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Quality-Based

Procedures ClinicalHandbook for ChronicKidney Disease

Ministry of Health and Long-Term Care

March 2013


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Table of Contents1.0 Purpose .............................................................................................................. 32.0 Introduction ......................................................................................................... 43.0 Description of Chronic Kidney Disease (CKD) as a Quality-Based Procedure . 114.0 Evidence-informed practice guiding the implementation of CKD ...................... 145.0 How does CKD improve patient outcomes? ..................................................... 176.0 What does it mean for clinicians? ..................................................................... 187.0 Service capacity planning ................................................................................. 208.0 Performance, evaluation and monitoring .......................................................... 219.0 Support for Change .......................................................................................... 22

10.0 Frequently Asked Questions............................................................................. 2311.0 Committees ...................................................................................................... 34


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Quality-Based Procedures ClinicalHandbook: Chronic Kidney

Disease (CKD)

1.0 Purpose

This clinical handbook has been created to serve as a compendium of the evidence-based rationale and clinical consensus driving the development of the policy frameworkand implementation approach for Chronic Kidney Disease in 2013/14. The Ontario

Renal Network (ORN) has played an integral role in the planning and developmentprocess and providing advice on best practice care in the delivery of renal servicesacross Ontario. As well, ORN will continue to provide a key leadership role in theimplementation of the CKD policy framework while working in close collaboration withthe Local Health Integration Networks (LHINs) and all health sectors involved in theprovision of CKD services.

This clinical handbook is intended for a clinical audience. It is not, however, intended tobe used as a clinical reference guide by clinicians and will not be replacing existingguidelines and funding applied to clinicians. Evidence-informed pathways and resourceshave been included in this handbook for your convenience.


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2.0 Introduction

Quality-Based Procedures (QBP) are an integral part of Ontarios Health SystemFunding Reform (HSFR) and a key component of the Patient-Based Funding (PBF).This reform plays a key role in advancing the governments quality agenda and its

Action Plan for Health Care. HSFR has been identified as an important mechanism tostrengthen the link between the delivery of high quality care and fiscal sustainability.

Ontarios health care system has been living under a global economic uncertainty for aconsiderable period of time. At the same time, the pace of growth in health carespending has been on a collision course with the provincial governments deficitrecovery plan.

In response to these fiscal challenges and to strengthen the commitment towards thedelivery of high quality care, the Excellent Care for Al l Act (ECFAA) received royal

assent in June 2010. ECFAA is a key component of a broad strategy that improves thequality and value of the patient experience by providing them with the right care at theright time, and in the right place through the application of evidence-informed healthcare. ECFAA positions Ontario to implement reforms and develop the levers needed tomobilize the delivery of high quality, patient-centred care.

OntariosAc tion Plan for Health Care advances the principles of ECFAA reflectingquality as the primary driver to system solutions, value and sustainability.

2.1 What are we moving towards?

Prior to the introduction of HSFR, a significant proportion of hospital funding wasallocated through a global funding approach, with specific funding for some selectprovincial programs and wait times services. A global funding approach reducesincentives for Health Service Providers (HSPs) to adopt best practices that result inbetter patient outcomes in a cost-effective manner.

To support the paradigm shift from a culture of cost containment to qualityimprovement, the Ontario government is committed to moving towards a patient-

centred funding model that reflects local population needs and contributes to optimalpatient outcomes (Figure 1).

Internationally, PBF models have been implemented since 1983. Ontario is one of thelast leading jurisdictions to move down this path. This puts the province in a uniqueposition to learn from international best practices and lessons learned by others tocreate a funding model that is best suited for Ontario.


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PBF supports system capacity planning and quality improvement through directly linkingfunding to patient outcomes. PBF provides the incentive to health care providers tobecome more efficient and effective in their patient management by accepting andadopting best practices that ensure Ontarians get the right care, at the right time and inthe right place.

Figure 1: The Ontario government is committed to moving towards patient-centred, evidence-informed

funding that reflects local population needs and incents delivery of high quality care

CCuurrrreennt St Statatete

Based on a lump sum, outdated

historical funding

Fragmented system planning

Funding not linked to outcomes

Does not recognize efficiency,standardization and adoption of bestpractices

Maintains sector specific silos

How do we get there?

Strong ClinicalEngagement

Current Agency

Infrastructure

System Capacity

Building for Change

and Improvement

Knowledge to ActionToolkits

Meaningful

Performance

Evaluation Feedback

FutFutureure SSttaattee

Transparent, evidence-based to better

reflect population needs

Supports system service capacity

planning

Supports quality improvement

Encourages provider adoption of best

practice through linking funding to

activity and patient outcomes

Ontarians will get the right care, at the

right place and at the right time


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2.2 How wil l we get there?

The Ministry has adopted a three-year implementation strategy to phase in a PBFmodel and will make modest funding shifts starting in fiscal year 2012/13. A three-yearoutlook has been provided to the field to support planning for upcoming funding policychanges.

The Ministry has released a set of tools and guiding documents to further support thefield in adopting the funding model changes. For example, a Quality-Based Procedure(QBP) Interim list has been published for stakeholder consultation and to promotetransparency and sector readiness. The list is intended to encourage providers acrossthe continuum to analyze their service provision and infrastructure in order to improveclinical processes and where necessary, build local capacity.

The successful transition from the current, provider-centred funding model towards apatient-centred model will be catalyzed by a number of key enablers and fieldsupports. These enablers translate to actual principles that guide the development ofthe funding reform implementation strategy related to QBPs. These principles furthertranslate into operational goals and tactical implementation, as presented in Figure 2.

