The Quality Hierarchy for ESRD Patients

Transcription

1 The Quality Hierarchy for ESRD Patients The Integrated Care Management Imperative Allen R. Nissenson, MD, FACP Chief Medical Officer, DaVita HealthCare Partners, Inc. UCLA Nephrology Grand Rounds

2 Background We are working harder but making less Quality and financial incentives are not aligned Lack of understanding, cooperation, and collaboration between: Hospitals & physicians Physicians & physicians Current trends in healthcare growth and Medicare spending are unsustainable 2

3 Background: Estimated Numbers of Point Prevalent ESRD Patients USRDS

4 Background: Financial Drivers ~1.5% of Patients 1,2 ~10% of Costs ESRD + Late Stage CKD ~$30B per year Other Medicare Other Medicare 1 Source: USRDS (publicly available comprehensive clinical and financial dataset reported to and used by CMS) 2 ~375K ESRD + ~300K Stage 4 Chronic Kidney Disease 4

5 Reduce healthcare costs Donald M. Berwick, Thomas W. Nolan, and John Whittington. The Triple Aim: Care, Health, and Cost, Health Affairs, Vol. 27 No. 3 (May, 2008):

6 Shifting the Clinical Paradigm

7 Disparate Pieces Clinical Enterprise Compliance Strategy Risk RDs & SWs Planning OCMO Education Research Resources Initiatives Support Fab 5 Methodology Quality Safety Analytics Operations Reporting Governance Lab 7

8 Clinical Enterprise Multi-Year Objectives and Completion Dates 2014 Develop, install, and strengthen core operational discipline 2014 Eliminate single points of failure 2014 Effective clinical decision-making documentation 2017 Develop BHAG, expanded goal setting and corresponding analytics & goal mgmt capability Ongoing DaVita Clinical brand optimization 8

9 Universe of Options Pneumo Vacc. Kt/V Safety Diabetes Infections Hb EOL Care Fluid Overload Pt. Experience Med. Events Flu Vaccine CKD Mgt. Phosphorous Mortality Depression PTH Albumin CVC / AVF Calcium URR Missed treatments Limb Loss Pain Mgt. QOL Adv. Directives CVD 9

10 Organizing the Universe BUILD A FRAMEWORK THAT IS... EASILY UNDERSTOOD FLEXIBLE USE THAT FRAMEWORK TO... DETERMINE PRIORITIES, PROGRAMS, & METRICS COMMUNICATE TO EVERYONE 10

11 V1.0 CAO Sept 2013 QOL

12 QOL Mortality Hospitalization Pt. Experience V1.0 CAO Sept 2013

13 QOL Mortality Hospitalization Pt. Experience Fluid overload Med mgmt Diabetes Limb loss MBD mgmt EOL care CVD Infections Safety Depression Missed tx Others... V1.0 CAO Sept 2013

14 QOL Mortality Hospitalization Pt. Experience Fluid overload Med mgmt Diabetes Limb loss MBD mgmt EOL care CVD Infections Safety Depression Missed tx Others... Hemoglobin Kt/V Weight gain CVC / AVF PTH Phosphorus Iron URR Sodium Albumin Calcium Others... V1.0 CAO Sept 2013

19 What Matters Most to CMS, Payers, Hospitals, Docs? = most aligned with what matters most to stakeholder First Second Third Highest First Order (e.g. Kt/V) Second Order (e.g. Fluid) Mortality Hospitalization Patient Experience QOL CMS Private Payers Hospitals Physicians Average Alignment 19

20 We ve performed well in the Fundamentals Focus Metric Actual (%) Goal (%) Hit Goal? Clinical Value in Further Gains Fundamentals Adequacy Kt/V Yes Low URR Yes Low Immunizations Flu vaccination Yes Low Pneumo vaccination Yes Low Anemia Hb > Med Phos < Yes Low MBD Ca Yes Low PTH Yes Low Infection/Inflammation Albumin High Access CVC Yes Med AVF No Med Actuals as of December

