Case Study: Reducing Avoidable Dialysis on the Day of Discharge with ESRD Patients

Although I don’t recall this ever being discussed in medical school, serving as good stewards of limited resources has become increasingly important as health care costs rise. Notably, hospitalizations are a primary driver of cost for end stage renal disease (ESRD) patients. Patients with ESRD are hospitalized, on average, nearly two times per year, and their hospital discharges are often time consuming (for both the patient and staff) and can involve avoidable costs. These costs include providing dialysis on the day of discharge (DODD) to patients who could potentially receive dialysis at their outpatient facility. Several considerations can influence the timing of discharge, including patient satisfaction, transportation and clinical stability. Yet whenever possible, avoiding unnecessary DODD can help facilitate earlier discharges, reduce length of stay, improve the transition back to the outpatient dialysis center—and may ultimately help improve patient experience.

Wesley Medical Center, a 400-bed tertiary care center located in Wichita, Kansas, serves as an example: In January 2017, the center recognized an opportunity to reduce length of stay and responsibly decrease excess costs by reducing avoidable DODD.

For this process improvement project, Wesley Medical Center partnered with Patient PathwaysSM, a provider-neutral renal discharge planning and placement partner. Together they worked to facilitate a smooth transition of care from inpatient care to a dialysis center of each patient’s choice. These efforts included forming a committee of representatives from the medical center team, acute dialysis team, Patient Pathways and outpatient dialysis centers. The committee was responsible for:

• Defining avoidable and unavoidable DODD
• Establishing a process for reducing avoidable DODD and educating medical center clinicians (including hospitalists, nephrologists and case managers)
• Reviewing claims data that included information on DODD
• Executing hospital-based utilization reviews of patents who did receive DODD
• Encouraging physician-to-physician discussions

Patient Pathways served as a liaison between the teams on the committee (including representatives from local outpatient dialysis providers) and communicated with case management staff about discharge planning on a daily basis. This enhanced coordination and helped the hospital identify where to deploy resources. Through this proactive, collaborative approach, by the end of the first year, Wesley Medical Center reduced avoidable DODD by nearly 16 percent and decreased unnecessary expenditures. This is just one example of a way to address factors that contribute to the high costs of health care and patient experience.