1. MULTI-DISCIPLINARY NEPHROLOGY
DISEASE MANAGEMENT TEAM
BUSINESS PLAN
ONE TEAM - ONE MODEL
TO PREVENT PROGRESSIVE RENAL DISEASE WHERE
POSSIBLE,
MANAGE IT WHERE NECESSARY,
AND
PROVIDE TIMELY DIALYSIS AND TRANSPLANTATION
COST-EFFECTIVELY USING LITERATURE AND
INDUSTRY-SUPPORTED BEST PRACTICES
PREPARED AND PRESENTED BY:
DR. TJ O’NEIL
DR. SCOTT MOORE
DR. DAVID JOSEPH

2. ONE TEAM - ONE MODEL
TO PREVENT PROGRESSIVE RENAL DISEASE WHERE POSSIBLE,
MANAGE IT WHERE NECESSARY AND PROVIDE TIMELY DIALYSIS AND TRANSPLANTATION COST-
EFFECTIVELY
USING LITERATURE AND INDUSTRY-SUPPORTED BEST PRACTICES
EXECUTIVE SUMMARY
An unparalleled opportunity currently exists at James H. Quillen VAMC to significantly
reduce costs-of-care, improve patient outcomes, improve patient quality of life and become
a national model of Nephrology disease-management.
This opportunity exists because of an expansion of the Nephrology Physician workforce;
(from one to three providers) occurring simultaneously with the vacating of an ideal floor
space for a comprehensive renal disease-management.
This presentation will give the justification in detail for a major change in the model of care-
delivery for the Nephrology Section:
 Adopting a version of the “specialty PACT” structure using literature-proven methods to
delay progression to dialysis, manage high-risk/high-cost renal patients more efficiently.
 Having dedicated administrative/clerical support to identify Veterans most at-risk, identify
them for specialized care and manage transition to dialysis and transplantation.
 Placing all elements of care, from identification of patients at-risk, fusion of primary and
specialty renal care, education of patients and family in disease self-management, and
dialysis in one physical location to optimize Veteran access to multiple disciplines of care
 Fusing multiple clinics held in different locations at different times into one locus of care.
The strategy presented fulfills the criteria recently set forth by Undersecretary Shulkin in his
New England Journal of Medicine editorial in which he stated the VA’s enterprise goal is to
execute a “whole health” model of care as a key component of the VA’s proposed future
delivery system, incorporating 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. Dialysis money is Operational and Maintenance (O&M)
funded.
We are currently hamstrung in promoting these goals here because our clinical model is
outdated and delivered in multiple different clinics in different locations and it lacks a multi-
disciplinary approach integrating primary and specialty care.
To assure that this proposed plan met the required content elements, it was reviewed by Dr.
Susan Crowley, the VHA Nephrology Consultant, who responded:
“Great work - would love to see this implemented and measured- could then use as national
template.”

3. This presentation will request that:
 The Nephrology Service’s New Patient Consult, Follow-up, Patient Education, CVAT-
Tele-Medicine Dialysis Follow-up and Erythropoietin clinics be co-located in one space
adjacent to the Dialysis function, with dedicated clerical, transplant-management and
data-management support, and work-space for the current part-time Pharmacy and
Nutritional Medicine disciplines to perform their functions immediately adjacent.
 A fifth hemodialysis machine and two additional Dialysis Nurses added to expand ability
to deal with mechanical outages and the increasing number of inpatients requiring acute
dialysis and PICC lines.
 The modality of peritoneal dialysis(PD) be provided here using a contracted-in approach
to provide our Veterans on that dialysis modality inpatient support at this Facility, versus
being fee-based out to Johnson City Medical Center (JCMC) when they require inpatient
care for any reason.
 The modality of ambulatory blood pressure monitoring (for which we already have the
hardware) be staffed and included in the same floor space so it can be added to the
diagnostic armamentarium of this Facility.
For every year we delay a Veteran going on hemodialysis, we save $50,000 -
$80,000.
For every Veteran on PD vice hemodialysis, we save $20,000 each year.
For every Veteran transplanted versus remaining on dialysis we save between
$30,000 and $50,000 each year.
For every patient we must fee-basis out to JCMC due to lack of an inpatient
Peritoneal Dialysis (PD) capability we are charged in higher teens up to $30,000 in
O&M dollars for the cost of that patient’s entire episode of care.
**Note: We have sent out over a dozen such patients in the past two years. Contracting of
experienced PD Nursing support to provide that modality in house, would cost about the same
annually as sending one patient.
Finally, for every patient we misdiagnose as having fixed hypertension versus masked
hypertension or white-coat hypertension due to lack of Ambulatory Blood Pressure
Measurement (ABPM) outpatient clinic capability, we reduce our Primary Care metrics for
hypertension control, we risk over- or under-medicating Veterans with multiple co-
morbidities, putting them at-risk for unwarranted complications, and we increase the cost of
care for medications dispensed but not taken. We already have the hardware to run such a
clinic, but not the Nursing support or the location of care to set it up.
Even if we weren’t improving the quality of Veterans’ lives through this initiative, these would
still be worthy objectives.

4. It is a fact that in population health care the goal is to maximize “Value” as defined by the
equation:
Value = Quality (outcomes) / Cost
It is judged to be beneficial to maintain quality while lowering cost. If we apply a
multi-disciplinary approach as outlined above we have the opportunity to improve outcomes
very significantly and also lower costs vary significantly, thereby achieving a tremendous
increase in value.
This can be realized, however, only if we change the model of care as emphasized by Dr.
Shulkin.
We will discuss each of these points in more detail, showing projected cost savings from
preliminary data from DSS and the Office of the VA Nephrology Consultant

5. CLINICAL / BUSINESS PLAN FOR CREATION OF A MULTI-DISCIPLINARY
RENAL DISEASE MANAGEMENT TEAM
1. BACKGROUND
The Department of Veterans Affairs (VA), Veterans Health Administration (VHA), unlike
most other healthcare systems in the country, at this time, has long-term “ownership” of
costs and outcomes of its patients.
It has a robust Electronic Medical Record (EMR) designed for integrated patient care
delivery and allowing for the further build-out of the Patient Aligned Care Team (PACT)
model, realizing true population health care precepts. It therefore is the best-positioned
healthcare system in the country to benefit from comprehensive disease management
strategies.
It is uniquely positioned among US healthcare systems to promote cost effective healthcare.
Redesign of the Nephrology Clinic along the lines of a multi-disciplinary super Nephrology
PACT will allow for improved care coordination for the Veteran resulting in better outcomes
and a better quality of life. The enclosed referenced Taiwan experience, documents from
their study, the benefits to be realized from this type of Nephrology Service structure.
To quote Undersecretary Dr. David J. Shulkin in the March 2016 New England Journal of
Medicine:
 “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.”
The Nephrology multi-disciplinary disease management system proposal detailed in this
presentation follows literature-proven models which have shown the ability to delay onset of
dialysis, thereby averting costs of $89,000 per patient year of dialysis avoided and promote
use of more cost effective, life-quality promoting techniques of End Stage Renal Disease
(ESRD) treatments such as renal transplantation and peritoneal dialysis.
It will reduce reliance of catheter dialysis while smoothing the transition to whatever
treatment modality is most suitable for the Veteran`s circumstances, thereby reducing
mortality and morbidity.

