These presenters have nothing to disclose Value Based : The Top of the Population Health Pyramid Robert Albright, Jr., DO; Michelle Hedin, RN; and Kathryn Zavaleta, FACHE 26th Annual National Forum on Quality Improvement in Health Session: C22 December 9, 2014 2014 MFMER slide-1 2014 MFMER slide-1 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. 2014 MFMER slide-2 1
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 past day 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 2014 MFMER slide-3 2012 MFMER 3186021-3 I II III avr avl avf V 1 V 2 V 3 V 4 V 5 V 6 2014 MFMER slide-4 2012 MFMER 3186021-4 2
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 2014 MFMER slide-5 2012 MFMER 3186021-5 Emergently placed on dialysis 2014 MFMER slide-6 2012 MFMER 3186021-6 3
A little history He has seen Nephrology twice in the past 4 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 2014 MFMER slide-7 2012 MFMER 3186021-7 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 2014 MFMER slide-8 2012 MFMER 3186021-8 4
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 2014 MFMER slide-9 End Stage Renal Disease (ESRD): A Case Study in Accountable Complex Intermediate Population of ESRD patients is representative of the top of the pyramid Multiple chronic conditions Potentially fragmented care transitions Sub-specialist / multiple subspecialty care required Nissenson, et.al. Accountable Organizations and ESRD, 2012 Williams, et.al. Delivering Accountable to Patients with Complicated Chronic Illness, 2012 2014 MFMER slide-10 5
ESRD & Accountable Pre-2011 2011 2012 Accountable Model Medicare primary payer after 30 months Facility fee + 3 levels physician encounter ESRD PPS: Bundled meds, facility fee and labs Covers outpatient dialysis-related services under prospective payment ESRD Quality Incentive Program (QIP) Pay for Performance All dialysis and non-dialysis care is included in bundle--global capitation Watnick, et.al. Comparing Mandated Health Reforms, 2012 2014 MFMER slide-11 Annual Mortality Rates Reflect Current State and Opportunities P E R C E N T 30 20 10 0 Colon CA Lung CA Breast CA Dialysis Japan Dialysis Europe Dialysis U.S. Kidney News, American Society of Nephrology, 2005. 2014 MFMER slide-12 6
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 2014 MFMER slide-13 The U-Shaped Curve p= 0.002 A U-shaped cost curve illustrates an increase in costs during the first and last six months of ESRD care. 2014 MFMER slide-14 Source: Albright, et al, U shaped cost curve in an ESRD value-based integrated care system, American Society of Nephrology Abstract, 2012 7
Meeting the Needs of ESRD Patients Requires Quality at Each Level Complex Intermediate Population On-going dialysis care, management of ESRD and other acute / chronic needs Management of CKD & Patient-Centered Discussion Management of Chronic Conditions & Appropriate Referral From chronic kidney disease (Stage III & IV) to End-Stage Renal Disease (Stage V) 2014 MFMER slide-15 Improvement Work for Each Group Starts with the Patient s Perspective Understand Patients Perspective Envision Ideal Implement & Standardize Diffuse & Spread 2014 MFMER slide-16 8
Design Requirements: What Matters to Patients Shared Decision-Making Non-paternalistic discussion Collaboration & Empowerment Effectively exchanging information Open & Honest Communication Transparency of cost, data, modalities, and delivery of care Improved Education Intervals and Interpretation Real-time information that has a tighter feedback loops Clarified Relationships Mutual understanding of team member roles and activities Source: Mayo Center for Innovation 2014 MFMER slide-17 2012 MFMER 3186021-17 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 uncertainty o Create an effective self-management plan Enabling proactive discussions allow them to make quick decisions if required 2014 MFMER slide-18 9
Patients Can t Know What They Don t Know Patients need to understand the disease trajectory 2014 MFMER slide-19 Improving for Chronic Kidney Disease (CKD) The Patients Perspective Ideal : Out-Patient, Emergency, Inpatient, Dialysis Centers Future State: Standardized Ordersets, Documentation Templates, Schedules & Patient Education Processes Diffuse to all Sites 2014 MFMER slide-20 10
The Burden of Disease The Burden of 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 NANCY (F) with daughter AGE 60 CKD PT RECENT RETIREE HAS KIDS AND GRANDKIDS 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 2014 MFMER slide-21 Envisioning Ideal Chronic Kidney Disease Stage III & IV CKD Stage III & IV Acute Transition CKD Stage V (ESRD) Design focus: - Chronic Kidney Disease Management Program - Framing End of Life Discussions Improvement Target: Reduce in-hospital initiation of chronic dialysis from 65% to 20%. Managers Toolbox/ Patient Education Processes 2014 MFMER slide-22 11
Envision Ideal State: Drawing on Best Practices Inpatient CKD 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 Community ESRD May C, Montori VM, Mair FS. We need minimally disruptive medicine. BMJ 2009 and http://www.ihi.org/resources/pages/audioandvideo/wihiminimallydisruptivemedicine.aspx See also: http://www.ihi.org/topics/chronic/pages/default.aspx 2014 MFMER slide-23 Process Maps Translate 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 2014 MFMER slide-24 12
