BUILDING MULTI-DISCIPLINARY KIDNEY CARE INTO THE PACT WORLD

Patient-Aligned Kidney Care: Cost-Effective and Efficient Disease Management for the Future

In Synch With the Published Intent of Undersecretary ShulkinCalled “Possible National Model” by VHA Nephrology Consultant

Quoting Dr. David J. Shulkin, M.D.N Engl J Med 2016; 374:1003-1005 March 17, 2016Few 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 FREE-STANDING NEPHROLOGY CLINIC: AN ANACHRONISM

Renal care is one part of a complex processManagement 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

ELEMENTS OF RENAL CARESelection of patients at-risk CPRS has data tools no other healthcare system has!Management must following to uniform, literature- and-

outcomes-based algorithmsRequires special management expertise outside routine

PCCIdentification 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.

SELECTION OF PATIENTS AT-RISKStage 3 CKD patients tend to progress slowly

and can be managed by conventional PCCStage 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

ONCE IN CKD STAGE 4:Special PCP(s) for all Stage 4 patients, where practicable

Centralizing/standardizing the renal care aspectsA 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 candidatesCoordinating 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.

MULTI-DISCIPLINARY EXPERTISENephrology expert care for the renal disease in

coordination with Surgery, UrologyNurse case-management and Nurse EducatorData-management/ tracking Clerical schedulingNutritional managementPharmacologic expertiseNurse PICC Line coordination to “Save the Veins”Clinical Social Work facilitation and coordination

with transplant centers, dialysis vendors, Fee-BasisI.M. primary global care of the whole patient

MATRIX OF MULTIDISCIPLINARY CAREThe 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/PICCNurse

THE OPTIMAL LOCATION: THE OLD I.C.U.

Dialysis and PICC

Outpatient Clinic

Staff & PtEduc

WaitFutur

e Water Rx

Info, Diet, CSW Pharm Workspace

Nursing

MD

Meds

Dialysis / OP Clinic Ck-In

HD Supply

TRACKING PERFORMANCERate 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 dialysisRe-admissions to hospital for medical and surgical reasons

Medical: CHF, cardiac events, CVA’s, catheter and other sepsisSurgical: Graft or fistula maturation to point of ability to use

by time needed, loss of graft or fistula due to thrombosisRate of patients entering dialysis with fistulas versus grafts,

versus cathetersRate of patients getting transplantedDeaths, by causeRates of entry on hemo- and peritoneal-dialysis

OTHER MODELSGeisinger Health System has tried to build a

care consortium with risk-predictionIt is not truly multi-disciplinaryIt does not address up-stream preventionhttps://www.geisinger.org/for-researchers/instit

utes-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

A HUGE POTENTIALThe VA is the largest healthcare entity in the

U.S. that keeps its patients for 20-30 yearsIf 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.

OUR VETERANS DESERVE NOTHING LESSA small investment now in multi-disciplinary

care promises enormous savings in the future.Slower disease progression to ESRDLess 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 dialysisMore / earlier transplants at $30,000/Pt-Yr vice

higher dialysis costs

BACKUP SLIDES

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 CONSULT

S if 20% Could be

Prevented by Disease Manageme

nt

Prevalent Consults

If There is No

Disease-Managem

ent 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 Managemen

t

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 $1.49FY2016 56 45 148 133 $9.13 $7.16 $2.76FY2017 62 50 190 149 $11.36 $7.98 $4.20FY2018 68 54 237 166 $13.81 $8.83 $5.83FY2019 74 59 288 184 $16.48 $9.70 $7.64FY2020 80 64 343 202 $19.36 $10.58 $9.67FY2021 86 69 403 220 $22.46 $5.62 $11.88

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/Patient/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 Management Effect

Total Dialysis Costs if 85% Go on HD and 15% Go on PD With a 20% Delay in Going on Dialysis from Disease Management Effect

Cost Savings from 100% HD Model If 15% Go on PD Without a 20% Delay in HD from Disease Management Effect

Cost Savings from 100% HD Model If 15% Go on PD With Addl 20% Delay in HD from Disease Management Effect

FY10 12 12FY11 28 28F012 17 17FY13 33 33FY14 66 66 $9.2FY15 124 44 $11.84 $9.36

FY16 56 56 $15.2$0.70

8$10.82

8 $11.54 $9.37 $4.37 $5.83

FY17 62 62 $18.92$0.98

6$12.33

7 $13.32 $10.86 $6.58 $8.06

FY18 68 68 $23.00$1.08

6$13.87

7 $14.96 $12.19 $9.12$10.8

1

FY19 74 74 $27.44$1.18

6 $15.44 $16.63 $13.54$12.0

0$13.9

0

FY20 80 80 $32.24$1.28

6$17.02

0 $18.31 $14.90$15.2

2$17.3

4

FY21 86 86 $37.40$1.38

6$18.61

3 $19.99 $16.28$18.7

9$21.1

2

FY22 94 94 $43.04$1.50

4$20.35

2 $21.86 $17.79$22.6

9$25.2

6

X

THERE HAS BEEN A LARGE WORKLOAD INCREASE

DIALYSIS HAS BEEN INCREASING DRAMATICALLY, LARGELY BY FTE’S

THE POPULATION-AT-RISK FOR ESRD IS HUGE

EFFECTIVE MANAGEMENT OF EPOEITIN-ALPHA REDUCES USE

THE NUMBER OF VETERANS GOING ON DIALYSIS IS RISING