Figure 2: Principles guiding the implementation of funding reform related to Quality-Based Procedures

PPrriincnciipplleess fforor ddeevveellopopiinngg QQBPBPiimpmplleemenmentatatitioonn ststrrateateggyy

Cross-Sectoral Pathways

Evidence-Based

Balanced Evaluation

Transparency

Sector Engagement

Knowledge Transfer

OOpeperarattiionaonalliizzaattiionon of of priprinncciiplpleess ttoottacacttiicacall iimmppllememeennttaattiioonn ((eexxamampplleess))

Development of best practice patient

clinical pathways through clinical expertadvisors and evidence-based analyses

Integrated Quality Based Procedures

Scorecard

Alignment with Quality Improvement Plans

Publish practice standards and evidence

underlying prices for QBPs

Routine communication and consultation

with the field

Clinical expert panels

Provincial Programs Quality Collaborative

Overall HSFR Governance structure in

place that includes key stakeholders

LHIN/CEO Meetings

Applied Learning Strategy/ IDEAS

Tools and guidance documents

HSFR Helpline; HSIMI website (repository

of HSFR resources)


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2.3 What are Quality-Based Procedures?

QBPs involve clusters of patients with clinically related diagnoses or treatments.Chronic Kidney Disease was chosen as a QBP using an evidence and quality-based

selection framework that identifies opportunities for process improvements, clinical re-design, improved patient outcomes, and enhanced patient experience and potential costsavings.

The evidence-based framework used data from the Discharge Abstract Database (DAD)adapted by the Ministry of Health and Long-Term Care for its Health Based AllocationMethodology (HBAM) repository. The HBAM Inpatient Grouper (HIG) groups inpatientsbased on the diagnosis or treatment responsible for the majority of their patient stay.Day Surgery cases are grouped within the National Ambulatory Care Referral System(NACRS) by the principal procedure they received. Additional data was used from theOntario Case Costing Initiative (OCCI). Evidence such as publications from Canada and

other jurisdictions and World Health Organization reports were also used to assist withthe patient clusters and the assessment of potential opportunities. Specifically, for theChronic Kidney Disease (CKD) QBP, Ontario Renal Registry System (ORRS) data incombination with NACRS and the Self-Reporting Initiative (SRI) data are used to trackservices. Additional data from OCCI and the Ontario Joint Policy and PlanningCommittee (JPPC) are also used.

The evidence-based framework assessed patients using four perspectives, aspresented in Figure 3. This evidence-based framework has identified QBPs that havethe potential to both improve quality outcomes and reduce costs.


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Figure 3: Evidence-Based Framework

Does the clinical group contribute to a significant proportion of total costs? Is there significant variation across providers in unit costs/ volumes/ efficiency? Is there potential for cost savings or efficiency improvement through more consist ent

practice?

How do we pursue quality and improve efficiency?

Is there potential areas for integration across the care continuum?

Are there clinical leaders able to champion change in thisarea?

Is there data and reporting infrastructure in place?

Can we leverage other initiatives or reforms related to

practice change (e.g. Wait Time, Provincial Programs)?

Is there a clinical evidence base for an established standard of care and/orcare pathway? How strong is the evidence?

Is costing and utilization inform ation available to inform development ofreference costs and pricing?

What activities have the potential fo r bundled payments and integrated care?

Is there variation in clinical outcomes across providers,regions and populations?

Is there a high degree of observed practice variation acrossproviders or regions in cl inical areas where a best practice orstandard exists, suggesting such variation is inappropriate?

1. Practice Variation

The DAD has every Canadian patient discharge, coded and abstracted for the past 50years. This information is used to identify patient transition through the acute caresector, including discharge locations, expected lengths of stay and readmissions foreach and every patient, based on their diagnosis and treatment, age, gender, co-morbidities and complexities and other condition specific data. A demonstrated largepractice or outcome variance may represent a significant opportunity to improve patientoutcomes by reducing this practice variation and focusing on evidence-informed

practice. A large number of Beyond Expected Days for length of stay and a largestandard deviation for length of stay and costs, were flags to such variation. Ontario hasdetailed case costing data for all patients discharged from a case costing hospital fromas far back as 1991, as well as daily utilization and cost data by department, by day andby admission.


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2. Availabi li ty of Evidence

A significant amount of research has been completed both in Canada and across theworld to develop and guide clinical practice. Working with the clinical experts, bestpractice guidelines and clinical pathways can be developed for these QBPs and

appropriate evidence-informed indicators can be established to measure performance.

3. Feasibility/ Infrastructure for Change

Clinical leaders play an integral role in this process. Their knowledge of the patients andthe care provided or required represents an invaluable component of assessing whereimprovements can and should be made. Many groups of clinicians have already formedand provided evidence and the rationale for care pathways and evidence-informedpractice.

4. Cost Impact

The selected QBP should have no less than 1,000 cases per year in Ontario andrepresent at least 1 percent of the provincial direct cost budget. While cases that fallbelow these thresholds may in fact represent improvement opportunity, the resourcerequirements to implement a QBP may inhibit the effectiveness for such a small patientcluster, even if there are some cost efficiencies to be found. Clinicians may still work onimplementing best practices for these patient sub-groups, especially if it aligns with thechange in similar groups. However, at this time, there will be no funding implications.The introduction of evidence into agreed-upon practice for a set of patient clusters thatdemonstrate opportunity as identified by the framework can directly link quality withfunding.

2.4 How will QBPs encourage innovation in health caredelivery?

Implementing evidence-informed pricing for the targeted QBPs will encourage healthcare providers to adopt best practices in their care delivery models, and maximize theirefficiency and effectiveness. Moreover, best practices that are defined by clinicalconsensus will be used to understand required resource utilization for the QBPs andfurther assist in the development of evidence-informed prices. Implementation of aprice X volume strategy for targeted clinical areas will incent providers to:


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Adopt best practice standards;

Re-engineer their clinical processes to improve patient outcomes; and

Develop innovative care delivery models to enhance the experience of patients.