Testing the Future State The CKD Clinic Change Concepts Electronic cue for primary care for nephrology consult process algorithms standardized for primary care standardization with dashboard, auto template note Nurse-physician /NP/PA model (PDSA) CKD Inpatient ESRD 2014 MFMER slide-25 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 S P D A S P D 2014 MFMER slide-26 13
Envision Ideal Inpatient CKD Stage III & IV Acute Transition CKD Stage V (ESRD) Design focus: Processes in the acute setting supporting patient / family decision-making & preparations for dialysis. Smoothing transitions Improvement Target: Better decisions related to initiation and transitions of dialysis Managers Toolbox/ Patient Education Processes 2014 MFMER slide-27 Start with Patient s Perspective Key Decisions & Transitions 65% of patients start dialysis in the hospital setting. 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. Victoria's father is GEORGE (M) AGE 87 ACUTE ESRD (CATHETER) RETIRED WIDOWER 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? Source: Persona Descriptions (composite of interviews and observations) Mayo Clinic Center for Innovation 2014 MFMER slide-28 14
Results: Better Management of CKD Percentage of ESRD Patients Initiating Dialysis in Inpatient Setting 2011 vs 2013 p = 0.042 80% 70% 60% 50% 40% 30% 20% 10% 0% 73.2% 62.6% 58.4% 2011 2012 2013 Percentage of ESRD Patients Initiating Dialysis in Inpatient Setting 2014 MFMER slide-29 Hospital Management 2014 MFMER slide-30 15
Inpatient 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 CKD Metrics Inpatient ESRD 2014 MFMER slide-31 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 2014 MFMER slide-32 16
Envision Ideal in the Dialysis Center CKD Stage III & IV Acute Transitions CKD Stage V (ESRD) Design focus: Team-Based Chronic Disease Management for ESRD Improvement Target: Reduce avoidable utilization of emergency & inpatient services by 20% Managers Toolbox/ Patient Education Processes 2014 MFMER slide-33 The Patient s Perspective JOHN (M) AGE 42 ACUTE ESRD (GRAFT) HAD TO QUIT WORKING MARRIED WITH KIDS 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. Source: Persona Descriptions (composite of interviews and observations) Mayo Clinic Center for Innovation 2014 MFMER slide-34 17
An Opportunity for Improvement Medication Management Baseline N = sample of 29 patients Mean = 18 medications Mean = 25 doses/day Mean AWP drug cost = $thousands of dollars/month CKD Inpatient ESRD 2014 MFMER slide-35 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 2014 MFMER slide-36 18
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 2014 MFMER slide-37 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 CKD Inpatient ESRD 2014 MFMER slide-38 19
Redesigning Patient Education Standardized Resources CKD CKD Diet Access Treatment Options Inpatient New Dialysis Chronic Hemodialysis Admission Chronic Hemodialysis Ongoing Dialysis Diet 2014 MFMER slide-39 Providing Patient-Centered Education Consistent Across All Settings Used by all members of team: Physician, RN, Pharmacist, Dietician, Social Worker Standardized for all Sites Provides Individualized Core documents that every patient will need Expanded materials most patients will need Supportive materials/ patient-specific CKD Inpatient ESRD Patient Education 2014 MFMER slide-40 20
Huddles Across the System Dialysis 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 2014 MFMER slide-41 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 CKD Inpatient ESRD 2014 MFMER slide-42 21
Summary of Interventions 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 CKD Metrics Inpatient ESRD Patient Education 2014 MFMER slide-43 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 and symptom management CKD Inpatient ESRD Patient Education 2014 MFMER slide-44 22
Value Based 2014 MFMER slide-45 Results: Reduction in Hospitalization of ESRD Patients 2011 2012 2013 % Change Global costs/day* 100.0 83.23 78.44 21.6 0.004 P value (Mood median) Inpatient 100.0 71.74 78.75 21.5 0.014 costs/day (*) 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 2014 MFMER slide-46 23
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 CKD Inpatient ESRD Patient Education Diffuse Note: Template for multi-site spread included in hand-outs as a take-away 2014 MFMER slide-47 Lessons Learned Drivers of Cost-Effective of 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 Services through Enhanced Access Palliative Training for All Staff provided additional support for the very Highest Risk Patient 2014 MFMER slide-48 24
Other Considerations Delivering Patient-Centered : 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 2014 MFMER slide-49 Future Directions Models of population mgmt. for ESRD population: Primary Physician vs. Nephrologist as primary Integration of care managers Hospital / out-patient rule based approaches to identify high risk patient 2014 MFMER slide-50 25
Questions & Discussion 2014 MFMER slide-51 2014 MFMER slide-52 26