Bruce R. Gordon M.D. The Rogosin Kidney Care Alliance ESRD Seamless - - PowerPoint PPT Presentation

Bruce R. Gordon M.D.

The Rogosin Kidney Care Alliance ESRD Seamless Care Organization (ESCO)

**Prospective from a small dialysis

• rganization (SDO)

ESCO Participants – 4 Organizations* 13 ESCOs

Small Dialysis Orgs (SDOs) < 200 units 1 sided risk

The Rogosin Institute Non-profit ~1,600 patients 8 units 1 ESCO

Large Dialysis Orgs (LDOs) > 200 units 2 sided risk

DCI Non-profit 14,800 patients 233 units 3 ESCOs Fresenius For profit 178,337 patients 2,312 units 6 ESCOs Davita For profit 174,300 patients 2,173 units 3 ESCOs

*As of 2016; In 2017 new ESCOs likely added

The Rogosin Institute

Non-profit kidney care provider in NYC Affiliated with NewYork-Presbyterian Health System/Weill Cornell Medicine 8 dialysis units in Brooklyn, Manhattan, and Queens CKD clinic and clinical research Center for Health Action and Policy

• Outreach, education, outcomes research,

policy

Rogosin Kidney Care Model

Better Care, Lower Costs, Better Outcomes, Improved Quality of Life

Health Promotion and Disease Prevention

CKD 1,2,3 Primary Care Hypertension Diabetes control Nutrition Physical activity Healthy living

CKD 4,5

Intensive education Multi-disciplinary care team Emphasis on preparation and treatment choices

ESRD

Transplant In-center hemodialysis PD/home hemo Medical management

ESCO: Why Did Rogosin Participate?

• Improve clinical outcomes, quality, and

decrease cost

• Participate in the national health care

discussion

• Competitive advantage
• SDO will have more roots in the local

community compared to LDO

Challenges for an SDO

The application: Defining our approach, getting partners

and owners, agreements. Help from DCI, CDC and NKCA.

Getting started: Forming the LLC, finalizing agreements,

creating web site, educating staff and partners

Running the ESCO: Time/effort, EHR (using

Darwin/DCI), Data analytics/interpreting financial reports, Quality reporting

Cost: Achieving the minimal savings rate without

• aggregation. Allocate funding to infrastructure and projects

that we needed to do independent of ESCO

Investment Considerations Start Up Costs

• RKCA began in Fall 2016 with 400 aligned

beneficiaries, 300 actively managed

Direct Start Up Costs (approximate) Salaries & Benefits

• 2 Care Coordinators (1 month)

$20,000 ESCO Administration (4 months) $25,000 Legal Fees $8,000 Compliance Program $2,000 Total Direct Start Up Costs $55,000 Note: Excludes Compliance Officer, Quality Director and ESCO Management

Investment Considerations

Direct Annual Costs (approximate) Salaries & Benefits

• 2 Care Coordinators

$200,000 ESCO Administration $75,000 Medication Therapy Management $25,000 Care Management Platform $15,000 Patient Education iPad Program $15,000 Data Analytics $25,000 Travel $10,000 Legal Fees $3,000 Compliance Program $2,000 Total Direct Annual Costs $370,000 Note: Excludes Compliance Officer, Quality Director and ESCO Management

Focus: Reduction of Patient Admissions and Readmissions

• Provide upstream CKD education outside ESCO
• Provide in-patient education and counseling among

pre-ESRD and ESRD patients

• Create partnership with local emergency

department to manage our ESRD patients

• Target high risk patients via dedicated nurse care

coordinators

• Enhance health literacy of patients, families, and

care partners

PEAK

Program for Education In Advanced Kidney Disease

• Goal is to establish relationship between kidney disease

patients and care team early in care process

• Target Group: CKD Stage 4 and 5
• Patient Care Team: Nurse practitioner, nurse educator,

nutritionist, and social worker

• Facilitate informed decision making on renal replacement
• ptions with an emphasis on transplant and home dialysis
• Conservative medical care when appropriate
• Encourage AV access placement before starting dialysis

ESCO Field

Nurse Educator Social Worker Dietitian Nurse Practitioner

Welcome to Rogosin Stadium

PEAK Statistics

May 2015 - August 2016

Number of Patients Percentage Total New Patients Enrolled in Program 192 Started Dialysis 33 17% Referred to Vascular Surgeon 119 62% Vascular Access Placed 106 55% Start HD with AV Access (26% 2014) 19/33 58% Referred for Transplant evaluation 141 73% Started dialysis in the home 2 6%

Hospital In-Patient Program

Target groups:

• Patients who “crash” into dialysis
• Patients with eGFR <20 who are approaching dialysis
• Patients on hemodialysis who have catheters

Educator: Nurse Practitioner with experience as a dialysis nurse

Education regarding:

• dialysis modalities
• access type (if HD)
• urgent home dialysis start (if “crash start”)
• placement of AV access in hospital if appropriate

Role of Care Coordinator

• Target high risk patients based on daily

printout created by EHR (Darwin/DCI)

• Medication reconciliation post discharge
• Integration of RoundingWell program to

assist care coordinator

• Role is evolving
• Recruiting the right talent is critical

Health Literacy

• Definition: The degree to which individuals have the

capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions

• According to the Department of Education, only 12%
• f Americans are proficient in Health Literacy

Factors Impacting Health Literacy

• Culture, language, diversity
• In the NY metropolitan area, there are over 190

languages spoken in households

• Patient demographics, educational attainment
• Communication skills and context
• Complexity of healthcare system, demands on

healthcare systems, new technology, advances in scientific discoveries

Rogosin’s Health Literacy Strategy

• Work upstream with patients prior to dialysis
• PEAK program (CKD education)
• Hospital education program
• Work with current ESRD patients
• iPad education
• Peer to peer learning
• Patient interviews
• Work with Rogosin staff
• Health literacy training
• Work in the community
• Kidney health and transplant education with community-based

partners including senior centers, schools, faith-based

• rganizations, and recreational facilities

Work with Current Patients

• iPad Education Program
• Interactive educational e-books on topics including

coping with dialysis, access management, nutrition, transplant, treatment modalities

• E-books include videos, text, images, PDFs, and

web links

• Link to National Kidney Registry sign-up
• KDQOL completion
• Apps for therapeutic purposes (including meditation

apps, coloring apps, games)

Work with Current Patients

• Peer to peer learning
• Videos with patients discussing their experiences
• Support groups
• Roundtables
• Events bringing together experts from around the

country on topics impacting our patients to develop pilot projects

• Past: health literacy, mental health, nutrition
• Upcoming: transplant
• Interviews to collect patient voice and experience

Work with Rogosin Staff

• Hosted a health literacy staff training in January 2016

with representatives from all Rogosin facilities

• Skills taught: Teach-back, Plain Language, Universal

Precautions

• Formation of “health literacy champions” team
• Currently developing in-service to spread training

topics to all Rogosin staff

ESCO - Next Steps

• Broader provider participation/engagement
• Increase focus on home dialysis
• Advocacy for inclusion of kidney transplantation in the CEC

model

• Enhanced end-of-life care and planning
• Analysis of financial data
• Work toward aggregation with new participant SDOs in

2017

• One-sided risk 2017, two sided risk 2018?

Discussion and Questions

Thanks!