Clinical process improvement may include the elimination of duplicate or unnecessaryinvestigations, better discharge planning, and greater attention to the prevention ofadverse events, i.e., post-operative complications. These practice changes, togetherwith adoption of evidence-informed practices, will improve the overall patient experienceand clinical outcomes, and help create a sustainable model for health care delivery.


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3.0 Description of Chronic Kidney Disease (CKD)as a Quality-Based Procedure

The Chronic Kidney Disease QBP is applied to non-pediatric CKD patients based on thenature and progression of their renal impairment. This QBP relates to the provision ofmultiple services along the continuum of care for CKD patients, from early identificationand management to severe CKD on dialysis. This includes 33+ funded services related,but not limited to, clinics and procedures. Additional services may be included within thisframework in the future.

CKD has been identified as a QBP using the evidence-based selection framework, aspresented in Figure 4.

Figure 4: Evidence-based framework for Chronic Kidney Disease

Provincial fundin g for hospital CKD services: over $500M (3.79% of globalbudget)

Significant variation across providers in costs per service

Integration of Chronic Kidney Disease services with other providers e.g. Long-Term Care Homes, CCACs

Strong stakeholder support and interest for improving Chronic KidneyDisease services

Ontario Renal Network, with its clin ical leadership, is to pr ovideleadership in the implementation of the change

Expansion of current data and reporting structure to monitor performanceand best practices

Recognized best practices and clinic al guidelines available

CKD patient-based payment mod el (bundled and unbundl ed services) basedon best practice

Endorsement of Clinical Practice Guidelines from Clinical Expert Group Costing and utilization information available to inform development of

reference costs and pricing

First Ontario Chronic Kidney Disease Atlas released in November 2011,highlighting CKD services delivery in Ontario

Opportunity t o standardize practice and incorpor ate best practice acrossOntario


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The CKD patient-based funding model, developed by the Ontario Renal Network(ORN), has two components: Patient Based Bundled Services, and the Service BasedFunding.

The PBF component is a bundled payment, based on best practice, which covers the

costs of all services required by a standard patient for a years worth of a particular CKDtreatment. The framework includes seven (7) annual patient-based payment bundles asfollow:

Bundle A - Pre-dialysis;

Bundle B.1 - Home Peritoneal Dialysis - Automated Peritoneal Dialysis (APD);

Bundle B.2 - Home Peritoneal Dialysis - Continuous Ambulatory PeritonealDialysis (CAPD);

Bundle C - Home Hemodialysis - Daily/Nocturnal;

Bundle D - Home Hemodialysis - Conventional;

Bundle E - Chronic In-Facility or Satellite HD Daily/Nocturnal; and

Bundle F - Chronic In-Facility or Satellite HD Conventional.

The services contained within the bundles for each of these modalities were determinedby the ORN Clinical Advisory Committee (CAC) and the CKD Funding Working Group.

The service-based funding is a fee-for-service model which pays for services thatcannot be bundled because their occurrence and/or frequency cannot be predicted.This model works the same way as the current operating funding model. Examples ofunbundled services in 2013/14 include:

Home Visit Nursing Hours of Service;

Home Visit Technician Hours of Service;

Nephrology Clinic Visit;

Education Clinic Visit;

Central Venous Catheter-Temporary Insertion;

Acute Hemodialysis Level III;

Arterio-Venous Fistula Insertion; and

Vascular Graft Insertion.

This model will be implemented over a four-year period. The first year of implementationstarted in 2012/13 with the four (4) related home bundled payments. The remainder ofthe bundles (i.e., Pre-dialysis and In-Centre) are to be implemented in 2013/14.

CKD, within the QBP model, encompasses the management of the early stage of thechronic renal disease, the pre-dialysis, the body access insertions (abdominal and


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vascular) and dialysis aspects of the disease, but excludes, at present, the earlydetection and prevention of CKD, or transplant-related services.

The key objectives of this QBP are to: Be accountable to CKD patients

Improve health outcomes, and Manage the costs of CKD care.

The new funding framework for CKD provides payment which follows the patients in away that supports integration, quality and efficiency throughout the entire patientpathway. Equitable access to care for patients across Ontario remains a strong priority.In addition, the implementation of this QBP discourages the over-provision of services.The funding framework provides funding aligned to best practice, appropriate providerreimbursement, and improved accountability for outcomes.

The quality agenda for this QBP reflects four (4) clinical improvement priorities;

Early detection and prevention of progression Independent dialysis Improvements in vascular access, and Research and innovation.

The information and reporting systems for CKD services have undergone a transition asthe QBP was implemented. The Self Reporting Initiative (SRI) has replaced the WebEnabled Reporting System (WERS) for managing CKD data reporting requirements andprovides the financial and utilization data for the purpose of CKD service-basedreimbursement. Additionally the Ontario Renal Reporting System (ORRS) has beenfurther developed to better capture patient modality of care received and now acts asthe key information source for CKD patient-based reimbursement.

The CKD PBF model developed by the ORN has significant potential for positivechange, particularly when integrated with related ORNs initiatives to improve access toneeded services, develop an expanded performance measurement and reportingframework, and promote more evidence-informed practice and quality improvementacross the CKD system in Ontario.


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4.0 Evidence-informed practice1guiding theimplementation of CKD

4.1 How was the patient pathway defined?

Collaboration between medical leads, nephrologists and clinicians has led to theestablishment of seven distinct categories of CKD patients based on their type oftreatment modality. The clinical pathway for CKD patients can be summarized into theseven service bundles, which outline the best practice of care provided for each

1 Evidence-informed practice refers to a combination of best available evidence and clinical consensus


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category of CKD patient. The CKD funding framework currently encompasses dialysisand pre-dialysis care. The aim is to eventually cover most, if not all, aspects relating tothe continuum of CKD.