6. An additional goal of our multi-disciplinary clinic is to better build out and define peritoneal
dialysis in the VA. It is a very cost-effective and under-utilized both inside and outside the
VA.
One of our Nephrologists found that by using strong educational programs and a sound
home training program, he was able to put 33% of his ESRD patients on peritoneal dialysis
over a 2 - 3 year period. This was accompanied by a marked improvement in patient quality
of life and reduced re-hospitalization rates.
Here at Mountain Home VA Medical Center (MHVAMC), we are far less successful than we
could be at promoting these goals because:
 Our clinical model is outdated; we treat incident illness without preventing/slowing it
 Nephrology care is being delivered in multiple different clinics throughout the facility
 We lack a multi-disciplinary approach integrating primary and specialty care
In short, our proposal will, by leveraging the assets the VA already possesses, provide our
Veterans with improved quality of life measured by reduced hospitalizations, more cost
effective treatments and thereby realize here at the VA what is for the most part only being
envisioned at present on the outside under the rubric of “population health care”.
2. Renal Disease Is A Continuum: Largely Asymptomatic, Progressive, & Serious
Chronic Kidney Disease (CKD) is a continuum from normal kidney function-for-age to
severely compromised function progressed to the point of requiring substitution of dialysis or
transplant for the missing kidney function called ESRD. We are almost all born with two fist
sized kidneys containing 1 million tiny kidney filters in each kidney. These filters “burn out”
with normal wear and tear over years of life. This results in:
Stage 1: Normal Kidney Function: Taking into account age, since virtually everyone’s renal
filtration estimated glomerular filtration rate (e-GFR) falls by about 1mL/min/year.
(Diabetes, hypertension, overweight, systemic inflammatory disease, and exposure to
environmental and medical toxins to include over the counter (OTS) products increase the
slope of that decline.)
Stage 2: Elevated Risk: With identified diagnoses and risk factors attached to the patient
which may accelerate the normal decline, but with normal-for-age renal function and
importantly, no symptoms deriving from the renal disease for virtually all patients.
Stage 3: CKD: Exists when the renal function has decreased to less than 60mL/min but is
still above 30mL/min. During this period, in the evolution of the disease, decline is relatively
slow for most patients because there are still enough kidney filters functioning to buffer the
dropout of the diseased ones. However, the remaining filters are hyper filtering, (working so
hard under such pressure that they spill protein into the urine and burn out early.)
Stage 4: Exists when the e-GFR has dropped to between 30mL/min and 15mL/min: At this
stage, there are so few kidney filters remaining that the survivors cannot effectively buffer
small additional insults to the kidney function.

7.  It is during Stage 4, that the first subjective symptoms of progressive kidney disease
begin to bother the Veterans; ankle swelling, frequent nocturnal urination, loss of
appetite, anemia, and often bone pain.
 During this Stage, frequent follow-up, careful monitoring and management of blood
pressure, blood sugar, fluid status and judicious use of certain blood pressure control
agents can save the Veteran from a devastating crash into dialysis; it is a critical time
period for aggressive state-of-the-art management.
 Good management during at this Stage can and does change the slope of
the functional decay curve. It is, in this Stage, when we can make a major
difference in delaying the onset of dialysis and reserving residual renal
function.
 During this Stage, when the e-GFR declines to below 20mL/min the patient can
begin to undergo evaluation for potential renal transplantation and be listed at a
transplant center for pre-emptive transplantation, thereby improving the quality of life
and saving enterprise money for avoidable years of dialysis.
 This is also the Stage when detailed planning for ESRD must be done, with the
patient selecting the best form of dialysis for them and their overall medical situation.
If hemodialysis is the only option, planning is critical for a permanent vascular access
which will take 60-120 days to mature for use. Failure to see and manage this
aspect of the patient’s future care during this phase means that they may “crash”
onto hemodialysis with a temporary cuffed venous catheter, with all its attendant
complications. In the first 180 days of dialysis, having a catheter for dialysis as
opposed to a permanent vascular access increases a Veteran’s mortality by 60%. It
has been said that the 20% difference in first year hemodialysis mortality between
this Country and Europe is accounted for largely by the increased catheter use in the
US and poor transition onto dialysis.
Stage 5: ESRD: Is when the patient must be readied for and placed on dialysis. Social,
financial (including fee-basis contracting), emotional counseling, dietary, and other
arrangements must be made during this time.
“Annual U.S. expenditures on the treatment of chronic kidney disease exceed $48 billion,
with yearly per-patient costs of approximately $89,000 for hemodialysis and $25,000 after
the first post-transplantation year. Furthermore, kidney transplantation significantly improves
quality of life and decreases mortality as shown by Wolfe, et al, in 1999. [Wolfe RE, et al;
“Comparison of mortality in all patients on dialysis, patients on dialysis awaiting
transplantation and recipients of a first cadaveric transplant”, N Engl J Med 1999;
341:1725-30] http://www.nejm.org/doi/full/10.1056/NEJM199912023412303 edited from
Rostaing LPE and Malvezzi P in N Engl J Med; 374:982-984
http://www.nejm.org/doi/full/10.1056/NEJMe1601379

8. 3. Renal Disease is Extremely Common in the Population Served by the VHA
Fully 25% of the population over 60 years of age has Stage 3 or worse CKD, per the CDC
and the NIDDK:
Conversely, the fraction of patients with Stage 3 or worse kidney function in the 20 - 39 year
age group is almost invisible on the chart above.
In the past several years, the fraction of Veterans in the highest-risk (~25% prevalence)
population has been steadily maintaining at about 9.5 million, Nationwide:
0
5
10
15
20
25
30
1988-1994 1999-2002 2003-2006 2001-2008
20-39
60+
NHANES SAMPLING PERIOD
Patient
Age
20-39 Years 60+ Years
1988 - 1994 0.1% 18.8%
1999 - 2002 0.3 24.2
2003 - 2006 0.1 24.5
2001 - 2008 0.2 26
FIGURE 2: Number of Living Veterans by Age Group
FIGURE 1: National Distribution of CKD 3 or Worse by Age

