen Renal Region

Kelowna General Hospital Penticton Regional Hospital Rutland Community Dialysis Centre Vernon Community Dialysis Centre

Interior BC Renal Region Royal Inland Hospital Williams Lake Community Dialysis Unit

Kootenays Renal Region Kootenay Boundary Regional Hospital Cranbrook Renal Facility Sparwood Dialysis Unit Invermere Dialysis Unit Creston Dialysis Unit Grand Forks Dialysis Facility

NORTHERN HEALTH AUTHORITY Northern BC Renal Region

Prince George Regional Hospital Fort St. John Dialysis Center Northwest (Terrace) Community Hemodialysis Unit

VANCOUVER ISLAND HEALTH AUTHORITY Vancouver Island Renal Region

Royal Jubilee Hospital Cumberland Community Dialysis Facility Duncan Community Dialysis Unit Nanaimo Community Dialysis Unit Port Alberni Community Dialysis Unit Victoria Community Dialysis Unit

VANCOUVER COASTAL HEALTH AUTHORITY Vancouver Coastal Health/ProvidenceHealth Renal Region

Vancouver General Hospital & HSC St. Paul's Hospital Vancouver Community Dialysis Unit North Shore Community Dialysis Unit Powell River Community Dialysis Unit Richmond Community Dialysis Unit Sechelt Community Hemodialysis Unit Squamish Community Hemodialysis Unit

PROVINCIAL HEALTH SERVICES AUTHORITY Vancouver Coastal Renal Region

BC Children's Provincial Renal Program

Working and professional groups have developed guidelines for the care of patients with chronic kidney disease and standards of practice for caregivers. To ensure equitable care across the province, formal and informal continuous quality improvement processes for care delivery have been implemented in each of the regions.

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Committees and Working Groups The success of BC’s renal programs and services depends on work undertaken across our network through a wide range of committees and working groups. The following is a list of current committees and groups. Executive Committee Provides strategic direction to BC’s regional renal programs to ensure consistent delivery of services across the province. Medical Advisory Committee Advises the BCPRA on best medical practices within the provincial renal care community, and serves as a forum for physicians to discuss medical issues and care strategies. Renal Resource Management and Planning Steering Committee Enhances strategic decision-making with respect to resource allocation, and supports fiscal responsibility and accountability, as well as timely access and quality of care. Information Management/Information Systems (IM/IS) Steering Committee Develops an overall strategic plan and facilitates ongoing development and implementation of provincial renal information systems to support seamless clinical care, administrative and research activities. Pharmacy and Formulary Review Committee Determines the list of drugs most appropriate for the care of renal patients based on the best available evidence, and helps facilitate medication best practices across the province. Innovative Approaches to the Management of Hemodialysis (IAMHD) Provides overall direction to the groundbreaking, provincially-coordinated independent dialysis program, which includes both home hemodialysis and self-care within dialysis units. PD Clinicians’ Group Enhances the education and implementation of best practices for peritoneal dialysis (PD) patients, and ensures the appropriate delivery of services through provincial contracts. Strategizes regarding new methods and techniques to improve the outcomes of PD patients, as well as increasing the number of patients on PD across BC. Provincial Vascular Access Services Team (PVAST) Works to improve vascular access issues across BC, including developing provincial standards and supporting system changes. (Vascular access refers to the fistula or graft surgically inserted in a patient’s body to allow easy connection between blood vessels and the dialysis machine.) End-of-Life (EOL) Working Group Works to improve end-of-life care for kidney patients by enhancing training for health care professionals and by helping health authority renal programs develop and implement strong end-of-life care in the renal setting.