The funding bundles, as presented in Figure 5, provide a form of annual reimbursement

which follows the patient and discourages over-provision of services.

Figure 5: Funding bundles for CKD

Bundle A comprises the services for pre-dialysis patients as part of the clinic visits.

Upon further deterioration of the kidney function, patients may move on to renal

replacement therapies covered by bundles B1 through F. Bundles B1 and B2 are thegroupings of services for peritoneal dialysis (PD) patients. PD is an independent dialysismodality performed in the patients home. PD can be classified into two subtypes,automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis(CAPD). APD is performed at night while the patient sleeps, and is covered by bundleB1. CAPD involves a series of exchanges performed throughout the day, and is coveredby bundle B2.


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Bundles C and D are also comprised of services for independent dialysis. Bundle C isthe package for patients performing nocturnal or daily hemodialysis at home. Bundle Dprovides services for patients undergoing conventional HD in their home, which ischaracterized by approximately 3 day time hemodialysis treatments per week.

The last two packages, Bundles E and F, encompass services for patients receivingchronic in-facility or Satellite HD, either in a hospital-based or community-based facility.Patients who undergo daily or nocturnal in-centre HD are covered under Bundle E,while patients who receive conventional HD are covered under Bundle F.

As the CKD strategy implementation evolves, the CKD funding framework willencompass most, if not all, aspects relating to the continuum of CKD. In addition, whilefiscal year 2012/13 marked the initial implementation of CKD as a QBP, this wasconsidered to be a starting point to the move towards evidence-informed pricing (Figure6). In 2013/14, the remainder of the bundles will be implemented, some of which will beadjusted for specific provider or patient-level characteristics. Specifically, adjustments

will be made to the hemodialysis treatments provided to older patient populations andperformed in small satellites.

Figure 6: As implementation evolves, an evidence-informed price will be set for CKD services

40th Percentile Pricing

2012/13

Application to QBPs

which show narrow

variation between patient

cases

2012/13 QBPs include:

Primary unilateral

hip replacement

Primary unilateral

knee replacement

Cataracts

Chronic Kidney

Disease*

6.97 % **

Continue

development ofcross-sectoralclinical pathways

with guidance from

clinical expertpanels

Reconcile clinical

pathways withavailability of

clinical/administrativedata

Routine, iterative

sectorconsultations for

lessons learned tocatalyzeimprovement

Evidence-informed Pricing

2013/14+

Application to QBPs

which show wide variationand range of complexities

across patient cases

As implementation

evolves, more QBPs will

be introduced

30 % ***

* Interim price is based on actual direct cost retrieved from OCCI data

** In 2012/13, QBPs will comprise approximately 6.97% of the total hospital global budget

*** At the end of 2014/15, QBPs will comprise approximately 30% of the total hospital global budget


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5.0 How does CKD improve patient outcomes?

At the request of the Ministry, ORN has developed a PBF model for accelerating qualityimprovement and access to CKD services while improving system value.

The ORN has been working in close consultation with clinical, policy and financialexperts to develop a framework that links funding to best practice patient care. Thisframework has been shaped from the work of six separate committees:

1. CKD Clinical Advisory Committee (CAC)

The CAC was the main contributing body comprising of a team of seven Ontarionephrologists. The primary role of the CAC was to provide advice regarding clinicalpractice and quality care.

2. The Provincial Leadership Forum (PLF)

PLF provides counsel regarding operational practice, system planning and qualitycare. The PLF is comprised of fourteen ORN Regional Directors (RDs) for CKD carein Ontario.

3. Funding Model Reference Panel

To keep funding policies up to date, a funding panel was established beginning inAugust 2010 and ending in May 2011. The framework validation for CKD was led bythe Funding Model Reference Panel; a diverse committee which included CACrepresentatives, hospital administrators, RDs and members of the ORN.

4. Funding Model Working Group

The Funding Model Working Group was aligned with the Funding Model ReferencePanel, but focused dominantly on framework development. The Working Group iscomprised of clinical and administrative leaders (nephrologists, Regional Directors,

MOH representation and CCO/ORN staff), to guide its work. During Phase 2, CCACand LTC representation was added to the Working Group.

5. Regional Renal Steering Commit tee (RRSC)

Fourteen RRSCs have been established to participate in comprehensive andcoordinated planning of CKD services in each respective LHIN. In particular, the


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responsibility of each RRSC is to ensure that its respective LHIN is responsive tolocal needs and aligned with the ORN strategies and directions. Other aspects ofeach RRSC is to ensure optimal delivery of all CKD service levels across its LHIN,making recommendations and providing advice to the ORN to improve access andquality of care related to CKD. There are 14 RRSCs, corresponding to 14 LHINs.

Throughout the development and implementation of the CKD Funding framework,the RRSC memberships have been informed.

6. CKD Funding Panel

The Funding Panel was established in part to provide an ongoing governancestructure focused on the further development and implementation of the CKDfunding framework. The CKD Funding Panel is chaired by Dr. Peter Magner, andprovides expert advice to the ORN on matters related to the funding of CKD servicesin Ontario, including hospital funding allocation, system design, policy and quality of

care implications, and related data and reporting issues. All of the CKD FundingPanel members are also representatives on the Working Group.

6.0 What does it mean for clinicians?

6.1 How does CKD as a QBP align with clinician practice?

The QBP for CKD provides funding to promote the provision of evidence-informed, bestpractice care. Each patient will not require the exact type and amount of servicesprovided within this clinical pathway recognized as best practice. The bundles within thefunding framework are meant to provide payments aligned to the appropriate level ofcare for a patient requiring the average quantity of services. In allocating funding for theaverage level of treatments defined by best practice, the funding framework will providethe appropriate counterbalance between patients requiring a greater or lesser amount ofcare.