9. Because James H. Quillen VA Medical Center (JHQVAMC) is located in a region of high
obesity, hypertension, and diabetes mellitus, all of which are diseases that greatly increase
hyper filtration injury to the residual kidney filters and cause accelerated loss of kidney
function as noted earlier.
The above VA-wide data has been locally reduplicated, resulting in the number of patients in
NIDDK Stage 3 or higher and therefore at-risk for progression to ESRD being a large part of
our local patient-base.
The following DSS Data was obtained by Ms. Belinda Mink for fiscal year (FY) FY13 thru
FY15:
Although better blood pressure and diabetes care may be responsible for the very slight
decrease in the overall number of patients with Stage 3 and worse renal function, that group
is declining toward ESRD at a rate of 2-5mL/min/year, creating a future potential tsunami of
ESRD patients.
Furthermore, as seen in data above, the age of our nation’s Veterans is increasing at the
same rate as the general population and concurrently, thus resulting in an increase in the
expected prevalence of obesity, hypertension and diabetes mellitus.
Using the rich DSS database, we have obtained local data on the prevalence of Stage 2,
Stage 3 and Stage 4 CKD for the JHQVAMC enrolled population for FY13, FY14 and FY15.
For these three years, the prevalence has been fairly constant at 4,700 total patients in
Stage 3 and Stage 4 combined out of a total population of ~55,000 enrollees.
As the importance of good prospective management has been impressed on the Primary
Care Providers (PCPs) and the Stage 4 population has progressed toward ESRD.
However, the number of Nephrology consults has risen dramatically. This has led to a
corresponding rapid rise in both inpatient dialysis workload and consults for outpatient
maintenance dialysis.
FIGURE 3: Mountain Home Veterans with Stage 3 or Worse CKD

10. 4. Nephrology Workload
The above conditions have resulted in sharply rising inpatient consults and workloads for
Nephrology, which until recently was supported thinly by a contract workforce consisting of
five community Nephrologists who spent three hours at JHQVAMC on-site here five days a
week and occasionally provided care on-site when paged for inpatient/acute emergencies:
These patients are currently being managed separately by Primary Care, Nephrology,
Vascular Surgery and others without a single systems-based management system.
The default to comprehensive, prospective outpatient management is inpatient admission
with much more expensive crisis-management when the patient reaches the point of renal
failure without having had prospective outpatient advance-management.
As suggested by data collected from DSS that is currently occurring at a rising rate. For
inpatient acute/urgent dialysis alone, the number of procedures has gone from ~500 three
years ago to the current number of 700 per year.
0
10
20
30
40
50
60
70
80
90
Oct Dec Feb Apr Jun Aug
FY13
FY14
FY15
FY16
Linear
(FY13)
Linear
(FY14)
FY13 FY14 FY15
Workload 562 608 818
0
200
400
600
800
1000
Workload
Month FY13 FY14 FY15
Oct 24 20 48
Nov 29 27 47
Dec 25 45 51
Jan 44 41 82
Feb 35 30 61
Mar 57 50 53
Apr 32 56 29
May 60 48 44
Jun 31 25 53
Jul 55 44 78
Aug 25 68 54
Sep 60 43 82
Total 477 497 682
FY13 FY14 FY15 FY16
Hemodialysis
Workload Alone 562 608 818 306
Figure 4: Total Inpatient Consults per FY
Note:
Huge
jump
in
trend
line
Figure 5: Inpatient Workload CPT 90937 by FY

11. Hemodialysis treatment lasts from 3 – 4 hours, and requires an hour of machine setup and
calibration before each treatment, and another 45 minutes to an hour of take-down and
cleaning after each treatment, resulting in a “shift” for our three-machine dialysis unit being
able to handle three Veterans every 5 - 6 hours.
If there are more than six inpatient Veterans at a time, this results in dialysis Nurses working
15 -18hour days. That is not safe, due to “crew fatigue”
5. Renal Disease Is Expensive If Un-Managed or Poorly-Managed:
Patients who progress to ESRD requiring (renal replacement therapy (RRT), hemodialysis,
PD, or transplant) cost the VA an enormous amount of money.
- Every year of hemodialysis avoided saves $80,000-89,000.
- Every year of peritoneal dialysis avoided saves $60,000.
Prompt renal transplantation also saves money: After the first year, renal transplant
management costs $29 - $30,000, as opposed to the dialysis costs which continue to be
incurred every year the patient remains on dialysis pending transplantation.
Nationally, only 10 - 15% of patients maintained on hemodialysis can continue to work,
whereas ~40% can continue to work at least half-time if they are on peritoneal dialysis.
The societal costs of dialysis are also huge; many spouses who would otherwise be able to
work cannot do so in order to remain home and care for their chronically-ailing spouses on
hemodialysis who must be brought to and from dialysis three times a week.
There is no benefit to early start of dialysis and most Veterans are in no hurry to start
dialysis, unless it will improve their well-being and or give them a safety advantage.
Along with Ms. Mink’s help, we have only begun to dig into the tremendous DSS resources
available. However, at present we have been able to derive an estimate of the growth in the
prevalence of dialysis-requiring Veterans. If we take the literature-supported estimate of the
ability of multi-disciplinary disease management to delay the incidence of new ESRD cases
by 20% for at least a year and use the VA’s cost-estimates for dialysis, significant savings
can be achieved (See TABLE 7).
If we are able to encourage 15% of those Veterans appropriate for it to go on PD instead of
hemodialysis, the additional cost savings to the system, including those from decreased
predicted hospitalization, are even more significant (See TABLE 8).
These figures do not capture the very hard-to-quantify but real issues such as improved
quality of life on peritoneal dialysis versus in-center hemodialysis and just as importantly, the
reduced rate of hospitalization for the PD population. Once the baseline has been
established we will be able to track all this data and report on the effectiveness of our
approach using DSS for this crucial outcomes data.
6. Management Meeting Dr. Shulkin’s Goals Must Be Systems-Based:
Care in isolated specialist clinics has never been shown to be cost-effective; it is “illness
management” and not disease-management. On the other hand in the past five years two

