Multi-Disciplinary Renal Clinic Presentation to Exec Leadership
1. Patient-Aligned Kidney Care: Cost-Effective and Efficient Disease
Management for the Future
In Synch With the Published Intent of Undersecretary Shulkin
Called “Possible National Model” by VHA Nephrology Consultant
2. Quoting Dr. David J. Shulkin, M.D.
N Engl J Med 2016; 374:1003-1005 March 17, 2016
Few other systems enroll patients in areas where they have no
facilities for delivering care. Fewer still provide comprehensive
medical, behavioral, and social services to a defined population
of patients, establishing lifelong relationships with them. These
realities, combined with the wait-time crisis, have led the VA to
reexamine its approach to care delivery.
I believe that addressing veterans’ needs requires a new model of
care.
Our “whole health” model of care is a key component of the VA’s
proposed future delivery system. This model incorporates
physical care with psychosocial care focused on the veteran’s
personal health and life goals, aiming to provide personalized,
proactive, patient-driven care through multidisciplinary teams of
health professionals. The VA will also maintain care registries,
crisis lines, and centers-of-excellence programs in services for
veterans that are not available in many communities.
3. THE FREE-STANDING NEPHROLOGY
CLINIC: AN ANACHRONISM
Renal care is one part of a complex process
Management of this disease process should recognize
systems-based principles of organization and execution
Multi-disciplinary renal care has been proven to
decrease/delay progression to ESRD and to be cost-
effective and more efficient
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
4. ELEMENTS OF RENAL CARE
Selection of patients at-risk
CPRS has data tools no other healthcare system has!
Management must following to uniform, literature- and-
outcomes-based algorithms
Requires special management expertise outside routine PCC
Identification of the multiple specialties needed, bringing
them to the patient as part of an integrated team.
Management of critical transition from CKD 5 to dialysis
and transplantation in a compact, efficient process.
5. SELECTION OF PATIENTS AT-RISK
Stage 3 CKD patients tend to progress slowly and can be
managed by conventional PCC
Stage 4 CKD patients progress faster and require more
frequent followup than most PCC panels can provide
Intensive patient education/dietary/hypertensive
intervention and pharmacologic management delay
progression
Data-management &flexible scheduling are required
6. ONCE IN CKD STAGE 4:
Special PCP(s) for all Stage 4 patients, where practicable
Centralizing/standardizing the renal care aspects
A general Internist to manage the other diseases frequently seen
with renal patients (lung, heart, liver, neuro, urologic)
Simultaneous preparation is needed for ESRD/renal replacement
and selection of good transplantation candidates
Coordinating dialysis access (fistula/shunt/PD catheter),
coordination with Fee-Basis and open communication with the
dialysis unit taking the patient, vendor contracting, and
transplant centers
Preventing damage to potential future access sites through
integration of “Save the Vein” into renal disease management
from Stage 3 to ESRD.
7. MULTI-DISCIPLINARY EXPERTISE
Nephrology expert care for the renal disease in coordination
with Surgery, Urology
Nurse case-management and Nurse Educator
Data-management/ tracking
Clerical scheduling
Nutritional management
Pharmacologic expertise
Nurse PICC Line coordination to “Save the Veins”
Clinical Social Work facilitation and coordination with
transplant centers, dialysis vendors, Fee-Basis
I.M. primary global care of the whole patient
8. MATRIX OF MULTIDISCIPLINARY CARE
The Renal Multi-Disciplinary Care Team
At The Center:
The Veteran in Stage 4
CKD
The Veteran
in Stage 3
CKD
(PCC)
Clinical
Social Worker
The Veteran on Dialysis in the Community
Eligible Veterans Listed for Transplant at
GFR 20mL/min Prior to Going on Dialysis
(Return to VA after successful transplant)
Admin Assistant/
Data Manager ( I.D.
of Veterans in
Transition from CKD 3-
4, Coord of Transplant
Evals & Prep of
Transplant Packages)
3 Nephrologists (Renal Clinic, Joint
Dialysis Vascular Access / General Surgery
(P.D.) Clinics, EPO Clinic, Transplant Clinic,
Inpatient Care, Resident &Veteran Teaching)
DieticianNurse Educator (Self-Care,
ESRD and Transplant Options
Pharmacist
(EPO & Pharmacology
Expertise Incl Hep C)
Dialysis Vendors,
Fee-Basis and
Contract &
Transplant Centers
Renal PCP
Physician and Nurse
Educator Prevention
Classes (PC SMA RENAL EDU
& CVT-RENAL EDU GROUP)
Dialysis/PICC
Nurse
9. THE OPTIMAL
LOCATION:
THE OLD I.C.U.