6.2 Will this have any implications for clinicians?

The changes associated with QBPs focus on identifying and implementing evidence-informed practice driven by clinical consensus. Clinicians will be tasked with identifyingwithin their own practice standard treatment protocols and pinpointing where there arevariances from such practice. Collaboration with their hospital and/or community basedprovider administration will assist both the clinicians in identifying the challenges withinthe service, opportunities and the feasibility for changes to the treatment protocols.


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Clinicians will continue to play an essential role in guiding hospitals and communitybased providers to the needs of their patient population and ensuring that the highestquality care is provided for all their patients.

6.3 Will this change current practice?

The CKD PBF framework may create a change in current practice for certain cliniciansin Ontario. The baseline data published by the ORN in the CKD Atlas identifies apractice variation amongst CKD care providers throughout Ontario. Those who arecurrently delivering services beyond the standards of evidence-informed practice willneed to adopt greater efficiency and reduce the over-provision of services. On the otherhand, CKD care providers who deliver fewer services than the standards of care, will befunded to increase their volumes up to the evidence-informed clinical practice.

At this time, physician payment models and OHIP fee schedules, as they relate toQBPs, will remain unchanged. Physicians currently working under fee-for-service willcontinue to submit claims to OHIP for consultations, performing the procedure andfollow-up.


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7.0 Service capacity planning

7.1 How will clinician volume management be affected byor affect hospital CKD volumes?

The volumes of CKD services in each modality bundle will be based on evidence-informed practice, as determined by the ORNs CAC and other related expert groups.Though the number of services funded within the bundles is defined, there will be nopatient volume caps due to the life-support nature of the CKD dialysis services.

The CKD PBF, including the seven modality bundles, will be implemented over fouryears. Service volumes will align the number of services per patient according to the

agreed-upon best practice set out in the funding bundles.

7.2 How will the new model of budget planning includeclinicians?

Opportunities for clinicians to participate in the development and implementation of thenew CKD patient-focused funding model are available at all different levels throughoutthe province.

Clinical leaders may decide to have active participation on regional and provincial level

working groups or within their respective organization.

The new model for budget planning has included clinicians in the formulation ofevidence-informed practice and standards of care.


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8.0 Performance, evaluation and monitoring

Improving the quality and access of CKD services is central to the implementation ofCKD. Performance, evaluation and monitoring will be an essential aspect of the newCKD funding framework. The purpose of this QBP is rooted in providing quality CKDcare that meets expected outcomes, goals and objectives. Building on the ORNquarterly performance management cycle, the ORN will measure, monitor and report onfunding (bundled services) and services (provider practices) as well as clinical qualityand patient outcomes. All CKD funding policy measurement and reporting will be tied toexplicit goals and objectives and will help to inform a CKD Monitoring and EvaluationFramework (CKD MEF), which is being developed collaboratively by the clinician ledClinical Measurement Expert Group (CMEG) and the ORN.

Part of the evaluation process regarding efficiency and remuneration involves theassessment of standards set in other jurisdictions. In addition, part of the process ofassessing the impact of Health System Funding Reform on the health care system willbe developing a set of indicators to track and evaluate the performance of the CKDpatient-based funding model. Furthermore, the MOHLTC is leading the development ofan integrated QBP scorecard that will track and assess the impact of QBPs againstindicators of quality. This scorecard will be aligned with currently existing qualityindicators used in other reporting processes.


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9.0 Support for Change

The ORN will provide input on the overarching HSFR strategy for system change andspecifically, lead the change management related to CKD service delivery.

The Ministry, in collaboration with its partners, will deploy a number of field supports tosupport adoption of the funding policy. These supports include:

Committed medical engagement with representation from cross-sectoral healthsector leadership and clinicians to champion change through the development ofstandards of care and the development of evidence-informed patient clinicalpathways for the QBPs

Dedicated multidisciplinary clinical expert group that seek clearly definedpurposes, structures, processes and tools which are fundamental for helping tonavigate the course of change

Strengthened relationships with Ministry partners and supporting agencies toseek input on the development and implementation of QBP policy, disseminatequality improvement tools, and support service capacity planning

Alignment with quality levers such as the Quality Improvement Plans (QIPs).QIPs strengthen the linkage between quality and funding and facilitatecommunication between the hospital board, administration, providers and public

on the hospitals plans for quality improvement and enhancement of patient-centered care

Deployment of a Provincial Scale Applied Learning Strategy known as IDEAS(Improving the Delivery of Excellence Across Sectors). IDEAS is Ontariosinvestment in field-driven capacity building for improvement. Its mission is to helpbuild a high-performing health system by training a cadre of health systemchange agents that can support a approach to improvement of quality and valuein Ontario

We hope that these supports, including this Clinical Handbook, will help facilitate a

sustainable dialogue between hospital administration, clinicians, and staff on theunderlying evidence guiding QBP implementation. The field supports are intended tocomplement the quality improvement processes currently underway in yourorganization.


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10.0 Frequently Asked Questions

Question 1:

How can I obtain more information about this?