12. published studies have convincingly shown that multidisciplinary, systems- and outcomes-
based care delays progression to ESRD, saves money, and results in better care.
 Multidisciplinary Team Care May Slow the Rate of Decline in Renal Function, Bayliss
EA, et al; Clin J Am Soc Nephrol. 2011 Apr; 6(4): 704–710.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3069359/
 Multidisciplinary Care Program for Advanced Chronic Kidney Disease: Reduces
Renal Replacement and Medical Costs, Chen PM et al; The American Journal of
Medicine (2015) 128, 68-76. http://ac.els-cdn.com/S0002934314006871/1-s2.0-
S0002934314006871-main.pdf?_tid=f7d30c1e-ce9a-11e5-a2cc-
00000aacb35e&acdnat=1454960248_8ce94368851923372234eed68fac5f47
The elements of systems-based renal disease care across the continuum from elevated risk
to ESRD include:
 Selection of patients at risk from the PCC milieu
 We have unrivalled tools in VistA/CPRS and DSS data that no other healthcare
system has! A data manager can use that database to identify patients down to the
PACT of assignment, and determine their rate of loss of renal function.
 Management must be according to uniform, literature-and-outcomes-based
algorithms
 Management of CKD-associated anemia is an excellent example of the need for and
effectiveness of multidisciplinary care. Prior to FY 2010 renal anemia was being
managed at this VAMC with an expensive biologic (recombinant human erythropoietin)
at the Primary Care Clinic level without Pharmacy involvement or established, consistent
management. A study requested by Dr. O’Neil in 2011 found that 2/3 of those patients
were not having best-practices followed, including verifying that the problem was one
treatable with EPO, and that optimization of iron and erythropoietic co-factors, dosing to
keep HGB between 11 and 13Gm%, and monitoring for symptomatic changes such as
hypertension exacerbations and thrombotic problems were being done. The EPO Clinic
now with established criteria for patient enrollment and uniform consensus management,
has decreased the number of Veterans being needlessly or inadequately treated with
EPO, and the resulting costs, have fallen dramatically.
 Whereas 90 Veterans were being treated with EPO in 2010 at one dose/week,
most inappropriately, on the wrong dose, or inadequate iron stores, there are
currently 22 properly-managed Veterans on the drug. A properly-managed EPO
clinic has also been found to be effective at maintaining a sense of well-being in
our Veterans. The fact that EPO unfortunately does not delay progression to
ESRD was demonstrated by the TREAT study
(http://www.ncbi.nlm.nih.gov/pubmed/19880844 ). However, others have found
that initiation of dialysis is delayed by proper use of EPO can delay dialysis
initiation (http://annals.org/article.aspx?articleid=477522 ) as well.

13.  Identification of the multi-disciplinary mix needed for good care and bringing them to
the patient as part of an integrated team, as with the PACT model, are critical.
 Comprehensive Nephrology disease management using best-practices requires
special management expertise outside the routine PCC purview including:
 Nephrology
 Dietician/Nutritional Medicine
 Clinical Social Work
 Pharmacy
 Vascular and General Surgery
 Nurse Educator
 Dialysis Nurse
 Management of transition from CKD 5 to dialysis and transplantation must take place
in a compact, efficient process.
 Identification of Veterans rapidly declining to ESRD requires regular systematic
reviews of existing DSS data by someone knowledgeable.
 Decision points for abandoning attempts to delay progression and switching to
making concrete dialysis & transplant plans must be identified.
 Vascular/venous mapping for permanent hemodialysis access must be done timely;
this requires close cooperation between Vascular Surgery, Vascular Lab, and
Nephrology
 Patients must be identified whose medical condition and overall cognitive and
compliance ability is such that they are peritoneal dialysis candidates; and those
patients must be consulted to a General Surgeon who is following best-practice
guidelines for timely peritoneal dialysis catheter insertion.
 Those patients likely to be good transplant candidates must be identified and the 35-
test-and-consult criterion process of preparing them for VHA approval for
transplantation must be implemented in a timely fashion. We need to use this
process pre-emptively, if possible, and if not to utilize the concept of “dialysis as a
short-as-possible bridge” to transplant.
 Patients on contract dialysis in the community must have timely review of their status
and medications and when necessary re-evaluation of their vascular accesses or
peritoneal catheters by the VAMC through an orderly process. Also, at those reviews
TABLE 5: EPO
Cost by FY
Epotein Alpha
Patients
Cost/Year at
$100/Week
FY10 92 $478,400
FY11 61 $317,200
FY12 57 $296,400
FY13 36 $187,200
FY14 32 $166,400
FY15 39 $202,800
FY16 22 $114,400
0 100
FY10
FY12
FY14
FY16 Epotein
Alpha
Linear
(Epotein
Alpha)
Figure 6: Epotein Alpha Patients

14. the VA Nephrologist needs to be able to determine whether changing to alternative
dialysis modalities such as peritoneal dialysis should be suggested to the Veterans.
 The powerful tools of tele-medicine must be brought to bear for remote assessment
and medication reconciliation to preserve patient safety and minimize fragmentation
of care between Nephrology, the PACT’s-of-assignment, and community Providers
caring for day-to-day dialysis management under the contracts.
 The number of such patients being cared for by dialysis vendors in this VAMC’s
community catchment area under the VHA contract is rising very rapidly:
TABLE 6: Non-VA HD
Consults by FY
# NON VA
Dialysis
Consults
FY10 12
FY11 28
FY12 17
FY13 33
FY14 66
FY15* 124
FY16 28
*Outlier year due to re-certification of contracts
This data comes straight from DSS, from the question of “How many new fee-basis dialysis
consults were filed in each fiscal year, 2010 – 2015, to include the number thus far for
2016?” Some of this startling rise, and the accompanying cost, can be delayed or avoided
by systems-based prospective management to delay onset of dialysis.
Since the data from FY2015 was distorted by a mandated renewal of all the VA contracts
and distinguishing those truly new from those simply renewed is not possible from DSS data
without a time-intensive contract-by-contract search, 2015 will be treated as an anomalous
outlier year for purposes of trending.
A new trend line can be established by doing a least-squares-fit through the existing prior
year’s data and extrapolating the ½ year of data for FY2016 which are all new consults:
0
20
40
60
80
100
120
140
FIGURE 7B: New Non-VA Consults From FIGURE 7A Data
Incident New Non-VA
CONSULTS (Actual Data)
0 50 100 150
FY10
FY12
FY14
FY16
FIGURE 7A: # NON VA
DialysisConsults
# NON VA
DialysisConsults
Linear ( # NON VA
DialysisConsults)
1/2 year of data
*

