value based care: the top of the population health...

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©2014 MFMER | slide-1


Value Based Care: The Top of the Population

Health Pyramid

Robert Albright, Jr., DO; Michelle Hedin, RN; and Kathryn Zavaleta, FACHE26th Annual National Forum on Quality Improvement in Health Care

Session: C22December 9, 2014

These presenters have nothing to disclose


Objectives

• Explore how to meet the needs of the patients at the “top” of the population health pyramid, utilizing a value-based framework

• Illustrate the gap and opportunity to redesign care delivery for patients with complex needs

• Draw action-oriented conclusions

• Provide a take-away tool that can used tomorrow

The presenters have no relevant financial relationships or commercial interests to disclose.

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On any given Friday at 4:55 PM…

• 42-year-old with DM 2, HTN, obesity, OSA, hyperlipidemia and CKD Stage 3 (Cr. 3.2) presents with malaise, fatigue, nausea, shaking chills and purulent drainage from a chronically infected leg wound…

• Temp 39, BP 90/60, p 110, no urine for the pastday or so

• Chest: No rales, no rub

• Lower extremities: Purple, massive, an indurated weeping wound L shin, pulses absent

• Labs: HCO3 8, Cr. 8 mg/dL, Hgb 8 g/dL,glyco Hb 8%, K…


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I II III aVR aVL aVF

V1 V2 V3 V4 V5 V6

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What is His K?

A. 8 mEq/L

B. 8 mEq/L

C. 8 mEq/L

D. 8 mEq/L

E. All of the above


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Emergently placed on dialysis…

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A little history…

• He has seen Nephrology twice in the past4 years, both times creat “stable“ at 3.0,3.2 mg/dL

• He had a cough with his ACEi and stopped it

• His diuretics led to cramps, so he stopped them

• He recalls his kidneys were “bad” but does not recall any other discussions


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Chart Review

• BP: 160s systolic “despite 4 agents” (nl< 140/90)

• Glucose: A1C is suboptimal at 9.8% (nl <8%)

• Lipids: Above target despite statin at “maximal dose”

• Lifestyle issues: Smoking a little, no time for exercise

• Education about transplant and dialysis options could not be found

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Project RED (Re-Engineering Dialysis)

• Quality Improvement Initiative at Mayo Clinic Rochester, MN

• Participation of multiple sites and care settings

• Phased design, implementation & spread 2011-14

• Championed by Specialty Council for Division of Nephrology & Hypertension


End Stage Renal Disease (ESRD):A Case Study in Accountable Care

Care of ESRD patients is representative of the top of the pyramid

• Multiple chronic conditions

• Potentially fragmented care transitions

• Sub-specialist / multiple subspecialty care required

Complex Care

Intermediate Care

Population Care

Nissenson, et.al. Accountable Care Organizations and ESRD, 2012Williams, et.al. Delivering Accountable Care to Patients with Complicated Chronic Illness, 2012

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• Medicare primary payer after 30 months• Facility fee + 3 levels physician encounterPre-2011

• ESRD PPS: “Bundled” meds, facility fee and labs

• Covers outpatient dialysis-related services under prospective payment

2011

• ESRD Quality Incentive Program (QIP)• Pay for Performance2012

• All dialysis and “non-dialysis” care is included in bundle--Global capitation

Accountable Care Model

ESRD & Accountable Care

Watnick, et.al. Comparing Mandated Health Care Reforms, 2012


Annual Mortality Rates Reflect Current State and Opportunities

0

10

20

30

ColonCA

Lung CA BreastCA

DialysisJapan

DialysisEurope

DialysisU.S.

PERCENT

Kidney News, American Society of Nephrology, 2005.

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Caring for ESRD Population

• Hospital stay represents > 50% of total health care costs of a dialysis patient

• ESRD patients have a least two hospital stays in the course of a year*

• Readmission rates nation-wide greater than 30%

• A small number of patients account for a significant proportion of total hospital days

• Dramatic costs at initiation of RRT and at end of life

*USRDS 2012 Annual Data Report


The U-Shaped Curve

A U-shaped cost curve illustrates an increase in costs during the first and last six months of ESRD care.