21 Still have much room to improve in high impact, higher-order outcomes Focus Metric Actual (%) Goal (%) Hit Goal? Clinical Value in Further Gains Complex Programs Infection Bloodstream infections?? - High Diabetes Limb loss, hospitalizations?? - High Med. Management Reconciliation, etc.?? - High Fluid Management BP, weight, missed tx?? - High Measures of Effectiveness What Matters Most Mortality GMR High Hospitalization Days / patient years, etc.?? - High Experience of Care CAHPS, others??? - High Quality of Life KDQOL, others??? - High Actuals as of December

22 A Powerful and Meaningful Message Rallying our TMs, our Village QOL Mortality Hospitalization Patient Experience Bringing Quality to Life 22

23 Deaths per 100 Patient Years Gross Mortality 2012 preliminary figure derived from internal data 23

24 Patient Experience 1 CAHPS forms a strong foundation 2 Significant analytics in-progress 3 Goal: World-leader in patient experience 24

25 Admissions per Patient Year Hospital Admissions (DaVita) Unadjusted analyses; source: USRDS 25

26 Admissions per Patient Year Hospital Admissions by Provider (2009) Unadjusted analyses; source: USRDS 26

27 What Causes Hospitalizations? Percent of Total Admissions Fluid-excess (directly & indirectly related) 30.4% CVD (controllable) 9.9% Fluid overload 6.5% Hypertension 5.3% CHF 4.0% Fluid and electrolyte disorders 2.7% CVD (non-controllable) 2.1% Infection (directly related) 19.9% Vascular access 10.4% Septicemia 5.5% Vaccine preventable pneumonia 4.0% Diabetes (directly related) 5.1% Diabetes 4.3% Diabetes-related amputation 0.9% Other 0.3% Depression 0.3% Total listed above 55.7% All additional causes (e.g. brain aneurysm) 44.3% Grand total 100.0% 2009 USRDS data; DVA patients. 27

28 Innovation in the Clinical Model: DaVita s Clinical Focus Fluid Mgmt Infection Mgmt Med Mgmt Diabetes Mgmt 28

29 CLINICAL PROGRAMS: Development, Support and Goal-Setting

30 How it All Will Work, Effectively and Efficiently Where we have are going been 30

31 Structured Prioritization, Innovation, Testing, & Scale Alignment First, decide what projects to take on Aligned with strategy / value? Discovery Learn, hypothesize, define, test, pilot, analyze Go / no-go decision; if go, hand to Diffusion Diffusion Deploy, scale, make it sticky (integrate w/it) Determine next step Measurement Determine created value Next steps (continue? back to Discovery? etc.) 31

32 Clinical Execution Model: Requirements and Tactics Checklists Process Common Glossary language Committees Governance & Councils Execution Model Documentation StarPoint mgmt system Planning, Master calendar Promotion, & ticklers Preparation Information Communication sharing & plan collaboration 32

33 Clinical Execution Model Checklist Our Process (i.e. the steps) 33

34 Segment Checklist & Associated Forms Our Activities (i.e. actions) 34

35 Graduated Clinical Performance Support Opportunity Type of Support Developing Testing mode As needed (pilot facilities) Diffusing Mature Optimized Significant: mean and variability Minor: mean Significant: variability Minor: mean and variability Active surveillance and intervention (ASI) <20% ASI, >20 watchful monitoring (WM) WM for all 35

36 Increasing collaboration and communication

37 Calendar of Roll-Outs Illustrative Project 1 FAs Project 3 Physicians Project 5 SWs & RDs Mar Aug Nov Jan Feb Apr May Jun Jul Sept Oct Dec Project 2 FAs Project 4 Physicians Project 6 SWs & RDs 37

38 Pilot Networks Top 4 programs Each with multiple pilots Each across multiple years Additional pilots needed from other clinical teams (VH, Rx, Home, etc) Will require extensive network of pilot facilities, so none are overburdened 38

39 Clinical Roundtable Build a FORUM for people AROUND THE VILLAGE to talk about CLINICAL PROGRAMS in a MEANINGFUL WAY 39

