Download to read offline
More Related Content
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. DavidJ. 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 RENALCARE 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 PATIENTSAT-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 CKDSTAGE 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 Nephrologyexpert 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 MULTIDISCIPLINARYCARE 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 OLDI.C.U. D i a l y s i s a n d P I C C O u t p a t i e n t C l i n i c Staff & PtEduc W a i tFuture Water Rx Info, Diet, CSW Pharm Workspace Nursing MD Meds Dialysis / OP Clinic Ck-In HD Supply
- 10. TRACKING PERFORMANCE Rateof 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 GeisingerHealth 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 DESERVENOTHING 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
- 14.
- 15. TABLE 7: ProjectedNumber 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: ProjectedCosts 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
- 17. THERE HAS BEENA LARGE WORKLOAD INCREASE
- 18. DIALYSIS HAS BEENINCREASING DRAMATICALLY, LARGELY BY FTE’S
- 19.
- 20. EFFECTIVE MANAGEMENT OF EPOEITIN-ALPHAREDUCES USE
- 21. THE NUMBER OFVETERANS GOING ON DIALYSIS IS RISING
Editor's Notes
- #2 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”.
- #3 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.”
- #4 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
- #5 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.
- #6 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.
- #7 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
- #8 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.
- #9 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.
- #10 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.
- #11 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.
- #12 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.
- #13 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.
- #14 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.
- #16 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.
- #17 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.
- #18 When the number of Nephrology consults and dialysis procedures are viewed over time, the rate of increase in workload is dramatic.
- #20 We have close to 4000 patients in Stage 3 and over 900 in late Stage 3, Stage 4, and pre-dialysis Stage 5.
- #21 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.
- #22 Our rate of putting Veterans on dialysis currently using the present model of care is accelerating, with huge resulting downstream costs.