15. At the local contract-specific $308/HD treatment-only rate of $48,048 per patient-year, the
following interpretation can be made, based on the following conservative assumptions:
 The prevalence of dialysis patients is equal to the incidence plus prevalence adjusted for
mortality and leaving dialysis due to transplantation. Nationally, mortality on dialysis is
22.5 - 25% per year due to cardiac sudden death
 As a result, ~25% of the patients on dialysis currently will die or be transplanted annually
 Rigorous population health management can put off by at least one year the entry onto
dialysis of 20% the population currently reaching or predicted to reach dialysis per the
data-based trend line without population management.
TABLE 7:
Projected
Number and
Cost of
Maintenance
Hemodialysis by
FY
Incident New
Non-VA
CONSULTS If
FY15 is
Accepted as
an Artificial
Outlier
(Projected
from 2016)
Incident New
Non-VA
CONSULTS if
20% Could be
Prevented by
Disease
Management
Prevalent
Consults If
There is No
Disease-
Management
Benefit
Prevalent
Consults If
20% of
Incident New
Consults Could
be Prevented
Through
Disease
Management
Cost of Prevalent
Consults at
$48048/Pt/Year
(After Adjustment
for Anomalous
2015) With No
Disease
Management
Benefit
Cost of Prevalent
Consults if
Incidence Could
be Decreased by
20% by Disease
Management
Cost Savings if
Incidence Could
be Decreased
by 20% by
Disease
Management
FY2010
FY2011
FY2012
FY2013
FY2014
FY2015
FY2016
FY2017
FY2018
FY2019
FY2020
FY2021
These cost-saving projections are startling, and they may be over-estimates of savings if:
 The actual cost-of-total-care is less than the VA contract place-holder cost of $48,000 in
VSSC, or
 The trend line for the rising number of incident non-VA hemodialysis consults is too high.
However, the costs savings may be even higher if:
 More than 25 % of the prevalent dialysis patients do not die or get transplanted each
year and the number of prevalent dialysis patients.
 If the extended cost-of-care for the contract dialysis patients (contract cost plus duplicate
care at the VAMC by PCP’s) is actually closer to $80,000 per year than $48000.
The VA’s published rate of $48048/patient-year is dramatically lower than the validated
community cost of $87,945 per USRDS data published at
http://www.usrds.org/2013/pdf/v2_ch11_13.pdf ).
Currently, virtually all of our dialysis patients are placed on community in-center
hemodialysis, whether that is the best medical strategy for them or not. In part, this is due to
our past contract Nephrologists preferring hemodialysis, since they were the Medical
Directors of the community dialysis units. It is also in part because we do not currently have
the capability to care for our Veterans on PD in this Facility and must fee-basis them out to
other community medical centers for all care if they require inpatient care. That lack results
in a considerable additional cost, not just for the fee-basis send-out inpatient care, but also
for the contracted cost of care. If we encouraged PD as an option, it appears we could

16. achieve significant cost-savings. Many parts of the country have 30% of their ESRD
patients on PD. With a $20,000 lower annual cost for PD than HD, just a few patients
placed on PD would make a significant cost-saving opportunity. All the consults were
reviewed and renewed in 2015, so that renewal shows up as an outlier for which new and
renewed contracts could not be separated easily in DSS. The following estimates are based
on placing only 15% of our dialysis patients on PD each year:
TABLE 8: Projected Costs and Cost-Savings by Placing 15% of the Incident ESRD Patients Annually on
Peritoneal Dialysis (PD) Versus Hemodialysis (HD). (All Dollar Values Are in Millions):
FY
Incident
New Non-
VA ESRD
CONSULTS
(Actual
and
Projected
Data)
Incident
New Non-
VA
CONSULTS
If FY15 is
Accepted
as an
Artificial
Outlier
Incident
New PD
Patients
15%
Could
be Put
on PD
Instead
of
Hemodi
alysis
Preval
ent
PD
Patien
ts if
85%
Surviv
e Each
Year
Incident
New Non-
VA HD
CONSULTS if
15% Could
be Put on
PD
Prevalen
t HD
Patients
If 15% of
Incident
New
Consults
go on PD
versus
HD
Prevalen
t HD
Consults
(Predicte
d from
2016
Forward)
If
Everyone
Goes on
HD
Cost of
Prevalent
HD
Consults at
$48048/Pat
ient/Year
(After
Adjustment
for
Anomalous
2015) If
Everyone
Goes on HD
Cost of
Prevalent
PD at
$60,000/p
t-yr
Cost of
Prevalent
HD if
Incidence
Could be
Decreased
by 20% by
Disease
Manageme
nt at
$80,000/pt-
yr
Total
Dialysis
Costs if
85% Go on
HD and
15% go on
PD
Without a
20% Delay
in ESRD
from
Disease
Managem
ent Effect
Total
Dialysis
Costs if
85% Go on
HD and
15% Go on
PD With a
20% Delay
in Going
on Dialysis
from
Disease
Managem
ent Effect
Cost
Savings
from 100%
HD Model
If 15% To
on PD
Without a
20% Delay
in HD from
Disease
Managem
ent Effect
Cost
Savings
from
100% HD
Model If
15% Go on
PD With
Add 20%
Delay in
HD from
Disease
Managem
ent Effect
FY10 12 12
FY11 28 28
F012 17 17
FY13 33 33
FY14 66 66 115 $9.2
FY15 124 44 4 117 148 $11.84 $9.36
FY16 56 56 8 12 48 135 190 $15.2 $0.708 $10.828 $11.536 $9.37 $4.372 $5.83
FY17 62 62 9 16 53 154 237 $18.92 $0.986 $12.337 $13.323 $10.856 $6.583 $8.064
FY18 68 68 10 18 58 173 288 $23.00 $1.086 $13.877 $14.963 $12.188 $9.123 $10.812
FY19 74 74 11 20 63 193 343 $27.44 $1.186 $15.44 $16.626 $13.538 $12.00 $13.902
FY20 80 80 12 21 68 213 403 $32.24 $1.286 $17.020 $18.305 $14.902 $15.220 $17.338
FY21 86 86 13 23 73 233 468 $37.40 $1.386 $18.613 $19.999 $16.276 $18.787 $21.124
FY22 94 94 14 25 80 254 538 $43.04 $1.504 $20.352 $21.855 $17.785 $22.688 $25.255
7. Residence Locations of Our Current Population-At-Risk:
These patients are scattered over a wide area of three states (Virginia, Tennessee, and
Kentucky), but the majority are concentrated in the Johnson City/Knoxville area. However,
as best we are able to determine, about 2/3 reside within a 40-mile radius of the main
campus of the Mountain Home VAMC.
8. Current Model of Nephrology Care at This JHQVAMC:
The Nephrology Service is currently organized as a standard multiple-clinic/multiple-location
isolated model of care. There are Nephrology Consultation and Follow-up clinics that
depend on Primary Care to refer patients most at-risk for evaluation and treatment, then
discharge patients back to primary care providers who see them irregularly mixed in with
their other primary care patients at individually-variable time intervals.
EPO Clinic is only loosely joined to the Nephrology Clinic. Timely EPO use delays ESRD.
Ambulatory Blood pressure measurement devices are available on-station, but support for
an Ambulatory Blood Pressure Clinic has never evolved despite proven efficacy of this tool.
Patient education is not managed prospectively for maximal benefit. Education and
prevention counseling depends on Primary Care PACT clinics identifying patients whose
renal function is within their ability to manage, but yet who can benefit from in-depth patient
education regarding the nature and effects of renal disease. This means educating
Veterans on ways they can retard the progression of chronic renal disease, as well as the
options that might be required (such as dialysis) if they do not do so or if attempted

