AIM 2: BETTER HEALTH FOR THE ESRD POPULATION

AIM 2: BETTER HEALTH FOR THE ESRD POPULATION The Population Health Innovation Pilot Project: Promote Appropriate Home Dialysis in Qualified Beneficiaries The 2013 redesign of the ESRD Network Program came with a mandate for Networks to effect change through bold and innovative approaches, working in collaborative partnerships to achieve sustainable improvement in a population health pilot project. ESRD Network 9 and ESRD Network 10 chose the project to Promote Appropriate Home Dialysis in Qualified Beneficiaries Promote Appropriate Home Dialysis in Qualified Beneficiaries: The Network shall work with a sufficient number of facilities to include at least 10% of the Network area in-center hemodialysis patient population at baseline and throughout the project. The Network shall demonstrate at least a 7 percentage point improvement in the appropriate use of home dialysis by qualified beneficiaries by the end of the 3 rd contract quarter or the Network evaluation, whichever is later. Additionally, a disparate subpopulation must be identified within the sample group that shows at least five percentage points less than the non-disparate group at the baseline period. A steering committee was developed comprised of MRB members, patients, and community partners to develop the project, which was named On the Road to Home: Home Dialysis Treatment Options. CMS declared 2013 to be a pilot year for AIM 2, so much time and energy was devoted to developing partnerships, identifying existing resources which could be put to use as well as creating new resources, and community outreach to dialysis facilities as well as the targeted patient population. By year end, the pilot test included presentation of a patient empowerment workshop for patients and their family members, a packet of resources had been assembled, and a marketing strategy was written. Through this use of rapid cycle improvement, planning was under way to fully launch On the Road to Home in 2014. DATA ANALYSIS

The first step in the process of selecting a home innovation topic was analysis of the home dialysis populations using CROWNWeb data which was prepared and provided to the Network by the Network Coordinating Center (NCC). In Network 9, the in-center hemodialysis patient population to be impacted (at least 10% of incenter hemodialysis patients) was n=2,783, with the disparate subpopulation identified as African Americans with a disparity differential of 15.23. The Network 9 disparity was calculated using the fourth quarter 2012 Network 9 data from CROWNWeb that was provided by the NCC. Facilities listed as transplant and closed were removed from the analysis. There were 2.5% of the patients in the analyzed data without a modality listed. Network 9 Disparity Analysis* Network 9 Difference Race White 12.99% 6.01% Non-White 6.98% Ethnicity Hispanic 9.47% 1.57% Non-Hispanic 11.04% Gender Male 11.15% 0.36% Female 10.79% Age <65 13.46% 5.28% 65 8.18% Location Urban 11.73% 4.03% Rural 7.69% * 2012 Network 9 CROWNWeb data prepared and provided by the Network Coordinating Center. The Network 10 in-center hemodialysis patient population to be impacted was n=1,625, with the disparate subpopulation identified as African Americans with a disparity differential of 9.55%. The Network 10 disparity was calculated using the fourth quarter 2012 Network 10 data from CROWNWeb that was provided by the NCC. Facilities listed as transplant and closed were removed from the analysis. There were 5.1% of the patients in the analyzed data without a modality listed. Network 10 Disparity Analysis*

Network 10 Difference Race White 11.96% 5.06% Non-White 6.91% Ethnicity Hispanic 8.12% 1.98% Non-Hispanic 10.10% Gender Male 9.41% 0.92% Female 10.33% Age <65 11.62% 3.82% 65 7.80% Location Urban 9.44% 4.23% Rural 13.67% * 2012 Network 9 CROWNWeb data prepared and provided by the Network Coordinating Center. PARTNERSHIPS The next step was to conduct outreach activities to the renal community to look for partners and encourage general support of the project. Dialysis facilities were selected as the first partners in this effort. In ESRD Network 9, 25 facilities were chosen: Indiana 6 Kentucky 4 Ohio - 15 Patients in these facilities represented 12% of the Network 9 patient population, with home patients comprising 16.28% of the population. The disparity differential for African Americans in these facilities is 15.23%. In ESRD Network 10, 23 facilities were chosen: Chicago/Cook County = 14 Chicago/Suburbs = 2 Peoria 1 Champaign 2