Helplineo Email: [email protected] Phone: 416-327-8379

The ministrys public website: www.health.gov.on.ca

Access the Health Care Professionals pageo Excellent Care For All (www.health.gov.on.ca/en/ms/ecfa/pro/ )

o HSFR (http://www.health.gov.on.ca/en/ms/ecfa/pro/initiatives/funding.aspx ) Password protected website for provider: www.hsimi.on.ca

o Repository of HSFR resources, including HBAM results and educationmaterials

For further information, please visit:

Ontario Renal Networkhttp://www.renalnetwork.on.ca/

Cancer Care Ontario

https://www.cancercare.on.ca/

Excellent Care for All Acthttp://www.health.gov.on.ca/en/ms/ecfa/pro/about/

Health System Funding Reformhttp://www.health.gov.on.ca/en/ms/ecfa/pro/initiatives/funding.aspx

Ontario Medical Associationhttps://www.oma.org/Pages/default.aspx

Health Quality Ontariowww.hqontario.ca

Canadian Institute for Health Informationhttp://www.cihi.ca/CIHI-ext-portal/internet/EN/Home/home/cihi000001

Institute for Clinical Evaluative Scienceshttp://www.ices.on.ca/
mailto:[email protected]://www.health.gov.on.ca/http://www.health.gov.on.ca/en/ms/ecfa/pro/http://www.health.gov.on.ca/en/ms/ecfa/pro/http://www.health.gov.on.ca/en/ms/ecfa/pro/initiatives/funding.aspxhttp://www.health.gov.on.ca/en/ms/ecfa/pro/initiatives/funding.aspxhttp://www.hsimi.on.ca/http://www.renalnetwork.on.ca/https://www.cancercare.on.ca/http://www.health.gov.on.ca/en/ms/ecfa/pro/about/http://www.health.gov.on.ca/en/ms/ecfa/pro/initiatives/funding.aspxhttps://www.oma.org/Pages/default.aspxhttp://www.hqontario.ca/http://www.cihi.ca/CIHI-ext-portal/internet/EN/Home/home/cihi000001http://www.ices.on.ca/http://www.ices.on.ca/http://www.cihi.ca/CIHI-ext-portal/internet/EN/Home/home/cihi000001http://www.hqontario.ca/https://www.oma.org/Pages/default.aspxhttp://www.health.gov.on.ca/en/ms/ecfa/pro/initiatives/funding.aspxhttp://www.health.gov.on.ca/en/ms/ecfa/pro/about/https://www.cancercare.on.ca/http://www.renalnetwork.on.ca/http://www.hsimi.on.ca/http://www.health.gov.on.ca/en/ms/ecfa/pro/initiatives/funding.aspxhttp://www.health.gov.on.ca/en/ms/ecfa/pro/http://www.health.gov.on.ca/mailto:[email protected]


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Section A: Bundled vs. Unbundled Services, Service Volumes, ServiceDefinitions

Question 2:

What were the criteria upon which some services remain unbundled?

Unbundled services are those services that will continue to be reimbursed on a fee-for-service basis, similar to the current funding arrangement. Below are the criteria used forunbundling a service:

Volumes per patient vary considerably across providers (e.g., home nursingvisiting hours per home dialysis patient);

It cant be predicted which patients will be receiving the service (e.g.,hemodialysis [HD] treatments for peritoneal dialysis [PD] patients, or in-hospitalPD exchanges);

The service tends to take place in facilities that are different from where thepatient usually receives dialysis services, making it difficult to align patients andproviders of care (e.g., vascular procedures); or

Services are provided to patients visiting from other hospitals, but not recordedas transfers (short vacations or admissions to other hospitals).

Question 3:

What if six follow-up visi ts per PD patient per year, as estimated by best practice, arenot enough?

Based on the Clinical Advisory Committees recommendations regarding best practicevolumes and data regarding the number of follow-up visits provided to home PD andhome HD patients, the annual volume has been set at 6 follow-up visits per year.Certain patients may require more visits (e.g., 8 visits) or fewer visits (e.g., 4 visits), butthe providers total annual volume of follow-up visits should average out to 6 visits peryear.

Some new PD programs with a high proportion of incident patients indicated that theymay need to follow up on their patients more often than once every two months. Theannual number of follow-up visits per PD patient will be monitored on an ongoing basis

to determine if the best practice volumes need to be reassessed.

Question 4:

Are vascular access services bundled or unbundled?


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Vascular access services are unbundled because they tend to occur in facilities that arenot necessarily the same facilities where patients receive dialysis services and becausethe annual service volumes per patient are unpredictable (vary across patients andproviders).Also, see answer to Question 2.

Question 5:

Why is home HD training a bundled service, but PD training is not?

Analysis to date revealed that PD training per patient varies considerably acrosshospitals.

Question 6:

Would home HD retraining be funded as a bundled or unbundled service?

While the home HD initial training days are bundled (21 initial training days), retrainingfor home HD remains unbundled because the available evidence does not allow theprediction of the percentage of patients that will require retraining, how often they willrequire retraining and for how many days. This will be subject to ongoing monitoring andevaluation.

Question 7:

Why are follow-up dialysis patient clinic visi ts included in Bundles B1. (Home PD[APD]), B2. (Home PD [CAPD]), C. (Home HD Daily/Nocturnal) and D. (Home HDConventional), but not in Bundles E. (Chronic In-Facili ty or Satellite HDDaily/Nocturnal) and F. (Chronic In-Facility or Satellite HD Conventional)?

In-centre conventional HD patients visit the dialysis centre three times a week and in-centre nocturnal/daily HD patients visit the dialysis unit several times a week. It isexpected that ongoing patient follow-up is included as part of these visits.

Question 8:

What team members are included in the definition of pre-dialysis visits?

A pre-dialysis visit requires that the patient be seen by at least three of:

Nurse

Dietician

Social Worker


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Pharmacist/Pharmacy technician

Physician (associated pre-dialysis funding does not cover physicianreimbursement).

Question 9:

What about In-Centre Conventional patients that receive treatments four times perweek instead of three times per week?

The number of HD treatments per week for In-Centre Conventional HD patients is three,based on best practice. This number recognizes that certain patients may require fourtreatments per week, others may require less than three treatments per week, andsome may also miss treatments. Our most recent analysis shows that only twoproviders slightly exceeded the average of 156 treatments per conventional HD patient.This number will be re-evaluated on an ongoing basis to determine if the best practice

volume of 156 treatments per year needs to be re-adjusted.

Question 10:

What about HD treatments that are provided to home PD or home HD patients? Howwill these be funded?