D
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t
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l
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c
Staff &
PtEduc
W
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tFuture
Water
Rx
Info, Diet, CSW
Pharm Workspace
Nursing
MD
Meds
Dialysis / OP
Clinic Ck-In
HD
Supply
10. TRACKING PERFORMANCE
Rate of patient progression to ESRD
Rate per thousand patients under management/year going on
dialysis
Loss of GFR (mL/min)/year of those not on dialysis
Re-admissions to hospital for medical and surgical reasons
Medical: CHF, cardiac events, CVA’s, catheter and other sepsis
Surgical: Graft or fistula maturation to point of ability to use by time
needed, loss of graft or fistula due to thrombosis
Rate of patients entering dialysis with fistulas versus grafts,
versus catheters
Rate of patients getting transplanted
Deaths, by cause
Rates of entry on hemo- and peritoneal-dialysis
11. OTHER MODELS
Geisinger Health System has tried to build a care
consortium with risk-prediction
It is not truly multi-disciplinary
It does not address up-stream prevention
https://www.geisinger.org/for-researchers/institutes-
and-departments/pages/nephrology.html#initiatives--
projects
Durham VAMC is building a limited renal PACT but
without true multi-disciplinary involvement like the
Taiwan model shown to be cost- and outcomes-
effective
12. A HUGE POTENTIAL
The VA is the largest healthcare entity in the U.S. that
keeps its patients for 20-30 years
If any organization can save money through good
structured longitudinal care and prevention efforts, it
is the VHA
Unified/centralized team-based and outcomes-
literature-informed multi-disciplinary renal care can
save patients grief, save money, and promote highest-
quality care for our Veterans.
13. OUR VETERANS DESERVE NOTHING
LESS
A small investment now in multi-disciplinary care
promises enormous savings in the future.
Slower disease progression to ESRD
Less patient-years of hemodialysis at $80,00/Pt-Yr and
better/less onerous peritoneal dialysis care when
appropriate
A higher proportion of patients entering dialysis with
appropriate access in-place
Less hospital re-admissions once on dialysis
More / earlier transplants at $30,000/Pt-Yr vice higher
dialysis costs
15. TABLE 7: Projected Number and Cost of Maintenance Hemodialysis by FY
(All Dollar Values are in Millions)
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-
Managemen
t Benefit
Prevalent
Consults If
20% of
Incident
New
Consults
Could be
Prevented
Through
Disease
Managemen
t
Cost of
Prevalent
Consults at
$48048/Pt/Yea
r (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 12 - - -
FY2011 28 - - -
FY2012 17 - - -
FY2013 33 - - -
FY2014 66
FY2015 (124)44 Current) 117 $7.11 $6.37 $1.49
FY2016 56 45 148 133 $9.13 $7.16 $2.76
FY2017 62 50 190 149 $11.36 $7.98 $4.20
FY2018 68 54 237 166 $13.81 $8.83 $5.83
FY2019 74 59 288 184 $16.48 $9.70 $7.64
FY2020 80 64 343 202 $19.36 $10.58 $9.67
FY2021 86 69 403 220 $22.46 $5.62 $11.88
16. 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 Millons)
FY
Incident
New Non-
VA ESRD
CONSULTS
(Actual and
Projected
Data)
Incident
New Non-
VA
CONSULTS
If FY15 is
Accepted as
an Artificial
Outlier
Cost of
Prevalent
HD Consults
at
$48048/Pati
ent/Year
(After
Adjustment
for
Anomalous
2015) If
Everyone
Goes on HD
Cost of
Prevalent
PD at
$60,000/pt-
yr
Cost of
Prevalent HD
if Incidence
Could be
Decreased by
20% by
Disease
Management
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
Manageme
nt Effect
Total
Dialysis
Costs if 85%
Go on HD
and 15% Go
on PD With
a 20% Delay
in Going on
Dialysis
from
Disease
Manageme
nt Effect
Cost
Savings
from 100%
HD Model
If 15% Go
on PD
Without a
20% Delay
in HD from
Disease
Manageme
nt Effect
Cost
Savings
from 100%
HD Model
If 15% Go
on PD With
Addl 20%
Delay in
HD from
Disease
Manageme
nt Effect
FY10 12 12
FY11 28 28
F012 17 17
FY13 33 33
FY14 66 66 $9.2
FY15 124 44 $11.84 $9.36
FY16 56 56 $15.2 $0.708 $10.828 $11.54 $9.37 $4.37 $5.83
FY17 62 62 $18.92 $0.986 $12.337 $13.32 $10.86 $6.58 $8.06
FY18 68 68 $23.00 $1.086 $13.877 $14.96 $12.19 $9.12 $10.81
FY19 74 74 $27.44 $1.186 $15.44 $16.63 $13.54 $12.00 $13.90
FY20 80 80 $32.24 $1.286 $17.020 $18.31 $14.90 $15.22 $17.34
FY21 86 86 $37.40 $1.386 $18.613 $19.99 $16.28 $18.79 $21.12
FY22 94 94 $43.04 $1.504 $20.352 $21.86 $17.79 $22.69 $25.26
X
The VA unlike most other health care systems at this time in the country has long –term “ownership” of costs and outcomes of its patients. It has a robust EMR designed for integrated patient care delivery and allowing for the further build-out of the “PACT” model, realizing true population health care precepts. It is uniquely positioned among U.S. healthcare systems to promote cost effective healthcare. Redesign of the Nephrology clinic along the lines of a multi-disciplinary super Nephrology PACT (enclosed Taiwan experience in nephrology with reference to follow) outlined in this presentation will allow for improved care coordination for the veteran resulting in better outcomes and life quality.