Source: Albright, et al, U shaped cost curve in an ESRD value-based integrated care system, American Society of Nephrology Abstract, 2012

p= 0.002

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Meeting the Needs of ESRD PatientsRequires Quality Care at Each Level

Management of CKD & Patient-Centered Discussion

On-going dialysis care,management of ESRD and other acute / chronic needs

From chronic kidney disease (Stage III & IV) to End-Stage Renal Disease (Stage V)

Complex Care

Intermediate Care

Population CareManagement of Chronic Conditions & Appropriate Referral


Improvement Work for Each GroupStarts with the Patient’s Perspective

Understand Patients’ Perspective

Envision Ideal Care

Implement & Standardize

Diffuse & Spread

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Design Requirements:What Matters to Patients

• Shared Decision-MakingNon-paternalistic discussion

• Collaboration & EmpowermentEffectively exchanging information

• Open & Honest CommunicationTransparency of cost, data, modalities, and delivery of care

• Improved Education Intervals and InterpretationReal-time information that has a tighter feedback loops

• Clarified RelationshipsMutual understanding of team member roles and activities

Source: Mayo Center for Innovation


Decision-Making:Patients Think in Goals and Values

Patients want to be in conversation even when it is hard

With a care team they know and with whom they have an established relationship

Who can help them:o Understand the trajectory of the disease o Map uncertaintyo Create an effective self-management plan

Enabling proactive discussions allow them tomake quick decisions if required

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Patients Can’t Know What They Don’t Know

Patients need to understand the disease trajectory


Improving Care for Chronic Kidney Disease (CKD)

The Patients Perspective

Ideal Care: Out-Patient, Emergency, Inpatient, Dialysis Centers

Future State: Standardized Ordersets, Documentation Templates, Schedules & Patient Education Processes

Diffuse to all Sites

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The Burden of DiseaseThe Burden of Care

“I started in the Diabetic Nephropathy Clinic a couple years ago. I hadn’t retired the last time I saw him, but I think my doctor will be happy with my appointment today. I’ve been taking better care of my health now that I have more time to spend on exercising

I never thought my health would get this bad. I had never really been sick all of my life. Now I know what it’s like to have to take care of myself. I like coming to the clinic because they give me points when I come here. My other doctors don’t give me that feedback.

I just wish they had better training plans. I’m doing better with exercise but my diet is still the same as before. I don’t know if it’s better to have smaller portions or completely change what I eat”.

“I have a new career. My health is my new career.”

Source: Persona Descriptions (composite of interviews and observations)Mayo Clinic Center for Innovation

NANCY (F) with daughterAGE 60CKD PTRECENT RETIREEHAS KIDS AND GRANDKIDS


Improvement Target: Reduce in-hospital initiation of chronic dialysis from 65% to 20%.

Design focus: - Chronic Kidney Disease

Management Program

- Framing End of Life Discussions

Envisioning Ideal Care Chronic Kidney Disease Stage III & IV

Care Managers Toolbox/ Patient Education Processes

Acute TransitionCKD Stage III & IV CKD Stage V (ESRD)

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Minimally Invasive Medicine

• Capacity vs. Demand (Burden of Illness + Burden of Treatment)

IHI Chronic Disease Model:

• Self-Management Support

• Delivery System Design

• Decision Support

• Clinical Information Systems

• Organization of Health Care

• Community

Envision Ideal State:Drawing on Best Practices

CKD ESRDInpatientCare

May C, Montori VM, Mair FS. We need minimally disruptive medicine. BMJ 2009 andhttp://www.ihi.org/resources/Pages/AudioandVideo/WIHIMinimallyDisruptiveMedicine.aspxSee also: http://www.ihi.org/topics/ChronicCare/Pages/default.aspx


Process MapsTranslate Ideal Delivery to Standard Work

Objective: Decrease number of patients with CKD who enter dialysis as a result of an acute episode during an chronic inpatient hospital stay

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Testing the Future State — The CKD Clinic

Change Concepts• Electronic cue for primary care for

nephrology consult • Care process algorithms standardized

for primary care• Care standardization with dashboard,

auto template note• Nurse-physician /NP/PA model (PDSA)



Designing & Implementing Solutions -Small Tests of Change

What can we do by next Tuesday?