17. management fails. Although a two-hour patient education class with tele-medicine outreach
exists currently, referral is spotty because disease data-management is not developed.
Patients approaching ESRD may or may not be recognized timely for placement of vascular
accesses. Most patients are not told of the possibility of PD until late in the course of their
disease. Opportunities for patients to see dialysis and understand viscerally the effect it will
have on their lifestyles if they do not take disease-management ownership are few and far
between, and sometimes do not occur at all until the patient is at the point of requiring RRT.
Each Provider/clinic draws blood studies independently of the others, without coordination of
timing, resulting in additional unnecessary blood loss for patients already anemic and
possibly on expensive erythropoietic stimulating agents. Dietary and pharmacology
counseling is dependent on a standard delayed-consultation model.
The predictive population management potential of DSS to identify patients whose rate of
renal function loss is excessive is currently not being utilized.
This situation often results in a “crash” onto dialysis, necessitating initiation of dialysis with a
hospital admission rather than a more appropriate outpatient transition to dialysis.
Renal transplant candidacy evaluation, a 35-step testing process, must be managed by the
Nephrologists essentially without support, because the one Transplant Coordinator working
with Gastroenterology (GI) is effectively fully-utilized by GI. This results in transplant
evaluation frequently not occurring until after the patient is on dialysis. A recent change in
VHA policy allows evaluation and listing of appropriate renal transplant candidates for
transplant upon reaching e-GFR of 20mL/min, can meaningfully shorten the waiting time on
dialysis for a transplant by 1 - 2 years.
Vascular Surgery Clinics which service the needs of patients approaching HD or already on
dialysis with a temporary catheter are held without active participation by Nephrology. PD, a
renal replacement technique associated with increased quality of life for many patients,
better survival, and improved outcomes, is not currently offered here, resulting in any
Veterans using that technique who require inpatient admission being fee-based out for all
care, regardless of the need for admission.
9. Current Nephrology Workflow:
The patient flow plan for Nephrology begins with an inpatient or outpatient consult. The
Nephrologists determine which procedures are indicated (dialysis, transplant candidacy
evaluation, vascular or PD catheter access referral).
Consultations, either e-Consults or face-to-face consultation requests are individually
reviewed by a Nephrologist within three days of their release (typically same-day or one day
later). That evaluation includes a brief records review and selection of the tests needed for
a one-visit diagnosis and treatment and ordering with performance dates corresponding to
available in-person consultation appointments, so results are timely and relevant.
The consultation is then arranged and the patient is notified by a Patient Services Assistant
(PSA) working with Nephrology Service. This practice, introduced in 2015, has reduced the
number of return visits required by inadequate data to an average of two per patient, and
has resulted in significant reduction in waiting time for Nephrology consults.

18. If a Veteran is admitted in need of inpatient dialysis, we can care for up to six such patients
at a time without putting the Nursing staff on overtime. Unfortunately Dialysis Unit overload
and Nursing overtime has occurred over 40 times this past year, due to workload increase.
If a Veteran on PD is consulted for inpatient admission either through the Emergency
Department (ED) or one of the outpatient clinics, they must be fee-based to Johnson City
Medical Center (JCMC) for the entirety of their inpatient care. Since we cannot provide PD
support for inpatients. This has occurred twelve times in the past two years.
There is no dedicated Nursing support for prevention education. There is a once-monthly
two-hour group clinic held in Building 160 either in-person or by tele-medicine taught by one
of the Nephrologists which teaches patients voluntarily referred by the PCP’s what kidney
disease is, how it affects their bodies, and how they can take ownership of the disease and
reduce its progression. The education also includes, in detail, the Veteran’s options if it
progresses to ESRD.
We currently offer six new-outpatient Nephrology consultations a week and thirty-six
outpatient Nephrology follow-up appointments by placing two Nephrologists in the outpatient
clinic. If an East Tennessee State University (ETSU) Medicine Resident is rotating on
nephrology that Resident is also in the morning outpatient clinic under close supervision
seeing 1-2 consults or follow-ups.
One Nephrologist performs as many inpatient consultations and follow-ups as needed, plus
provides night and weekend call, supervising inpatient acute HD and CVVHDF. In that way,
a break from outpatient clinic is not required to attend to an unstable dialysis patient or
critical new consultation. The in-patient Nephrologist also provides inpatient Resident
teaching. The roles (in-patient and outpatient) rotate every week.
We currently have 35 Veterans at various stages of transplantation evaluation:
 18 Veterans active in workup
 7 Veterans listed and awaiting transplant
 10 Veterans pending resolution of a question delaying active listing
Each of these Veterans require individual attention to the details of their transplant
evaluation status and monitoring of which tests have been accomplished and which need
expediting. There is currently insufficient time for Nephrologists to do this, and the
Transplant Coordinator working for GI has her own long and growing list of patients. Due to
delays and the fact that the mortality from cardiac disease on dialysis is 22.5% annually, five
patients have died on dialysis awaiting transplantation in the past three years.
There is also a separate joint Pharmacy/Nephrology Erythropoietic Stimulating Agent (ESA)
clinic held for three hours every other Tuesday afternoon. This clinic seeks to reduce the
cost and improve the quality of management of those patients placed on erythropoietin for
literature-supported indications.
As of early May the next available new Nephrology Consultation is mid-June (5-6 weeks)
Dialysis and CVVHDF are available immediately to inpatients, although the small number of
RN’s requires overtime or extra shifts if there are more than six in-patients requiring dialysis
at any given time.

19. The limited number of dialysis machines with occasional mechanical or bacteriological off-
line periods may mean that on any given day we are attempting to provide care for six
patients with two working machines, which also requires additional overtime for Nursing
Staff. This problem is too important to continue with the same operating plan, as it
jeopardizes Veteran safety and leads to Nurse burn-out and has resulted in emergency
presentations to the ED being fee-based to JCMC. We can do better!
10. Current Nephrology Staffing:
Nephrologists under Medicine Service
 3 full time attending Nephrologists
 Transplant Coordinator (10% Nephrology/90% GI)
The Dialysis Unit Staffing under Nursing Service
 3 RN’s
Renal Replacement Treatment Devices
 3 Gambro Phoenix® Hemodialysis machines with paired MARCOR 300H® reverse-
osmosis machines
 2 Gambro Prismaflex® machines
11. Proposed Nephrology Workflow:
The sort of multidisciplinary Renal Care Center proposed would incorporate the current
pre-reviewed Outpatient Consults and immediate Inpatient Consults currently used, but
would place the Veteran in the center of a comprehensive care matrix.
 The Nephrologists would provide specialized renal care using best-practices.
 The expertise of Nutritional Medicine would be employed from the beginning.
 An Administrative Assistant (AA) with data-management expertise who would act as
transplant coordinator, and data-miner to identify patients most at-risk for out-reach.
 Clinical Pharmacy would perform medication reconciliation and medication
counseling for pre- and dialysis-dependent patients and EPO followup.
 Clinical Social Work would assist with transitions to dialysis and to help with
arrangements for dialysis-associated re-admissions and procedural arrangements.
 A Nurse Educator who could be called upon to educate patients on kidney disease,
its effects on their bodies, how they could take ownership of preventing its
progression, as well as the options available if ESRD supervened would be vital.
 Dialysis Nursing would perform PICC line insertions, provide dialysis treatments and
educate patients placed on dialysis.
 A Renal PCP (NP) would provide general non-Nephrology medical care for the most-
at-risk (Stage 4/5) enrolled Veterans residing in a reasonable radius of the Facility.
Together this mix of personnel would create a treatment and learning environment for those
Veterans not yet on dialysis in effect giving them the tools to slow progression of their renal
disease. Those Veterans already on dialysis would have either tele-medicine or face-to-
face availability of care to minimize fragmentation of care that can exist between the VAMC
and their community dialysis clinic, as well as to expedite their transition to renal transplant if
their overall condition made them a viable candidate.