Because it is difficult to predict if and when HD treatments will be provided to home PDand HD patients, this is an unbundled service and will be funded on a fee-for-service

basis. Please refer to question 2 for criteria specifying what services are to beunbundled.

Question 11:

What if an In-Centre HD patient exceeds best practice numbers? Will thesevolumes be funded on a fee-for-service basis?

Best practice has been set to156 treatments a year for In-Centre Conventional patientsand 260 treatments a year for In-Centre Daily Patients. Some In-Centre Conventional

patients may require more treatments per week, while others may require less (or misstreatments). As a result, the average number of treatments per week should reflect thebest practice volumes.

For providers that exceeded or provided less than the best practice number oftreatments per patient, funding will still be set at the best practice level.


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The set volumes will be carefully monitored in the future and if the average volumes perpatients are systematically higher for some providers and are associated with improvedpatient outcomes, the best practice levels will be revised.

Question 12:

If bundled service volumes are not achieved, will funding be clawed back?

Funding will not be clawed back, the same standard bundle reimbursement rate will beprovided for every annualized patient, based upon best practice. Bundledreimbursement is tied to and based upon the count of annualized patients in eachbundle, not on the delivery of specific components or services within the bundles.Reported volumes will continue to be monitored and our Expert Panel will continue toevaluate and refine the bundles based upon new and up-to-date data and theirexpertise.

Question 13:

Why is there no cost adjustment for Academic Health Science Centres for dialysiscare when there is an adjustment for acute inpatient services in HBAM?

Please refer to question 23. Analysis of provider characteristics has not providedevidence to support a cost adjustment for academic health science centres for dialysisservices. Further analyses will be carried out when improved data become available.

Section B: Modality and Location Switching

Question 14:

What happens if a patient needs to move?

What about patients who swi tch types/modalities during the year?

The count of patients in ORRS takes into account modality changes, provider changes,transfer-outs, deaths and file closures. Prior to May 2012, changes in modality andprovider reported only after 30 days. As of May 2012, the ORRS reporting requirementis that ALL modality and provider switches will need to be reported, including those thattook place within less than 30 days.

For example, Mrs. Smith starts on home PD with provider A and after five months shetransfers to In-Centre HD Conventional for three months, also with provider A. After


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three months, the patient moves and transfers to another provider (provider B) andbegins In-Centre HD Conventional at the new location for the remainder of the year.

Funding would flow as follows:

Provider A would be reimbursed based on:- Five months of PD patient care (annual cost of PD x 5/12)- Three months of in-centre HD patient care (annual cost of HD x 3/12)- Fee-for service reimbursement for all unbundled services the patient received

throughout the eight months

Provider B would be reimbursed based on:- Four months of in-centre HD patient care (annual cost of in-centre HD x 4/12)- Fee-for-service reimbursement for all unbundled services the patient received

throughout the four remaining months

Question 15:

What happens if a patient receives hemodialysis treatments at another hospital on along-term basis? On a short-term basis?

Patient receiving services from another hospital - Long-term basisPatients that receive hemodialysis treatments from another hospital on a long-termbasis would be considered transfer patients. Money would flow to the hospitalproviding the treatment.

Patient receiving services from another hospital - Short-term basisFor patients that receive hemodialysis treatments from another hospital on a short-termbasis, the hospital providing these treatments would be reimbursed for those HDtreatments on a fee-for-service basis. Hemodialysis treatments for transient patientsfrom other hospitals is a line item included with the unbundled services. The patientsPRIMARY provider (where the patient usually receives HD treatments) would NOT berequired to report the missed treatments, and payment for the primary provider wouldnot be reduced.

Question 16:

How will you know when the patient got sick and stopped being in the Home PDmodality and was in an inpatient setting?

ORN will track each patients start and end dates on each modality, as captured inORRS. When a home PD patient gets sick and goes to an inpatient setting, a modalitychange from PD to inpatient will be recorded in ORRS for the duration of the inpatientstay.


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Section C: Reimbursement Rates and Funding

Question 17:

Will the proposed reimbursement rates be assessed on an ongoing basis?

Yes, the reimbursement rates will be continuously re-assessed and adjusted. Theavailability of case costing data will be particularly useful for this purpose.

Question 18:

Will there continue to be funding for acute dialysis?

Yes, acute dialysis services will continue to be funded on a fee-for-service basis.

Section D: Patient and Provider Characteristics (Adjustors)

Question 19:

Why are there no proposed cost adjustors at the provider (hospi tal) level? Would thebundled reimbursement rates vary, according to d istance travelled by providers orpatients, or according to the distance(s) between the regional centre and its site(s)?

Extensive analysis has been completed to explore associations between providercharacteristics and service costs. The evidence gathered from the analysis completedto date does not demonstrate any consistent impact of provider characteristics on cost.

Provider-level characteristics explored included the following:Isolation/Rurality:

Distance between satellites and corresponding Regional Centre (in km)

Patient travel time from residence to hospital (in minutes)

Program size

Number of dialysis operating stations

Dialysis unit total expenses (MIS)

Peer Group


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Academic Health Sciences Centres, Large and Small hospitals

Regional centre vs. Satellite

Additionally, there are a number of services that remain unbundled, which reduces the

risk to providers that may be providing a greater VOLUME of services due to theirisolation. For example, nursing hours of service for home visits remain unbundled. Assuch, providers that are more isolated and require more nursing time to travel to thepatients home would NOT be penalized and would be reimbursed for the number ofhours reported - which may be much higher than other providers that are not isolated.

Question 20:

Was data analyzed at the regional centre level only, or were satellites included?

Where data were available, the analysis has been completed at the satellite level.Additionally a survey was sent out to all providers requesting data pertaining to providedetails on their expenditures, human resource complement, patient activity and thenumber of dialysis machines in order to conduct supplementary satellites-levelanalyses.