• Test Group Education

• Trial processes to trigger Annual Nutrition Consult for CKD Stage III & IV

• Test Scheduling RN Patient Education Follow-up

A P

S D

PA

S D

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Improvement Target: Better decisions related to initiation and transitions of dialysis

Design focus: Care Processes in the acute setting supporting patient / family decision-making & preparations for dialysis. Smoothing transitions

Envision Ideal Inpatient Care


Acute TransitionCKD Stage III & IV CKD Stage V (ESRD)


Start with Patient’s PerspectiveKey Decisions & Care Transitions

Victoria (the daughter):

“My mother died years ago, and I try to get to see my dad when I can, but I can’t manage it all on top of my personal responsibilities.”

“I got a call from the hospital that he was admitted. He’s not very conscious or awake. I’m not sure if he knows where he is right now. Now I have to make all these decisions myself. The care team told me he would die if he didn’t start dialysis right away. I don’t know what other options I have.”

“Is this really the best thing for him?”

65% of patients start dialysis in the hospital setting.


Victoria's father is GEORGE (M)AGE 87ACUTE ESRD (CATHETER)RETIREDWIDOWER

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Results: Better Management of CKDPercentage of ESRD Patients Initiating Dialysis in Inpatient Setting

0%

10%

20%

30%

40%

50%

60%

70%

80%

2011 2012 2013

2011 vs 2013 p = 0.042

Percentage of ESRD Patients Initiating Dialysis in Inpatient Setting

73.2%

62.6%58.4%


Hospital Management

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Inpatient Care Change Concepts

• Standardized inpatient care order sets

• Co-location of medical patients when possible

• Improved transitions to renal replacement therapy or supportive care

• Template for team hand-offs

• Teleconferenced “huddle” between inpatient team and dialysis center team

MetricsCKD ESRD

InpatientCare


Leveraging Huddles for Transitions:“We all start the day on the same page.”

Discussion Items• Who has been hospitalized:

• Patient goals & concerns• New patients needing dialysis• Scheduling issues• Vascular access issues• Rounds & orders• Medication changes for established patients• Transition planning

• Expected discharge date• Expected discharge location

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Improvement Target: Reduce avoidable utilization of emergency & inpatient services by 20%

Design focus: Team-Based Chronic Disease Management for ESRD

Envision Ideal Care in the Dialysis Center


Acute TransitionsCKD Stage III & IV CKD Stage V (ESRD)


“I started dialysis in the hospital. I thought I was getting sick a couple months ago, but I didn’t have a primary care doctor. To be honest, I was afraid of the cost and never imagined getting so sick so quickly.

Now I have a lot of hospital bills to pay, and I’m trying to organize my Medicare all at once. It’s so confusing. I need to find a primary doctor that I like. I’m just now starting to understand the process. Sometimes I have to skip dialysis, because of my work schedule. I know that it messes up my schedule, and that scares me. I don’t have a choice though. I have to put food on the table for my young kids.

My wife is already doing most of the work. To pay for all of these pills and diabetes appointments, I have to work extra shifts when I can. Then on top of this, the care team wants me to exercise and diet. I have so much stress that I can’t imagine where I will find the time. I want to be a dad too.”

“I’ll CROSS THAT BRIDGE LATER.”

JOHN (M) AGE 42

ACUTE ESRD (GRAFT)

HAD TO QUIT WORKING

MARRIED WITH KIDS

The Patient’s Perspective


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An Opportunity for ImprovementMedication Management

Baseline

• N = sample of 29 patients

• Mean = 18 medications

• Mean = 25 doses/day

• Mean AWP drug cost = $thousands of dollars/month



Common Drug Therapy Problems* & Associated Conditions

• Nonadherence – blood pressure lowering

• Nonadherence – hyperphoshatemia

• Nonadherence – nutritional supplements

• Nonadherence – aspirin use

• Dose too low – hyperphosphatemia

• Unecessary therapy – nutritional supplements

* The above were identified 10 or more times in 62 patients

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Redesigning Pharmacist Role

• Medication review with patient

• Adherence assessment and monitoring

• Drug information to staff and patients

• Round with consultants in dialysis center

• Group visits for home dialysis

• Med review after hospital dismissal (previously not ordered for all)

• Med review for new patients


Results: Medication Management

As a result of pharmacist identification and resolution of medication related problems