40 Goals of NQW Advance the clinical agenda in pursuit of becoming TGHCTWHES... By assembling a CROSS-FUNCTIONAL group of leaders... To provide INPUT AND GUIDANCE on key clinical strategic and tactical issues, and To improve COLLABORATION AND UNDERSTANDING between Atlas & Field leaders 40

41 NQW 2013: Continuing the Momentum 2012 Topics & Outcome Infection management Clinical prioritization filters Infection mgmt now one of Big 4 Complex Programs Output from deep-dive used in program design 2013 Topics & Outcome Preparedness for large influx of complex clinical programs in coming years Field preparedness for earlier and more effective self-management of mature clinical programs 7 high-value topics to be tackled by NQW sub-groups Filters developed at NQW now used in Alignment prioritization process 41

42 Integrated Care Mgmt

43 The Key Issues Heredity vs environment (what makes us tick) Physicians are humans Companies are collections of humans FFS, and Bundles are not conducive to true integrated care Most integration services are separate from core dialysis care delivery Existing TMs main role will be to achieve excellent results from Fundamentals and Complex Programs aimed at Mortality, Hospitalizations, and Patient Experience 43

44 Innovation in the Delivery Model PAST Provider-centric Volume driven Quality given attention No focus on inefficiency Lack of alignment FUTURE Patient-centric Quality driven Utilization focused Collaboration focus Safety focus Safety?? 44

45 Integrated Care Management (ICM) Clinical Interventions CKD Program (Stage 4-5) ESRD Program Delay CKD Progression Prepare for Dialysis Adapt to Dialysis Avoid Hospitalization Accurate staging CKD education, awareness Medications Nutrition Nephrologist referral Manage co-morbids Diabetes Hypertension Vascular access Elective start Modality choice Advanced care planning Identify before dialysis start Enroll at admit Standing orders Catheter removal Biometric monitoring Medication Therapy Management Kidney Smart Clinical Decision Support System (Capella) Field and Call Center-based Clinical Team Vascular access Re-admission protocol Fluid management Immunizations Nutritional supplement End-of-life counseling 45

46 ESCO Model of Care Model of Care Clinic Clinic based Care Manager Clinic Clinic Nephrologists Geography based Nurse Practitioner VillageHealth Care Manager Coordinates with clinic Teammates to deliver VillageHealth interventions Drives patient engagement Coordinates patient care with Nephrologist and Care Team VillageHealth Nurse Practitioner Focus on high risk patients / frequent hospital admissions Coordinates with hospitals and home visits Partners with social workers on behavioral health *VillageHealth experience proven to generate 15% y-o-y non-dialysis cost savings in Southern CA *ATL Pilot early results reflect decreased hospitalizations, improved chronic/acute coordination, and enhanced patient/doc engagement 2013 DaVita Healthcare Partners Inc. All rights reserved. Privileged and Confidential. Internal Use Only. 46

47 Summary

48 Shifting the Clinical Paradigm PATIENT- FOCUSED HIERARCHY BUSINESS DISCIPLINE & PROCESS COLLABORATION AND COMMUNICATION Focus on complex programs that drive QOL No deterioration in fundamentals Execution model Checklists & documentation system New clinical performance mgmt process Better Air Traffic Control for clinical programs More input from Field & physicians 48

49 Integrated Care Management (ICM) Clinical Interventions CKD Program (Stage 4-5) ESRD Program Delay CKD Progression Prepare for Dialysis Adapt to Dialysis Avoid Hospitalization Accurate staging CKD education, awareness Medications Nutrition Nephrologist referral Manage co-morbids Diabetes Hypertension Vascular access Elective start Modality choice Advanced care planning Identify before dialysis start Enroll at admit Standing orders Catheter removal Biometric monitoring Medication Therapy Management Kidney Smart Clinical Decision Support System (Capella) Field and Call Center-based Clinical Team Vascular access Re-admission protocol Fluid management Immunizations Nutritional supplement End-of-life counseling 49