20. 12. Analysis of Staffing Needed to Support Multi-Disciplinary Nephrology Care
With Workload Increases:
Nephrologists under Medicine Service
 3 full time Attending Nephrologists
 Transplant Coordinator (at least 1/2-time)
The Dialysis Unit staffing under Nursing Service
 4-5 Dialysis RN’s
Renal Replacement Treatment Devices
 For Hemodialysis: 5 Gambro Phoenix® Hemodialysis machines with associated
supplies and expendables and 5 paired MARCOR 300H® reverse-osmosis units
 For Continuous Veno-Venous Hemofiltration/Dialfiltration: 3 Gambro Prismaflex®
machines with associated supplies and expendables.
 For Peritoneal Dialysis: A contract to bring qualified, proficient peritoneal dialysis
nursing personnel to this facility as-needed when patients on peritoneal dialysis are
admitted, for any reason. Explanation and cost listed below.
 For Ambulatory Blood Pressure Monitoring (ABPM): Two Nurses available 4 half-
days a week to instruct patients referred for ABPM testing, to place the devices on
them, to remove them at the end of the testing, and to download and prepare the
data for analysis by the Nephrologists.

21. 13. Analysis of Infrastructure Required to Support Multi-Disciplinary
Nephrology Management Clinic Matrix:
Currently, when a Veteran with renal disease is seen by a Nephrologist, it is in a clinic
isolated from other related specialties, remote from Dialysis and the Intensive Care Unit
(ICU) where medical emergencies during dialysis may result in the need for immediate care
to prevent serious complication or death. This arrangement not only frustrates delivery of
the multi-disciplinary care that Dr. Shulkin is advocating, it may also endanger the individual
Veteran on inpatient urgent dialysis.
Placing the entire multidisciplinary matrix of Nephrology care, from outpatient management
and patient education to ESRD/renal replacement in one physical location would increase
immediacy and quality of care and permit achievement of the results positively extolled by
Bayliss, et al, and Chen, et al, as referenced above. Such a locus of care exists, and
exploratory talks with Engineering have indicated the costs of creating that environment
from its current configuration would be minimal.
The ICU complex of rooms, located immediately adjacent to the Hemodialysis Unit in B030,
contains exactly the right number of rooms and working space to create the Renal Care
Center envisioned in Dr. Shulkins’ and our proposal. It is extremely fortunate that this ideal
setting for comprehensive, systems-based nephrology care is available here at our facility
exactly where it is. Engineering advises that it would only be necessary to put a door on
one current copier workspace, close over one door leading from the nephrologist’s current
office opposite the Dialysis Unit, and open the non-weight-bearing wall from that office to the
ICU area. Also, drilling five drain holes from rooms B020 to B028 for an already-existing
Dialysis Unit drain would complete the renovation.
Everything else except for minor movement of some data drops is already in place. This
makes for a uniquely cost-effective remodeling, allowing for the inaction of a game-changing
new care paradigm.

22. Dialysis
/ PICC
#1
Dialysis
/ PICC
#2
Dialysis
/ PICC
#3
Dialysis
/ PICC
#4
Dialysis
/ PICC
#5
HD
Nurse Med
Room
MD
Office
Supply Rm
Patient & Staff
Classroom
and Education
Rm
Staff
Break
Rm
Patient
Care /
Clinic
Office
#1
Patient
Care /
Clinic
Office
#2
Patient
Care /
Clinic
Office
#3
Patient
Care /
Clinic
Office
#4
Patient
Wait
Area
for
Appts
Clinic
Check In
HD Nursing
Station
Clea
n
Utili
ty
Dirt
y
Utili
ty
Pt BR
AA, CSW, Pharmacy
Nutr
ition
E
&
M
Staff Locker
Staff Locker
Emergency Access/Exit

23. 14. Analysis of Staffing and Infrastructure to Support Peritoneal Dialysis:
We currently lack the ability to provide PD treatment to either inpatients or outpatients. As
part of an exploration of institutional options for providing inpatient-acute PD services,
vendors were sought who provide those services to other federal facilities. It was found that
Fresenius Medical Care Holdings, Inc. currently provides such services under contract to the
Dwight D. Eisenhower Army Medical Center (DDAMC). After confirming by telephone that
such a contract was in-place at DDAMC, I requested information on what such a service
based on that provided to the Army would involve for our facility.
BACKGROUND:
We currently provide only inpatient/acute hemodialysis, and we send all inpatients on
peritoneal dialysis whether admitted as a result of complications of PD or with unrelated
medical conditions to Johnson City Medical Center for their inpatient care. On average to-
date we have transferred 4-6 such patients annually, at a fee-basis cost of >$250,000
annually.
A cost-effectiveness study resulted in determination that leasing PD hardware and training
the number of Nursing and Pharmacy personnel necessary to perform PD services safely for
that low number of cases might be cost-effective. However, the low number of procedures
annually is not expected to provide current-competency for the Nursing staff. Due to a
national-level VHA emphasis on all home- and ambulatory-based RRT modalities, it is
anticipated that an increase in the number of annual PD-requiring admissions/transfers to
JCMC will occur; 8-12 in FY2016 and probably more in the out-years.
Institutional policy considerations will require that even if patients are placed on and taken
off PD by a non-VA Nurse to minimize technique-associated peritonitis at its most crucial
points, a core of Nurses on affected units would need to be trained in basic safety and
contingency procedures in case of catheter obstruction, machine malfunction, and other
foreseeable PD-related events. Those basic competencies and the training that led to
establishing them would need to be auditable and documented.
Fresenius Medical holdings, Inc., a subsidiary of Fresenius U.S.A., has a contract with the
Dwight D. Eisenhower U.S. Army Medical Center at Fort Gordon, Georgia, for providing PD
hardware and expendables on an as-needed/per-patient basis.
Fresenius Medical provided on a no-obligation basis a boilerplate contract proposal with
rates for services based on those charged to the U.S. Army at Fort Gordon. Under this
contract, a qualified Nurse with current competency comes to the Medical Center and puts
patients on/takes patients off PD using a cycler machine provided by Fresenius, checks on
their status daily, and provides 24-hour “help” services if the Ward Nurses have questions or
problems:

24. SPECIFIC COST DATA:
CAPD (We would use this for ED patients with PD
$100.00/Exchange
Problems that did not need to be admitted as inpatients
CCPD (Treatment includes initiation and termination – Inpatient
daily monitoring to be provided by HOSPITAL)
$360.00/Treatment
Daily Supervision Visit $65.00/Visit
Nurse Call Back $65.00/Hour*
Nurse Training $65.00/Hour*
Additional Dialysis Charges:
Incomplete procedure [100]% of rate
Canceled procedure after setup [75]% of rate
Canceled procedure after nurse arrival before setup [30]% of rate
Canceled procedure before 2 hours of scheduled start time [No charge]
Education (Education other than CRRT Nurse Training) $65.00/Hour*
Delay initiation due to HOSPITAL issue [10]% /Hour*
After hours or between 5:01PM and 7:59AM…(Weekend/Holiday
procedure (New Year’s Day, Memorial Day, 4th of July, Labor
Day, Thanksgiving Day, Christmas Day)
[125]% of rate
Other Dialysis Service Charge (Charge to include other services
requested by Nephrologist or HOSPITAL that require a Call Back
visit or dialysis-related patient intervention, eg catheter care,
antibiotic instillations)
$65.00/Hour*
*Hourly services will be billed at a [1 hour] minimum, with any time exceeding [1 hour] billed in
quarter-hour increments.
For 4-10 patients/year, staying 4 days ALOS each:
Minimum Maximum
Costs for Fresenius Nurse to put 4-10 patients/year on
and take those patients off PD:
Anticipated training costs for Nurses at a minimum of
twelve hours of training for providing inpatient PD
supervision between Fresenius Nurse putting patients on
and taking patients off cycled PD:
$1,360 $3,600
Anticipated one-hour daily supervision visits with ALOS 4
days and 4-10 patients: $65/visit for 4-day ALOS for 4-10
patients/year:
$780 $800
Anticipated call-backs to Fresenius Nurse during
treatments for troubleshooting and problem resolution; 4
hours/patient with 4-10 patients @ $65.00/hour (all hourly
services are billed at a 1-hour minimum regardless of the
length of the call);
$1,040 $2,600
Total projected annual cost for contracted services: $4,300 $9,600
In comparison, here are the rates and expendables costs for leasing the PD cycler;
Liberty Cycler Rental: 150/month ($1800/year; we would need to lease two to be assured
of having one operational at all times: $3600/year).

25. All inpatient Nursing management would need to be provided by VAMC Nurses, in this
scenario, which would incur FTE costs for competency training of a significant number of the
VAMC Inpatient Nursing Staff if PD care was to be provided outside the ICU setting.
Fluids and Expendables: 5L Delflex® (solution) 8.85 each on average, patients require
30L/day of fluid exchanges, or $53/day/patient with an ALOS of 4 days and an anticipated
range of 4-10 patients/year: $850-2120/year . Expendable tubing and supplies needed on-
hand: $80/4-day ALOS for 4-10 patients/year: $240-800/year
Total costs for hardware and expendables to lease PD equipment: $4700-$6500/year
ASSESSMENT:
Based on the attached proposed contract from Fresenius and after computing anticipated
costs based on generous projections, it appears reasonable to have a qualified VA
Contracting Officer and a representative of James Quillen VAMC Nursing initiate further
detailed discussions with Fresenius Medical holdings, Inc., regarding contractual provision
of inpatient PD support services for about 8-12 admissions, annually.
Critical but difficult-to-project “sunk costs” involved in the two options would be those
associated with the storage of the leased equipment and supplies and those associated with
the selection and training of sufficient Nurses in the SCU’s and on the Wards to provide
competent care for routine checks and basic procedural safety and contingency issues
during PD treatments between initial and terminal treatment care. Legal issues not
considered are whether and how contracted Nurses could be administratively cleared and
liability-covered to operate within the VAMC and the response time for those personnel to
report to this VAMC upon notification of an admission, and whether competencies meeting
VA standards could be developed, whether a 24-hour help-info system for VAMC Nurses to
safely deal with situations falling outside those defined competencies.
15. Analysis of Staffing and Infrastructure Needed to Support Ambulatory Blood
Pressure Measurement (ABPM) Clinic:
Nephrologists under Medicine Service: No change
Clinic Nursing Staffing under Nursing Service: 1.0 FTEE (.5 FTEE for two LPNs)
(to instruct patients, put on and take off BP cuffs, and post results to Nephrologists for
interpretation)
Equipment: We already have five SPACELABS® ABPM units on-hand that have not
been usable due to lack of dedicated personnel to run a clinic.

26. 16. OVERALL SUMMARY PRO-CON ASPECTS OF BUSINESS PLAN:
Adoption of this Nephrology Business Plan and the concept of care underlying it is
recommended.
 Pro-Factors for This Concept and Its Proposed Siting:
 Its adoption would result in creation of an integrated model of renal care with
proven value in the literature and very high promise for long-term savings to the
VAMC and the VHA in the multi-million-dollar range, while executing a model of
care publicly declared by senior VHA figures as being consistent with the desired
enterprise model for future care.
 Execution of the above model could proceed with minimal additional FTE; in
most cases existing personnel from multiple specialties would perform what they
are currently doing in a more efficient and compact manner.
 Minimal cost would be incurred to modify/renovate existing space adjacent to
Dialysis which is being vacated soon, creating an extremely efficient space
utilization.
 There would be increased continuity of care with less outsourcing to JCMC for
procedures which can be done here but which would exceed staff and equipment
constraints. Specifically, expensive outsourcing of patients to JCMC for
peritoneal dialysis, which currently cannot be done here, would cease.
 Veteran quality of life would be improved by delaying onset of ESRD and the
need for dialysis.
 Con-Factors:
 Need for one-two more Hemodialysis Nurses over the next 2 years for
maximum efficiency and minimizing the risk of personnel burn-out or
fatigue-caused errors in care and one more GAMBRO PRISMAFLEX
machine to provide safety backup.
 Need for a peritoneal dialysis contract to avoid the expense of training
and leasing equipment, FTE costs of training and routine re-training time.
_________________________________ ____________________
Chief, Medicine Service Date
_________________________________ _____________________
Chief Nurse, Medical Outpatient Services Date

27. ___________________________________ _____________________
Chief, Engineering Date
___________________________________ ______________________
Medical Director, Dialysis Unit Date
____________________________________ _______________________
Medical Center Director for Date
Patient Care/Nursing Service
____________________________________ _______________________
Chief of Staff Date