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Professional Groups • Dietitians • Renal Managers • Biomed Technicians • Pharmacists • Social Workers • Nurses

BCPRA Achievements at a Glance The BC Provincial Renal Agency (BCPRA) is the driving force behind the BC renal network, a model unique in Canada and internationally, designed to improve patient quality of life and outcomes, and to support sound fiscal management and system sustainability. Among our “first and onlys:” • BCPRA has been praised by national reviewers for operating the only province-wide integrated registry for kidney disease patients (PROMIS), and for covering all medication required by dialysis patients. PROMIS leads Canada with respect to developing benchmarks and supports all aspects of renal care delivery and planning. • BCPRA is a key partner in a province wide lab initiative to promote early identification of kidney disease. The first collaborative approach of its kind in North America, this initiative standardized measurement and reporting of kidney function across BC labs. This is critical, as lab tests trigger 75 percent of medical decisions, and inaccurate test results and interpretation lead to incorrect diagnoses and incorrect or lack of treatment. • BC is the only province in Canada with a provincially-coordinated independent hemodialysis program with local implementation. This groundbreaking program promotes optimal patient care and system sustainability. • BC is the only province in Canada with provincial standards for vascular access creation, maintenance and repair. Vascular access refers to the surgical insertion of a fistula or graft to provide access to the bloodstream for dialysis. Many patients have repeated problems with their vascular access, placing additional demands on the already-stretched health system. • BCPRA has developed provincial renal program guidelines, which provide a methodology and set of principles for health authorities and institutions to follow in the management and ongoing development of care programs. Marking a national first, these guidelines have been formally endorsed by the BC Ministry of Health. The guidelines support equitable distribution of high quality renal care to patients across BC, and guide prioritization for new program development, which is critical in the context of increased requests for services in communities across BC and limited resources. • BCPRA has a provincial Peritoneal Dialysis Clinicians’ group dedicated to developing standards of care specific to PD patients and increasing the PD rates in BC. They are already amongst the best in Canada, but we are hoping to achieve even higher rates.

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• BCPRA has developed a patient-focused funding/resource management model that is unique in Canada. This model provides a more accurate assessment of costs and enables flexible, patient-focused, multidisciplinary care based on patient needs. Key Achievements • In the first year of the independent hemodialysis program, the BCPRA reported a 178 percent growth in patients who enrolled in the home hemodialysis program across the province. This groundbreaking initiative helps patients with end-stage kidney disease manage their hemodialysis in their own home, which has proven health and lifestyle benefits. Through the BCPRA, costs are covered for home renovations, equipment and supplies. • Year after year, BCPRA and the health authority renal programs have expanded access to services, including a 25 percent increase in dialysis chairs and significant expansions to CKD clinics since 2002. (CKD clinics provide services to patients diagnosed with kidney disease who do not yet require dialysis.) • BCPRA hosted the Chronic Kidney Disease Summit in Vancouver in June 2005, a landmark event that engaged a host of healthcare professionals, senior health administrators and key stakeholders from BC, across Canada and internationally. The agency is now providing leadership to four projects stemming from this event to address the care needs of people at risk for diabetes, kidney and heart disease. • BCPRA is providing leadership to an initiative designed to improve timely access to services and to reduce complications and hospitalizations related to vascular access that occur across BC. The initiative’s three pilot projects (in Vancouver Coastal Health/Providence Health Care, Interior Health and Northern Health) have clearly illustrated the clinical and financial value of vascular access interventions. In the first six-month period, the projects achieved a 10 percent increase in fistula creation (the superior access method) and a 15 percent reduction in the use of perm catheters. The projects also reduced costs by approximately 15 percent, due to reductions in the use of catheters, thrombolytic therapy (tPa) and antibiotics, as well as pharmacy and nursing time. • BCPRA is providing support and leadership to a provincial end-of-life (EOL) initiative. The goals of the initiative are to: assist health authority renal programs to develop and implement strong EOL care in the renal setting; enhance the level of education/understanding among and between health care practitioners re: Advanced Care Planning (ACP) and EOL care; and to enhance training of nephrology fellows in the area of EOL care through advanced work in areas such as pain and symptom relief.

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Who we serve

The BCPRA serves:

• BC and Yukon Territory residents with kidney disease, with a particular focus on those with reduced kidney function and/or those requiring renal replacement therapy.

• Kidney disease caregivers, educators and researchers.

The majority of BCPRA resources are focused on the delivery of dialysis services; however key initiatives to fund care prior to dialysis have contributed in part to reduced growth rates of dialysis demand (from 9 per cent in 1999, to 6 per cent in 2005).