Since the dialysis and renal disease-consequence dollars are all VAMC O&M funds, this institution has a definite stake in succeeding in implementing cost- effective renal disease care!
Our VAMC is at a critical point, with the opportunity to fuse true renal disease management with the perfect location for that care.
The Nephrology super PACT proposal outlined in this presentation will delay onset of dialysis, promote use of more cost effective, life quality promoting techniques of ESRD (end stage renal disease) 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. In short, I believe you will agree that by leveraging the assets the VA already possesses, we will be able to 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”.
Our VA Leadership has clearly and publicly stated that the sort of multi-disciplinary care envisioned in this business plan is the enterprise goal.
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.”
Like many disease processes, renal disease is a continuum of states driven by differing underlying pathophysiologic processes, but with management susceptible to analysis using a systems-based approach with a unifying management approach based on multi-disciplinary involvement.
Control of weight, diabetes, hypertension smoking, and exposure to OTC nephrotoxins such as NSAID’s are all well-recognized as effective means of arresting or slowing the progression of renal disease.
The end result of late, partial or absent management of renal disease is dialysis, at $60-80,000 per patient per year, or transplant at $120,000 for the first year and $30,000 for each succeeding year. Mortality is increased 60% in the first 180 days of dialysis with a catheter. Only 15% of hemodialysis patients can continue to work. 40% of peritoneal dialysis patients can do so, at least half-time. These costs both institutional and societal and the excess mortality can be delayed or avoided with effective disease-specific intervention, as has been proven in the peer-reviewed published literature cited.
Starting with Stage 3 CKD, with a GFR of 30-59mL/min , the renal disease patient needs to be recognized and then educated on the feasibility and effectiveness of self-management to retard the loss of renal filtering ability. Veins potentially needed at the next stage need to be protected in an organized way, with the patient assisting.
When Stage 4 CKD is reached, with a GFR of 15-29mL/min, planning is crucial to avoid transition to dialysis with a catheter, delayed transplantation, or missed opportunities for peritoneal dialysis
The elements of renal care, broken down in a systems-based analysis are these:
Selection of patients at-risk from the PCC general population
CPRS allows us to do this from our entire patient base, identifying patients, their residence, where they get their care, and how fast they are progressing toward ESRD; no other health care system in the country can do this at the scale we can.
When management of the CKD Stage 4 patient population is farmed out to the general Primary Care system it is inefficient:
The PCP’s have too many patients to follow to allow for monthly or every-other-weekly followup of a sub-population rapidly approaching ESRD
The average PCP does not have the management tools at his/her fingertips to coordinate monitoring, vascular or peritoneal access preparation, transplant candidacy evaluation, correct erythropoietic agent use, patient and spousal education, pharmacologic adjustments for declining renal function, and social work facilitation of changes in work and life-style.
Because PCP’s cannot interleave the appointments for advancing renal disease patients between separate visits to the Nephrology Followup Clinic, multiple overlapping and duplicative blood draws for monitoring studies tend to be taken, worsening CKD-driven anemia.
Once patients go on dialysis, their care is split three ways;
The community nephrology Attending at their dialysis unit
The Primary Care Provider they are required to be assigned to by the VA for total-patient care coordination.
The VAMC Nephrologists and dialysis unit, for as-needed dialysis during crises.
CPRS/VistA allows unparalleled identification of patients with renal disease, and a data-manager can pick out those who are deteriorating faster than others in their CKD Stage class. The literature has defined specific variables that can be obtained from DSS that mark those in Stage 3 likely to deteriorate; the rate of kidney function loss, the variability of visit-to-visit BP, and the variability of visit-to-visit kidney function.
In Stage 3, patients tend to progress slowly enough that education of patients and significant others can effect changes in diet and lifestyle in a significant enough proportion to make a difference in their evolution toward more severe renal disease. This is the essence of preventive proactive care.