Question 21:

How does the framework account for patients with unique challenges who requiregreater t reatment resources? Examples include patients wi th diabetes and patientswith gambling and food addictions who miss appointments.

The new funding framework would provide reimbursement to hospitals for treating in-centre HD patients based on a best practice annual service volume (156 treatments peryear for in-centre conventional and 260 treatments per year for in-centre daily). Missedtreatments would not result in a reduced reimbursement. This recognizes that resourcesare still used when patients do not show up for a treatment, and providers shouldtherefore be compensated accordingly.

Co-morbidities are important patient-level characteristics which will be further examinedas soon as better data become available.


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Question 22:

Other research/studies have shown that other patient characteristics, includingsocio-economic status, may be associated with higher costs. Why are these nottaken into account?

To conduct this analysis, patient-level data on socio-economic status will need to becombined with patient level cost and utilization data. This information is not currentlyavailable and is unlikely to become available in the near future.

Question 23:

Does the proposed funding framework take into account the distance that providers(e.g., nurses) travel to deliver certain services?

Nursing hours of service are unbundled. As such, providers that are more isolated andthat require more nursing time to travel to the patients home will be reimbursed for thenumber of hours reported - which may be much higher than other providers that are notisolated.

This ensures that isolated hospitals are not penalized for using more nursing andtechnician hours for home visits.

Question 24:

Will the bundles and proposed reimbursement rates apply to all sites/satellites, notjust regional centres?

Yes, bundled and unbundled services, as well as the proposed reimbursement rates,will apply equally to patients of satellites and regional centres.

Question 25:

What are BMI and BSA, and why were they explored as patient characteristics thatcould be associated with HD treatment cost?

BMI (Body Mass Index) and BSA (Body Surface Area) were explored as patientcharacteristics that could potentially impact the cost of a treatment, or that could impactthe number of hemodialysis treatments required by a patient.

The model adopted by the Centre of Medicare and Medicaid System (CMS) adjusts forthese factors for the following reasons:


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Low Body Mass Index: Individuals with a body mass index below 18 have higher levelsof acuity and frailty. As a result, the HD treatments they receive require more nursingand non-nursing resources. However, the analysis of Ontario renal data has shown novariation in the percentage of patients with low BMI across hospitals.

Body Surface Area: in the U.S., individuals with a high body service area usually needto be dialyzed for a longer period of time, resulting in a higher cost per treatment. InCanada, however, everyone is dialyzed for three to four hours, regardless of their size.

As a result, this variable was not used in Ontarios CKD proposed funding framework.

Question 26:

Will the age adjustment to the in-centre HD treatment proposed reimbursement rateapply to sites/satellites, as well as regional centres?

Yes, each satellite and each regional centre has a unique patient age mix, based uponwhich the age adjustment will be determined. The age adjustment will apply to the costof an in-centre hemodialysis treatment only. None of the other services will be affected.

Question 27:

What happens when patients get older from year to year? Does the age adjustmentget updated?

Yes, the age mix for each provider will be recalculated yearly and the adjustment will beupdated accordingly.

Question 28:

Is the age adjustment for in-Centre HD treatments meant to encourage providers toassign younger patients to home modalities?

No. The age adjustment for in-centre HD treatments is strictly meant to account for thehigher level of patient acuity and resource usage required by older patients, to ensure

providers are compensated accordingly.


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Question 29:

Can hospitals get bumped up for BMI and down for Age?

Age has been the only adjustor incorporated into the model, for in-centre HD only, andwill be implemented when the in-centre HD bundles are implemented in 2013/14.


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11.0 Committees

11.1 CKD Clinical Advisory Committee (CAC) Membership

Dr. Peter MagnerProvincial Lead, Funding, ORNRegional Medical Lead, Champlain LHIN, ORN

Associate Professor of Medicine, University of OttawaHead, Division of Nephrology at The Ottawa HospitalDirector of Hemodialysis, The Ottawa HospitalMember, ORN Clinical Advisory Committee

Dr. Mark Benaroia

Nephrologist, Grand River Hospital Corp.Member, ORN Clinical Advisory Committee

Dr. Andrew HouseAssociate Chair, London Health Sciences Centre, Division of Nephrology AssociateProfessor, University of Western Ontario Member, ORN Clinical Advisory Committee

Dr. William McCreadyAssociate Dean -Faculty Affairs, Senior Associate Dean-West Campus at the NorthernOntario School of Medicine Nephrologist, Thunder Bay Regional Hospital Member, ORNClinical Advisory Committee

Dr. David BerryDivision Head of Nephrology & Medical Director of the Renal Program, Sault Area Hospital

Member, ORN Clinical Advisory Committee

Dr. Paul TamDivision Head of Nephrology, The Scarborough Hospital Medical Director, ScarboroughRegional Dialysis Program Member, ORN Clinical Advisory Committee

11.2 CKD Funding Panel

Dr. Peter Magner

Provincial Lead, Funding, ORNRegional Medical Lead, Champlain LHIN, ORN

Associate Professor of Medicine, University of OttawaHead, Division of Nephrology at The Ottawa HospitalDirector of Hemodialysis, The Ottawa HospitalMember, ORN Clinical Advisory Committee


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Dr. Al KadriCKD Funding Panel member, Erie St. Clair LHIN Regional Medical LeadDivision Head, Nephrology, Hotel Dieu Grace Hospital

Dr. Chris RabbatCKD Funding Panel member; Hamilton Niagara Haldimand Brant LHIN Regional MedicalLead

Associate Professor, Division of Nephrology, Department of Medicine, McMaster University

Peter VargaRegional Director, ORN for the Waterloo Wellington LHINProgram Director, Renal Dialysis, Grand River Hospital


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