Service drivers

The data and projections demonstrate that with increasing awareness of chronic kidney disease (CKD) we project more patients identified, but of those who reach dialysis, there will be an increase in home-based therapies. These projections are predicated on the availability of home based therapies and training. The projections speak to availabilities and the demographics of the population. The increase in home-based therapies will offset the limited increase in peritoneal dialysis therapies, due to the increasing age and co-morbidities of the population.

Growth Trends: FY00/01 FY01/02 FY02/03 FY03/04 FY04/05 FY05/06 FY06/07

Pre-dialysis clinics/ CKD Clinics 30% 58% 20% 35% 31% 27% 13%

Hemodialysis units in hospitals 10% 6% 3% 8% 0% 5% 5%

Hemodialysis clinics in community hemodialysis units 18% 7% 15% 20% 8% 6% 5%

Home dialysis 8% 10% 49% 48% 42% 164% 63%

Peritoneal dialysis 0% 4% 11% 8% 7% 2% 10%

TOTAL DIALYSIS 9% 6% 8% 8% 5% 6% 8%

In British Columbia and around the world, the incidence and prevalence of childhood chronic kidney disease has not been well defined. In order to more accurately project growth in requirements for pre-dialysis and renal replacement therapy, the incidence and prevalence must be more closely defined.

Program profile

The following table details actual patient numbers projected, and budgeted for each of the programs. The conservative estimates for home-based therapies have been adjusted upwards as the infrastructure to support these therapies is established.

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FY00/01

Actual FY01/02 Actual

FY02/03 Actual

FY03/04 Actual

FY04/05 Actual

FY05/06 Actual

FY06/07 Planned

Number of patients receiving*:

Pre-dialysis clinics/ CKD Clinics 1,200 1,871 1,817 2,457 3,218 4,098 4,642

Hemodialysis units in hospitals 887 944 969 1,015 1,019 1,066 1,120

Hemodialysis units in community hemodialysis clinics

400 426 489 565 611 650 682

Home dialysis 13 15 22 21 30 80 131

Peritoneal dialysis 458 479 531 575 618 628 689

TOTAL DIALYSIS 1,758 1,864 2,011 2,177 2,278 2,425 2,622

Note: *The above patient numbers are in terms of patient years defined as: • hemodialysis is funded per patient year with an average of 156 runs per year. • predialysis/CKD is funded per patient year with an average of eight follow-up clinic visits including patient

education sessions. • peritoneal dialysis is funded per patient year with an average of 10 follow-up clinic visits including patient

training sessions.

How we connect with other parts of the BC health system and the PHSA

The agency functions as a provincial resource by serving as a repository for key information regarding kidney disease patients, ensuring adequate funding is secured for all patients with kidney disease irrespective of the health authority in which they reside. The BCPRA works to ensure that the health authorities are provided with necessary, appropriate and timely information to facilitate long-term planning for their region.

The BCPRA has linkages to a variety of organizations, both formally and informally as follows:

• Hospitals and health authorities: Front-line care to kidney disease patients is delivered by eleven hospitals and more than 24 community clinics in health authorities throughout BC. For each, support for funding, accountability and information systems is imperative to the delivery of care and is provided via BCPRA.

• PHSA: The BCPRA has links with many PHSA programs/agencies including the BC Transplant Society, Cardiac Services, and BC Children’s Hospital (the sole location where children with kidney disease can access services). BCPRA also participates in the PHSA’s information, finance and population health initiatives.

• Research and education: The BCPRA has collaborated with and sponsored research activities with the UBC Division of Nephrology, the Centre for Health Evaluation and Outcome Services, and the Kidney Foundation research committees. BCPRA collaborates regularly with the Provincial Immunology Lab and Cardiology Research group at UBC. Collaboration with the BC Institute of Technology has fostered ‘accelerated time frame’ training opportunities for nephrology specialty nursing students and the promotion of the technical program. Vancouver Community College and BCPRA work closely in delivering the Renal Technician training program.

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• Collective efforts: The chronic disease management group at the Ministry of Health has fostered a strong alliance with the BCPRA in the development of some key strategic initiatives including alliances with the BC Association of Laboratory Physicians, the BC Medical Association, the Guidelines Protocol Advisory Committee, and the Kidney Foundation. The current initiative regarding chronic kidney disease identification and treatment strategies is an example of the potential value of such alliances.