• Pharmacist service resulted in medication cost savings of 8.8% patient/year

• Cost avoidance of unnecessary lab testing, avoidance of additional clinic visits, selection of cost effective drug therapy, avoidance of serious adverse drug reactions


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Redesigning Patient Education

Standardized Resources• CKD• CKD Diet• Access• Treatment Options• Inpatient New Dialysis• Chronic Hemodialysis

Admission• Chronic Hemodialysis

Ongoing• Dialysis Diet


Providing Patient-Centered Education

• Consistent Across All Care Settings

• Used by all members of team: Physician, RN, Pharmacist, Dietician, Social Worker

• Standardized for all Sites

• Provides Individualized Care−Core documents that every patient will need−Expanded materials most patients will need−Supportive materials/ patient-specific


Patient Education

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Huddles Across the SystemDialysis Center (AM):

• NP/PA, Social Worker, Dietitian, Charge Nurse and Scheduler, access coordinator, pharmacist

• Team issues and / or concerns (i.e., access problems, exceptional patients, hypertension, fever, etc.)

• Plan-for-the-Day (goals, procedures, tests, priorities)

• Patient / Family coping and/or concerns

Dialysis Center (Shift): Huddle among RN and Tech staff

Between inpatient and outpatient teams (PM): • Hospital NP/PA and Liaison, Center NP/PA , Social

Worker, Dietitian, Charge Nurse and Scheduler


Results of Instituting Huddles:

“We all start the day on the same page.”

• Top 3 Improvements Staff Attributed to Team Huddles:

• 37% survey respondents reported improved communication

• 30% reported improvement in addressing patient issues

• 18.6% highlighted improved focus of team / unit


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• Shared Decision-Making: Expanded patient education toolkit for all settings

• Population Health Management:Best practice processes for Kidney Disease Stage 3 or 4

• Multi-disciplinary team management in specialty setting

• Redesigned support for patients facing initiation of dialysis

• Enhanced care and support at transitions:

o Improved discharge processes

o Early post-discharge follow-up

Summary of Interventions

Patient EducationMetrics



Multi-faceted Approach Across the Continuum• Pharmacist-directed medication therapy

management safer and more cost-effective

• Addressing therapy adherence: A business case for care managers for the very highest risk patients

• Team approach to Palliative Care and symptom management

Patient EducationCKD ESRD

InpatientCare

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Value Based Care


Results: Reduction in Hospitalizationof ESRD Patients

2011 2012 2013%

ChangeP value(Mood median)

Global costs/day* 100.0 83.23 78.44 ‐21.6 0.004

Inpatient

costs/day (*)

100.0 71.74 78.75 ‐21.5 0.014

Outpatient

costs/day (*)

100.0 105.91 88.45 ‐11.6 0.024

n hospitalized (%) 129 (67.5) 108 (59.7) 100 (54.9) ‐22 0.04

(Fisher

exact)

*Adjusted for inflation: costs stated as % of 2011 costs

Albright, et.al., J Am Soc Nephrol 25: 2014, Supplement, 2014

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Sustaining the Gains:

• Specialty Councils provide guidance

• Multi-disciplinary workgroups charged with continued improvement

• Dashboard of key performance metrics

• Diffusion matrix tracks extent specific processes in place

DiffusePatient EducationCKD ESRD

InpatientCare

Note: Template for multi-site spread included in hand-outs as a take-away


Lessons LearnedDrivers of Cost-Effective of Care

• Standardized care of the patient stage III or IV to slow or prevent progression

• Shared Decision-Making: -Dialysis vs. No Dialysis-In-Center Dialysis vs. Home Dialysis

• Reduce Utilization of In-patient Servicesthrough Enhanced Access

• Palliative Care Training for All Staff provided

additional support for the very Highest Risk Patient

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Other Considerations

• Delivering Patient-Centered Care:In order to put the needs of the patient first, one must understand the patient’s perspective

• Diffusion:IT Resources an important enabler but not a show-stopper

• Measurement: Data Warehousing / patient registries key

• Structure for Improvement Team: Project Executive Team with Working Groups provided traction

• Integration: Process-redesign supports integration and vice-versa


Future Directions

• Models of population mgmt. for ESRD population:Primary Care Physician vs. Nephrologist asprimary

• Integration of care managers

• Hospital / out-patient rule–based approaches to identify high risk patient

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Questions & Discussion

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