Decatur 3 Patients in these facilities represented 18.1% of the Network 10 patient population, with home patients representing 9.14% of the population. The disparity differential for African Americans in these facilities was 9.55%. Contact was made with each facility and an orientation Webinar was held to provide background to the facility staff members on the parameters of the pilot project. The next step was to assemble a steering committee, which included Network staff, patients, MRB members, and members of the renal community. On the Road to Home Steering Committee Michael Kraus, MD Marcia Silver, MD Sandra Hashman, CHT Craig Fisher, Ph.D., LCSW Helen Neale, MSW Mary Ellen Brabec, RD, LD Lorraine Edmond Beth Smith, RN Peter DeOreo, MD Hap Pierce, CHT Francine JnBaptiste, RN Amanda Northrop, RN Pam Kent, MS, RD Andrew Lazar, MD Lana Schmidt Brenda Colley Kelli Lester Dori Schatell Todd Brading Rebecca Haire Leslie Wong, MD MRB Member/Director of Home Hemodialysis- Indiana University MRB Member /FMC MRB Member /Indiana University MRB Member/Independent MRB Member & PAC/DaVita MRB Member/ DaVita PAC & MRB Member MRB Member /Nationwide Children s Hospital MRB/Centers for Dialysis Care-Cleveland MRB Member /DaVita MRB Member /FMC Renal Advantage, Inc. The Cleveland Clinic Centers for Dialysis Care-Cleveland PAC & MRB Member, Home Dialyzers United FMC Regional Quality Manager Baxter/Home Alliance Medical Education Institute NxStage University of Louisville/Home Program The Cleveland Clinic PROJECT DESIGN Given the CMS requirements and the stated goal, the steering committee met in person and via Webinar to develop the pilot innovation project. The first factor to consider was the requirement for attributes as stated by CMS, so the steering committee designed the project activities ensuring that all attributes were put to use.

Project attributes to be incorporated into the project were: Rapid cycle improvement Customer focus and value to beneficiaries, providers, and CMS Sustainability Innovation Boundarilessness Unconditional Teamwork RAPID CYCLE IMPROVEMENT: A root cause analysis tool in the form of a facility culture questionnaire was developed for participating facilities to use to identify their barriers to home modality initiation in the community. Interventions, which will include resources and Webinars, will be geared to the facility need based on the barriers. Best practices will also be provided to the targeted facilities. Home dialysis programs that are participating will provide home dialysis rates on a monthly basis. They will identify patients who have begun training as well as completed training. They will identify referral sources such as in-center facilities or physician group practices so that Network staff can intervene on those groups that are not referring to home modalities. Network staff will contact those facilities or physicians to discuss changes to processes to ensure rapid cycle improvement. CUSTOMER FOCUS AND VALUE TO BENEFICIARIES, PROVIDERS AND CMS: Patient Value: Patients have reported that home dialysis options allowed them to take more control of their dialysis schedule and as a consequence to exercise more control of their day-today activities. This renewed sense of freedom and decision making related to their treatment is credited by patient focus group members with improving their quality of life. Literature indicates that patients report home dialysis options give patients a sense of empowerment and control and also indicates that home dialysis patients have better overall outcomes. Network staff will involve patient SMEs as well as participating facility patients in all home modality improvement activities so the patient voice is utilized to develop initiatives. Provider Value: Providers will be ensuring patients are afforded a choice in their modality and they will decrease facility overhead. (Lacson et al (2007) point out that peritoneal dialysis therapy results in improved outcomes, greater patient satisfaction, and lower overall costs.) Operationally, moving eligible patients to home dialysis allows clinics to overcome chair capacity limits. Identifying eligible home dialysis patients reduces the cost and time associated with expanding hemodialysis chair capacity.

CMS Value: CMS should realize a decrease in costs due to better outcomes with fewer hospitalizations. According to the 2012 USRDS Annual Report, the per person Medicare ESRD cost for in-center hemodialysis patients was $87,561 compared to $66,751 for peritoneal dialysis patients. Another study by Shih et al (2005) suggests that peritoneal dialysis is the economical initial dialysis modality from an expenditure perspective. The longer the patient is on peritoneal dialysis the better the economic advantage even if the patient has to switch modalities because the cost savings are sustained. SUSTAINABILITY: The innovation pilot project will evaluate the culture of the facility to determine the facility specific disparities to be targeted. Identifying barriers and utilizing best practices will aide dialysis facilities to develop programs to educate patients and facility staff. Medical directors and home training nurses will be expected to use Network home modality resources and the Website page for training patients on an ongoing basis. In addition, the Network Patient Representative Program (NPRP) will assist facility staff in promoting home modalities through information provided by the Network. The Network will ensure that in-center facilities and physician group practices are aware of the LDO modality training programs and their contact persons. The implementation of these programs will allow project facilities to sustain what was learned and put into place during the project. This will ensure that all patients receive modality education and social support to be able to choose the modality best suited to each patient. INNOVATION: Network staff will evaluate the processes that are in place in targeted facilities to educate patients and family members on modality choice and patient empowerment. The Network will collaborate with industry stakeholders and local stakeholders in the targeted areas to provide two hour workshop/informational type meetings to area patients and facility staff. These meetings will include presentations by Social Workers, Dieticians, Nephrologists, Nurses, and other patients. There will be opportunities for patients to sign up for additional education and/or sign up for the next step to change to a home modality. In addition, Network staff will evaluate whether the targeted facilities have a patient centered culture by questioning participating facility staff and patients to get their perception of patient involvement at the facility level. Specifically, it will be determined if the facility promotes patient involvement in governing body, support groups, and encourage patients to take part in their own care and care planning. Network staff will bring patients, family members, and facility staff together to develop goals, identify barriers to home modality choice, and change facility culture. Network staff and Patient Engagement LAN members will develop and conduct a home modality