• Common interest support: BCPRA has long-standing relationships with the Kidney Foundation of BC, Chinese Renal Patients’ Association, Vancouver Island Renal Patients Association and the Canadian Collaborative Nephrology Clinical Research Groups (CREDA: Canadian Renal Disease Alliance Group).

Events and Initiatives BCPRA believes in innovation – in using the latest research and the collective knowledge, relativity and ingenuity of the BC renal community (caregivers and patients alike) to develop new and better solutions to the challenges of chronic kidney disease. Through a range of innovative events and initiatives, BCPRA is improving early diagnosis and intervention, providing improved treatment options, and ensuring that the system of provincial renal care is financially sustainable, so that patients have access to the care they need, when and where they need it. The following are some of our initiatives. BC Nephrology Days Sponsored by BCPRA, this annual conference offers renal and other health professionals from across the province and throughout Canada an opportunity to network with their peers and keep up to date with the latest information about renal care with the goal of improving treatment for people with kidney disease. Kidney Summit Projects BCPRA hosted the first ever Chronic Kidney Disease Summit in Vancouver in June 2005, a landmark event that engaged a host of healthcare professionals, senior health administrators and key stakeholders in BC, across Canada and internationally. The agency is now providing leadership to four projects stemming from this event to address the care needs of people at risk for diabetes, kidney and heart disease: • Policy Initiatives: promote primary and secondary prevention-related policy initiatives and decisions. • Interdisciplinary Collaboration: encourage collaboration among kidney, heart and diabetes communities. • Clinical Tools for Complex Patients: identify and promote a shared clinical tool for use by kidney, heart disease and diabetes health professionals. • Patient Self-Management: Develop a project for the self-management of kidney and heart disease and diabetes, building on existing self-management strategies.

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The Kidney Summit projects are cosponsored by BCPRA, PHSA Cardiac Services, The Kidney Foundation of Canada (BC Branch), Ministry of Health and UBC Department of Medicine. Kidney Month and World Kidney Day March is Kidney Health Month in Canada. Sponsored by The Kidney Foundation of Canada, this annual fundraising initiative involves thousands of volunteer canvassers going door-to-door in neighbourhoods across the country to raise money for Canadians and their families living with kidney disease. BCPRA is involved in media relations activities during Kidney Health Month to help raise awareness of kidney disease and promote good kidney health. In 2006, the International Society of Nephrology and the International Federation of Kidney Foundations jointly launched World Kidney Day to increase awareness and draw attention to the urgent global need for early detection and prevention of this growing epidemic. World Kidney Day will be held annually on the second Thursday of March. On this day, BCPRA will join colleagues around the world in efforts to raise awareness about one of the body’s most vital organs. Chronic Kidney Disease Management Chronic disease management (CDM) is an approach to health care that helps individuals maintain independence and keep as healthy as possible through prevention, early detection, and management of chronic conditions such as kidney disease. BCPRA is a key partner in the development of a chronic kidney disease (CKD) management program designed to improve identification, evaluation and care of patients. The evidence-based initiative is backed by research that shows the progression of CKD can be slowed or even prevented through good management at the community level. The initiative includes: • Lab Strategy for Early Diagnosis: With early diagnosis, kidney disease can be managed through diet and lifestyle adjustments that can delay and sometimes prevent the need for dialysis. With this in mind, an early diagnosis strategy was developed by BCPRA, the Ministry of Health, the BC Medical Association and laboratory physicians throughout the province. The goal is to identify people at highest risk for kidney disease at an earlier stage through the first collaborative approach of its kind in North America. Through this initiative, BC labs automatically report estimated glomerular filtration rates (GFR) in addition to serum creatinine in the blood test results submitted to general practitioners and other doctors. Lab tests are a critical component of kidney care, as they trigger 75 percent of medical decisions, and therefore inaccurate test results and interpretation lead to incorrect diagnoses and incorrect or lack of treatment. Through this strategy, and the ongoing work on standardization across the province’s labs, BCPRA is leading the way in early detection of kidney disease. • Clinical Practice Guideline for Physicians: BCPRA was a key partner in the development of a clinical practice guideline (Identification, Evaluation and Managementof Patients with Chronic Kidney Disease).Based on the best current scientific evidence, this guideline dispels the common belief that very little can be done to slow or prevent the onset of end-stage renal disease. The clinical guideline also includes patient flow sheets and a guide for patients on managing their health and accessing community-based resources. The flow sheets are valuable tools for summarizing the care patients have received, identifying any gaps in care, and for planning future patient visits. Through the Ministry of Health Chronic Disease Management (CDM) Toolkit, physicians can easily access the guidelines, the patient flow sheets and a patient reminder and recall system. The CDM Toolkit also enables members of practice networks to securely share