Once so identified, renal disease patients cam be tracked longitudinally in the VA using CPRS/VistA over years in a way no other health-care system can accomplish.
This permits patient-specific accurate prediction of the point of ESRD requirement
It also allows early identification of those progressing rapidly, allowing more intensive management attempts to delay progression.
Because different patients at different stages of renal disease progress at different rates, a disease-focused clinic system needs to have the flexibility to adjust followup to the individual Veteran rather then trying to fit them into a crowded general PCC schedule.
It is known that patients in Stage 4 require intensive interactive management of the entire milieu of renal disease:
Blood pressure must be maintained at 130-135/80-85
Smoking must be eliminated, if possible.
Efforts to get diabetes under the best possible management using drugs adjusted in type and dose to the declining GFR are essential.
Weight reduction to as close to lean as possible decreases the rate of GFR loss through hyperfiltration.
Detection and control of hyperuricemia are needed, because even if asymptomatic this accelerates loss of GFR.
Since the VA now allows initiation of renal transplant evaluation at GFR of 20mL/min or less, patients who are good transplant candidates can be listed well in advance of needing dialysis, and some can be transplanted before ever needing dialysis.
Protection of veins and timely referral for vascular mapping and General Surgery evaluation for peritoneal dialysis catheter placement are also crucial
To make a systems-based approach like this work, a defined group of area-experts within the healthcare team need to be dedicated to the effort.
Each of these individuals brings a unique piece to the task, making the overall management of this expensive and high-risk patients more efficient, less expensive, and more effective. The nephrologist is just one piece.
The assembled team places the Veteran with renal disease at the center, as any PACT is designed to do, surrounding the patient with immediacy of multi-disciplinary care, and reducing the chance of missing opportunities to intervene early and effectively, thereby making the management of the patient’s disease both an efficient and effective process and the transitions in care and lifestyle created by that disease process the center of their undistracted efforts.
Not all these folks need to be dedicated to the Renal Disease Management Team full-time, but the working core is the Admin Assistant/Data Manager, the Nephrologists, and the Renal PCP. The others need to be dedicated to the Team for a significant fractional FTE. The Dialysis/PICC Nurses are under Nursing, and work in parallel with and in close proximity to the rest of the pre-dialysis management team.
Our VAMC has the ideal location to site that multi-disciplinary care, located next to the current dialysis unit, in an area scheduled to be emptied for creation of a newer, more modern ICU elsewhere.
This location has been reviewed by Engineering, and their verdict was that with virtually no substantial expense the current ICU could be turned into a one-stop location for all renal care and prevention activities, both inpatient and outpatient, with enhanced infection control and patient safety aspects, at practically no cost.
Any disease-management process should be monitored and its outcomes tracked as a means of making the care team a “learning machine” that can adjust its procedures to better and more efficiently reach the desired objective of the right care in the right place at the right time.
These are the recognized metrics for the efficiency of a renal disease management process.
Others outside the VA have tried to build systems-based renal care models. None of them have incorporated all the pieces of this proposed model, and for that reason none of them can hope to reach the same level of sophisticated disease-management care.
We have the right tools, the right capabilities, and the strong economic motivation to build this renal disease management model.
Those who fund us expect it.
Our Veterans deserve it.
These are O&M funds we are proposing to save.
Our Veterans will be better served, with better quality of life and higher-quality lifestyle.
Savings to O&M funds from effective disease management are potentially huge; thiese calculations make the conservative assumptions of $47000/patient-year for hemodialysis 9CMS assumes $80,000 total package care cost per year but the VA figures the internal cost at $47000 annually and assumes the rest of the medication costs will largely come from the VA Pharmacy and VA-supplied Vascular Surgical and Interventional Radiology services.
Also assumed are a 20% reduction in the annual rate of entry into ESRD and the death or transfer to transplant of 25% of patients on hemodialysis annually.
If we also assume a 15% rate of placing patients on peritoneal dialysis, the cost savings are increased, because of fewer hospitalizations annually for PD patients as well as lower rates of complication. This does not even take into account the enormous increase in the quality of a PD patient’s life versus that when on thrice-weekly hemodialysis.
When the number of Nephrology consults and dialysis procedures are viewed over time, the rate of increase in workload is dramatic.
We have close to 4000 patients in Stage 3 and over 900 in late Stage 3, Stage 4, and pre-dialysis Stage 5.
The effectiveness of prospective disease-management is illustrated in the reduction in the number of patients on EPOEITIN. The resulting cost reduction for the drug, from over $400K a year to $100K/year, is an illustration of what good multi-disciplinary management can save.
Our rate of putting Veterans on dialysis currently using the present model of care is accelerating, with huge resulting downstream costs.