campaign for patients in order to raise awareness. Network staff and Patient Engagement LAN members will educate through individual and joint meetings and utilize patient representatives at each facility to engage patients in modality choice. BOUNDARILESSNESS: Network staff and targeted facilities will work with local home modality champions, LDO quality improvement staff, and mentor facilities that have a large home modality population. Network staff will research and engage community minority partners such as community centers, African American church groups, newspapers, and radio stations. We will research and engage organizations that have conducted African American community outreach such as African American Health Matters (AAHM), Gift of Life Donor Program, and Patient Advocate Foundation (PAF). We will also use home modality companies and their training programs as a resource for this project. UNCONDITIONAL TEAMWORK: The Network and facility participants will work with community partners to develop the project plan, identify barriers affecting home dialysis rates in minority communities, and develop effective interventions to address cultural issues and meet project goals. The Network will share best practices and/or tools that are identified and/or developed through this project with the NCC, patient and family engagement LAN, and community partners. THE PLAN Using these core concepts, the steering committee developed a pilot project which will inform participants about the availability of home dialysis through a workshop format. The workshops will be interactive sessions focusing on empowerment strategies for patients, family members, and facility staff. Topics covered will include the strengths and barriers presented by patient and staff culture as they relate to communication and self-management. The workshops will be held regionally in the cities where the participating facilities are located. The agenda will include: Explanation of Culture and Cultural Change New and Emerging Technologies Patient Stories/Peer Mentoring Impact of Home Therapy on Nutrition

Quality of Life Action Planning and Goal Setting PILOT WORKSHOP Pilot workshops were conducted in the fourth quarter. NETWORK 9: On November 14, 2013, TRN sponsored an event, An Evening with David Rush, in Indianapolis, Indiana. The keynote speaker, David Rush, is a rap artist and a former dialysis patient. Using a NxStage hemodialysis system, David traveled on a 40-city concert tour with another rap artist, Pit Bull. Frequent home hemodialysis also helped him get much healthier so he was eventually able to get a transplant. Facilities were sent a letter and a poster regarding the event, personal calls were made to facilities, and patients in an identified radius were sent letters of invitation. The purpose of the event was to empower patients to understand their treatment choices, especially focusing on home dialysis. A physician, social worker, dietitian, and four patients were the speakers for the meeting. A total of 39 persons were in attendance: 20 patients, 15 family/friends of patients, and 4 dialysis staff members. During the program, the Network provided resources and information about its LAN and its projects to participants. NETWORK 10: On December 5, 2013, TRN sponsored an event, An Evening with David Rush, in Chicago, Illinois. The keynote speaker, David Rush, is a rap artist and a former dialysis patient. Using a NxStage hemodialysis system, David traveled on a 40-city concert tour with another rap artist, Pit Bull. Frequent home hemodialysis also helped him get much healthier so he was eventually able to get a transplant. Facilities were sent a letter and a poster regarding the event, personal calls were made to facilities, and patients in an identified radius were sent letters of invitation. The purpose of the event was to empower patients to understand their treatment choices, especially focusing on home dialysis. A physician, social worker, dietitian, and four patients were the speakers for the meeting. A total of 33 persons were in attendance: 15 patients, 9 family/friends of patients, and 9 dialysis staff members. During the program, the Network provided resources and information about its Network Patient Representative Program (NPRP) and LAN and its projects to participants. TRN also talked with individual participants about joining the NPRP and LAN. At year-end, Network staff and the steering committee gathered the evaluations from the pilot workshops and, working in a continuous quality improvement (CQI) methodology, planned improvements to the workshops and the pilot project, and prepared for the program launch in 2014.