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information (e.g. consult notes and referral letters) necessary for ensuring continuity of patient care. • Patient Self-Management Support: People who have chronic kidney disease live with their condition twenty-four hours a day. They need to make daily decisions and take action to control pain and fatigue, use medications properly, and incorporate diet, exercise and stress reduction into their daily routines. A valuable resource available to help empower people to become experts in managing their health is the BC Ministry of Health Chronic Disease Management website: www.healthservices.gov.bc.ca/cdm/. The site includes patient information on chronic kidney disease and links to valuable self-management resources such as BC Nurseline, BC HealthGuide, BC Dial-ADietitian Program, The Kidney Foundation of Canada and the National Kidney Foundation and its Disease Education Program. As well, the Chronic Kidney Disease Care Guidelines on the Ministry’s website includes a patient guide and patient log designed to facilitate self-management. • Integrated Clinics: Given the strong linkages among kidney disease, heart disease and diabetes, an increased focus on integrated care is required. A number of initiatives in different health authorities involve specialists and primary care physicians to varying degrees. BCPRA is providing support with our PROMIS database, as well as through evaluative expertise, for a variety of projects, including: Early Kidney Care at Vancouver Island Health and two integrated clinics (in Penticton and a randomized control trial initiative based at St. Paul’s Hospital /Providence Health Care). The two specialty integrated clinics will provide important data on the value of shared care and patient self-management in the prevention and treatment of the “vascular” cluster of diseases.

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Looking Forward: Opportunities and Pressures There are significant internal and external influences that will shape our ability to move forward strategically. The internal issues include the multiplicity of pressures and accountabilities felt by all renal care workers with respect to the institutions, the health authorities, the BCPRA’s greater renal community, and the patients. The integrated system, which uniquely co-ordinates different aspects of renal care, is significantly challenged by competing pressures to be accountable to several organizations, each with independent leadership and priorities. Furthermore, a shortage of trained nurses, dieticians, pharmacists, educators and physicians is a problem within the context of the growing community and expectations. External influences include the growing patient group of diabetics and those surviving heart disease and other diseases. These ‘external’ factors will impact the need/demand for services.

External influences

The external trends (i.e. outside the control/mandate of the agency) that will have a significant influence on the BCPRA in the coming three to five years include:

• Lack of funding to ensure that strategic initiatives are implemented. In a constrained financial environment, the additional costs of change in systems and methods of caring for patients with kidney disease may not be available.

• Social trends and demographic trends (which include the erosion of the nuclear family and thus limited support for independent-based care strategies), and migration of high-risk populations to BC (elderly, diabetics, heart disease patients) will certainly strain the resources and may change the current forecast of eight to 10 per cent growth of dialysis demand.

• Lack of human resources (i.e. MDs, nurses, pharmacists, and allied health professionals) will impact on the ability to both deliver current care and develop a viable set of changes within a resource-constrained environment. These trends may seriously impact our ability to change existing systems due to fatigue and burnout of existing staff, as well as the true overwhelming nature of the growth of the community.

• The BC cardiac registries group and BCPRA could work collaboratively to ensure that the high-risk population (with heart disease and kidney disease) are identified early and to maximize the potential for strategies that prevent the need for dialysis care.

• Kidney patients have an overwhelming burden of cardiovascular disease, thus important initiatives to ensure appropriate diagnosis, management and improved outcomes of these patients is key. Furthermore, of all cardiac patients in BC, it is estimated that approximately 40 per cent of them have some degree of kidney dysfunction. Improved integration of clinical care, information systems and research endeavours will serve both populations well.

