Improving Care in the Late Stages of Kidney Disease Steven Fishbane - - PowerPoint PPT Presentation

Improving Care in the Late Stages

• f Kidney Disease

Steven Fishbane Hofstra Northwell Health School of Medicine

What Should be Accomplished in late Stages of CKD?

• Determine suitability for ESKD treatment
• Educate on modality choices

– Hemodialysis, peritoneal dialysis, transplantation

• Transplant- facilitate complicated process
• PD- Full assessment and get timing right
• HD

– Place AV fistula well in advance

• Other

Costs in the Peri-Dialysis Period

Kidney Int. 2014 Aug;86(2):392-8

Preparation for ESKD

• 80% of U.S. hemodialysis patients

start with catheter

• 65% of dialysis patients start with a

hospitalization

• Only 9% start on home dialysis
• Only 2.6% receive preemptive

kidney transplantation

• 60% state never received education
• n choices

Healthy Transitions in Late Stage Kidney Disease History

2011 Began Development 10/2012 First pilot phase patient 1/2014 Began RCT 9/2014 Started HCIA 1/2016 Completed RCT 2/2016 Partnered with NKF – payment model 5/31/2016 563 total patients from inception

HT Program Committee Structure

Program Steering Committee Joe Schulman

• S. Fishbane, MD

Sofia Agoritsas Candice Halinski Chrystal Flourentzou Medical Advisory Board Committee NSLIJ Medical Group Nephrologists

• E. Ilamathi, MD

LHH Nephrologists ACP Nephrologists

• A. Husain, DO

Program Management Committee/Daily Operations

• S. Fishbane, MD Craig Gordon

Sofia Agoritsas Terry Tan Candice Halinski Vipul Sakhiya Chrystal Flourentzou Mary Rzeszut

• A. Hazzan, MD

Patient Management Review HT RN's

• S. Fishbane, MD
• A. Hazzan, MD

Chrystal Flourentzou Candice Halinski Vipul Sakhiya Mary Rzeszut Finance and Payment Model Committee DOM Leadership Sofia Agoritsas

• S. Fishbane, MD

Matthew Jelavic Ella Parys Richard Miller Joseph Schulman Chrystal Flourentzou Candice Halinski Advanced Illness Committee

• H. Koncicki, MD
• S. Fishbane, MD

Terry Tan Chrystal Flourentzou Sofia Agoritsas Candice Halinski Vipul Sakhiya Mary Rzeszut HT RN's IHI

Healthy Transitions in Late Stage CKD

• Improve poor national outcomes –

Break Through Barriers:

• Promote evidence based practice
• Nursing care management

– Collaborating with nephrologists

• Informatics

– Decision support – Nursing efficiency – Bring protocols to life

HT Program Components

• Home visits
• HT Countdown to Fistula Program
• Healthy Transitions PhoneLink
• Universal dietary consultation
• Medication review
• HT Safe at Home Program
• Social work - depression and anxiety screening
• Conservative Care Management Program
• Physician score card

HT Late Stage Kidney Disease Program

Potential for Stage 4/5 Care Management

Key Savings Areas U.S. 2013 HT Program 2012- 2016 Benchm ark % ∆ Change Annual Cost Savings per ESRD Patient Potential Annual U.S. Savings Increase in Preemptive Transplantation 2.6% 10% 7.4% $56,000 $1.7 Billion Increase in Outpatient Dialysis Starts 30% 65% 35% $22,000 $400 Million Avoid Catheter per HD Patient 19% 60% 39% $15,000 $420 Million Increase in Home Dialysis 8% 24% 16% $20,000 $760 Million Total $3.3 Billion

HT Pilot Results

U.S. Average HT Results Implied Savings Hospitalizations 1.21-1.99 1.14 Mortality 0.14 0.04 Modality Selection 0.35 0.68 Preemptive Transplantation 2.6% 11% $60,000 per year Home Dialysis 7% 27% $20,000 per year HD Catheters 81% 26% $30,000 HD AV Fistulas 24% 68% Same Start HD as Outpatient 20% 65% $25,000 one time

Why is Advanced Care Management Needed?

• Nephrologists are very busy
• Late stage CKD care episodic

– Complex processes

• Fragmented care
• Resistance

– Nephrologists – Patients

• Patients who are never seen by a nephrologist

Regulatory Scan

Changes in Payment Legislature

• Medicare Access & CHIP Reauthorization Act of 2015 (MACRA)

– Alternative Payment Models (APMs) – Merit Based Incentive Payment Systems (MIPS)

• Kidney Disease – Integrated Care Management

– ESCOs (2014) – Dialysis Integration legislation – CMS Updates to Policies and Payment Rates for End-Stage Renal Disease Facilities for CY 2016 and Changes to the ESRD Quality Incentive Program

• Specifically asks for new models for late stage CKD care / payment

Can an HT Type Program Work More Broadly?

• Yes
• Any nephrology practice could provide care

management services

– Would require a practice nurse at a minimum – Ideally, centralized informatics

• Centralized care management services
• All would cost money

– Better outcomes would require a new payment model

The End