Addressing ESRD Complexities with Integrated Care

End stage renal disease (ESRD) represents a population health conundrum. It affects a relatively small part of the U.S. population, yet the rate of ESRD diagnosis continues to increase faster than the rate of U.S. population growth. ESRD also disproportionately affects underrepresented minorities. These patients suffer from significant comorbidities (such as hypertension, diabetes and heart disease) that are often addressed in primary care settings.

On average, ESRD patients experience approximately 11 days per year in the hospital and consume 19 pills a day. Thus, the complex treatment of these patients comes with significant costs, the majority (more than 90 percent) of which is paid by government insurance. Despite being only 0.2 percent of the U.S. population, ESRD patients account for 7.2 percent total of all Medicare claims costs.

Patients with ESRD represent an ideal patient population to benefit from a combination of personalized care and population health management. Most ESRD patients spend 12 to 15 hours a week in a dialysis clinic. This provides a unique opportunity to routinely engage these patients in addressing their non-dialysis health care needs and helping them better navigate the health system. This can lead to not only better outcomes and quality of life but also improved cost savings for an overburdened health care system. For example, a leading provider of ESRD integrated care programs has reported 29 percent fewer days in a hospital, which translates to more time patients can spend living their lives.

As with other population health programs, risk stratification is critical. The ability to regularly review and adjust patient risk allows care managers (nurses) to target patients at the highest risk of complications. Nurse practitioners can work with patients and their physicians to facilitate access to specialists and services known to deliver high-value care for specific problems when necessary.

Data related to hospitalizations and patient risk are given back to patients’ nephrologists on a regular basis. This allows physicians to adjust their clinical emphasis as needed, improving the ability to prevent complications for patients. Care managers engage patients on a regular schedule, developing appropriate care plans for new problems and tracking progress for ongoing clinical and social concerns in a care management system. The combined efforts of this multidisciplinary team reinforce care delivered in the dialysis center and provide opportunities for additional touch points outside of a facility, enhancing patient engagement.

The Medicare Advantage Chronic Condition Special Needs Program (MA C-SNP) in California exemplifies the value of an integrated care model for ESRD patients. This program operates with monthly Medicare Advantage payments and flexible service area options, enrolling insurance-eligible patients, often individuals who are dually eligible, via a payer. It offers transportation, dental and vision benefits tailored to ESRD patients. Such programs have achieved decreased hospitalization and admission rates and lowered rates of central venous catheters as primary access for dialysis. These results clearly exemplify what can be accomplished through an integrated care model for ESRD patients.

Some of this content has been republished, with permission, from Accountable Care News.