• The BC Transplant Society and BCPRA could work more closely together to ensure maximum efficiency and effectiveness of administrative and clinical human resources (i.e. many of the nephrologists care for both transplant and non-transplant kidney patients).

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Internal influences

The strengths and successes internal to the Agency that the BCPRA can build upon include:

• The BCPRA has proven synergies and long-standing relationships with all of the key organizations in the provincial renal community and most predominantly the health authorities responsible for delivering direct care. The strength of the BCPRA collaborative approach, using clinical and administrative representation from all health authorities, has led to improving issue clarity and problem solving on a provincial basis.

• Provincial contracts, guidelines and standards are all proven, successful projects and processes spearheaded by the BCPRA have led to improved resource utilization and patient outcomes.

• The PROMIS database has proved useful in demonstrating accountability and facilitating planning activities based on real data. This could be more overtly utilized if more appropriately recognized by each of the health authorities and renal programs as essential to disease research, prevention and management, and care delivery.

• Being a member of the PHSA may support more rapid and extensive collaboration with other key PHSA organizations and facilitate system-wide perspectives and problem solving. This would be particularly useful in furthering the continuum of care approach that BCPRA has adopted.

The trends and influences within the agency that will influence future strategies include:

• Current human resources within the BCPRA secretariat are becoming inadequate to support the multiple functions and accountabilities (to each health authority, PHSA, Health Authority Renal Programs and working groups etc). This $127 million enterprise is supported by an administrative/ organizational budget of less than two per cent of its total budget. While the intent has always been to maintain a lean administrative organization, the current demands are rapidly outgrowing the current resources. Again, within limited budgets it is difficult to ask for further financial resources other than for those directly related to patient care.

• The BCPRA is well positioned to respond to challenges given its flexibility, adaptability, history of collaboration and creative problem solving.

Being part of the PHSA poses distinct challenges including the need to focus some of the resources of the BCPRA towards the corporate needs of the PHSA; given the structure and original mandate of the BCPRA these tasks, while important, are redirecting resources and time away from the renal community and towards the PHSA. Given the value of the PHSA, this challenge is relative.

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Our Strategic Directions The BC Renal Agency, working with key partners, plans to improve the effectiveness of care for those with kidney disease by focusing on the continuum of care, from early identification to renal replacement therapy. Our strategic goals and strategic action items are:

Improve the continuum of kidney care • Accurately assess the true burden of chronic kidney illness in BC, using population health

strategies. This will include determination of true point and period prevalence of co-morbid diseases associated with kidney disease, and other chronic diseases associated with CKD. Implement population health strategies to reduce this burden, monitoring progress over time.

• Assess the education and training needs of professionals, caregivers and patients with kidney disease. Work in partnership with health authorities, non-profit agencies and the private sector to ensure appropriate resources and plans are implemented for those needs.

• Develop and implement recruitment, retention and succession plans for health care professionals and allied health care professionals in order to ensure patients continue to receive the highest quality kidney care.

• Promote living donation and pre-emptive transplantation for patients with kidney disease thereby reducing the need for dialysis and increasing patient quality of life.

Cost efficient and cost effective care • Continue to enhance and expand the comprehensive, province-wide independent care

program of dialysis delivery and modality choice, such that individual patients and groups of patients are receiving appropriate care in the appropriate facilities/ location to foster independence and health.

• Continue to enhance and further develop the Renal Resource Management Model for the care of adult and pediatric patients with kidney disease, which aligns incentives and patient outcomes in a fiscally responsible manner. Related future goals include:

a. Modify and validate financial models that:

Capture the flow of patients through the health care system within the context of renal care.

Reflect both the direct and important indirect costs of renal patient care (i.e. include vascular access creation and maintenance).

Develop gap analysis in the model using processes like Time & motion studies

Help to ensure linkages between financial models and best practices.

b. Ensuring cost effective practices and decision-making within the context of chronic kidney disease.

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• Continue to facilitate medication best practices across the BC renal care community. The implementation of best practices processes in the management of expensive medications could save an estimated 5-10 percent of the current $29 million renal drug budget. By using medication in a fiscally responsible manner, BCPRA will be able to either expand the list of formulary offerings at little additional cost, or provide more individuals with current drugs, at little additional cost.

