Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support...
Transcript of Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support...
![Page 1: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/1.jpg)
Breaking Down the Silos of Dialysis Care
October 10, 2019
![Page 2: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/2.jpg)
PARTNERS POPULATION HEALTH Confidential – do not copy or distribute 2
![Page 3: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/3.jpg)
3
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
![Page 4: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/4.jpg)
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
![Page 5: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/5.jpg)
5
Biggest Challenge
Dialysis Center/Nephrologist PCP Practice Hospital Other-SNF/Pharmacy
![Page 6: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/6.jpg)
Gaps in CareUncoordinated ESRD Care
• Patchwork of providers
• Absent or ineffective communication
• Redundant treatments
• Uneducated and overwhelmed patients
![Page 7: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/7.jpg)
Missed Opportunities for Intervention
Poor Outcomes
• High cost and utilization of services
• Increase in readmissions
• High morbidity and mortality rate
• Frustrated and uneducated patient
![Page 8: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/8.jpg)
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
![Page 9: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/9.jpg)
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
![Page 10: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/10.jpg)
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
![Page 11: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/11.jpg)
1111
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
![Page 12: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/12.jpg)
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
![Page 13: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/13.jpg)
13
IT InfrastructureDocumentation of Care Management Program and Care Coordination Note in EMR
![Page 14: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/14.jpg)
14
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
![Page 15: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/15.jpg)
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)
![Page 16: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/16.jpg)
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
![Page 17: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/17.jpg)
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
![Page 18: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/18.jpg)
1818
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
532
![Page 19: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/19.jpg)
1919
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
![Page 20: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/20.jpg)
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
![Page 21: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/21.jpg)
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
![Page 22: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/22.jpg)
PARTNERS POPULATION HEALTH Confidential – do not copy or distribute 22
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
![Page 23: Breaking Down the Silos of Dialysis Care - IPRO€¦ · Data driven analytics . to support strategic decisionmaking and operations- • Intensive, on-going support and training .](https://reader034.fdocuments.in/reader034/viewer/2022042414/5f2f1847f844ed7b161424e6/html5/thumbnails/23.jpg)
Diane Goodwin ESRD iCMP RN Care CoordinatorBrigham and Women’s Hospital75 Francis StBoston, MA 02115
Questions ?
Thank you