Integrated access to information • Continue to modify and implement a consolidated renal/chronic disease data management

system (PROMIS) that provides important clinical, educational, qualitative, administrative and research data about patients living with kidney disease (both prior to and after receiving renal replacement therapy) and

a. Permits efficient and effective care of patients.

b. Maintains an accountability framework within the context of agreed-upon clinically relevant performance measures.

c. Interfaces with multiplicity of systems, to avoid duplication of data entry.

d. Provides a model for chronic disease management databases and health outcomes research initiatives.

e. Enables the BCPRA to become a national resource for benchmark data and models of care delivery.

• Ensure that education and research endeavors align to enhance care delivery, and demonstrate delivery, accountability and fiscal responsibility, while ensuring state-of-the-art care for patients with kidney disease.

Improve relationships with regional health authorities • Improve integration of services for kidney patients within each health authority through an

increased understanding of the linkages and inter-relationships between acute care services, community services and primary health care.

• Define patient outcomes that rely on integrated services, and work with health authorities to ensure the best patient and health care system outcomes.

• Build on the strength of the now established Health Authority Renal Programs, which include both administrative and medical leads.

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Strategic Action Items Goal 1: Improve the continuum of kidney care

Action Item: Assess the true burden of chronic kidney illness in BC, using population health strategies.

Action Item: Assess the education and training needs of professionals, caregivers and patients with kidney disease, and ensure appropriate resources and plans are implemented for those needs.

Action Item: Develop and implement recruitment, retention and succession plans for health care professionals and allied health care professionals in order to ensure patients continue to receive the highest quality kidney care.

Action Item: Promotion of living donation and increased pre-emptive transplantation for patients with kidney disease by working in partnership with the BC Transplant Society.

Goal 2: Cost efficient and cost effective care

Action Item: Enhance and expand the comprehensive, province wide independent care model of dialysis delivery and modality choice.

Action Item: Continue to enhance and further develop the Renal Resource Management Model for the care of adult and pediatric patients with kidney disease, which aligns incentives and patient outcomes in a fiscally responsible manner.

Action item: Continue to facilitate medication best practices across the BC renal care community. The implementation of best practices processes in the management of expensive medications could save an estimated 5-10 percent of the current $29 million renal drug budget. By using medication in a fiscally responsible manner, BCPRA will be able to either expand the list of formulary offerings at little additional cost, or provide more individuals with current drugs, at little additional cost.

Goal 3: Integrated access to information

Action Item: Continue to modify and implement a consolidated renal/chronic disease data management system (PROMIS) that provides important clinical, educational, qualitative, administrative and research data about patients living with kidney disease.

Action Item: Ensure that education and research endeavours align to enhance care delivery, and demonstrate delivery, accountability and fiscal responsibility, while ensuring state of the art care for patients with kidney disease.

Goal 4: Improve relationships with regional health authorities.

Action Item: Improve integration of services for kidney patients within each health authority through an increased understanding of the linkages and interrelationships between acute care services, community services and primary health care.

Action Item: Define patient outcomes that rely on integrated services, and work with health authorities to ensure the best patient and health care system outcomes.

Action item: Build on the strength of the now established Health Authority Renal Programs, which include both administrative and medical leads.

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BC Provincial Renal Agency

Founded in 1997, the BC Provincial

Renal Agency (BCPRA) is a virtual

organization consisting of a small

group of staff at a central office,

complemented by a network of

health care professionals in affiliated

organizations throughout the

province. BCPRA has been part

of the Provincial Health Services

Authority (PHSA) since 2002.

Key partners include the BC

Ministry of Health, the five regional

health authorities, the University

of British Columbia, the Centre for

Health Evaluation and Outcome

Sciences (CHEOS), The Kidney

Foundation of Canada and the

entire renal community.

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BC Provincial Renal Agency

BC Provincial Renal Agency

620–16B, 1081 Burrard Street

Vancouver BC V6Z 1Y6

T 604.806.8845

F 604.806.8846

bcpra@bcpra.ubc.ca

www.bcrenalagency.ca21