CHRONIC KIDNEY DISEASE MANAGEMENT GUIDE

CHRONIC KIDNEY DISEASE MANAGEMENT GUIDE

Outline I. Introduction II. Identifying Members with Kidney Disease III. Clinical Guidelines for Kidney Disease A. Chronic Kidney Disease B. End Stage Renal Disease IV. Providing Complex Case Management to Members with Kidney Disease V. Providing Complex Case Management to Members with End Stage Renal Disease VI. Clinical Process and Outcome Measures VII. Evaluating the Program VIII. IX. Population Health Management Reports for Employer Groups Bibliography X. Revisions Appendices A. Kidney Disease Websites B. Kidney Disease Assessment C. Kidney Disease Intervention Educational Materials 2

Coventry Health Care s Chronic Kidney Disease Management Guide I. Introduction Coventry Health Care has developed and implemented a program to provide comprehensive care management to members with kidney disease. The program provides ongoing, comprehensive care that increases the member s awareness of their condition and the value of its treatment and self-management. With proper education and self-care, people with chronic kidney disease can prevent or control related complications and have healthier lives. The Chronic Kidney Disease (CKD) Management Guide describes the goals and components of the program. Each section provides a description of the steps to take. Chronic kidney disease is defined as either kidney damage or GFR<60mL/min/1.73m 2 for three months or longer. Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. Glomerular filtration rate (GFR) is calculated using the patient s serum creatinine level, age, race and gender. Following are the stages of kidney disease: Stage 1 Kidney damage with normal or increased GFR, GFR >90mL/min/1.73m 2 Stage 2 Kidney damage with mild decrease in GFR, GFR = 60-89mL/min/1.73m 2 Stage 3 Moderate decrease in GFR, GFR = 30-59mL/min/1.73m 2 Stage 4 Severe decrease in GFR, GFR = 15-29mL/min/1.73m 2 Stage 5 Kidney Failure, GFR <15mL/min/1.73m 2 Goals Coventry Health Care works with members and physicians to achieve the following goals: Educate and empower members towards self-management Educate and support physicians through evidenced-based guidelines Educate on the prevention of acute events due to chronic kidney/end stage renal disease Program Activities Care Management Services Provided to All Members with Chronic Kidney Disease. All members with the condition are identified and are included in the program. They are given information about how to opt-out, if they choose. Informing and Educating Practitioners Practitioners who care for Coventry members are provided information about the Chronic Kidney Disease Management Program. This information, which describes the program, is either mailed to them or available to them through our website. Some providers are provided a list of their members who are enrolled in the program. If requested, materials that are sent to members are also provided to the providers. 3

Specific Services Targeted to Members with Kidney Disease Complex case management* Access to community resources providing chronic kidney disease and dialysis education Coventry Health Care web-based education and web links for additional information. New member welcome kit upon identification and may receive a Newly Identified call. Quarterly educational mailings on self-care management, based on Plan/Group election. Personalized indicator mailings targeted for members who are missing important services, such as the importance of an annual physician visit and if elected by their Group/Plan, they will also receive a Non-compliant Call. * If member meets criteria for enrollment after case management assessment completed II. Identifying Members with Chronic Kidney Disease All members with a diagnosis of chronic kidney disease in the past 12 months are included in the program. Members are identified on a daily basis from a variety of sources including: Medical claims Staff identification (CSO, concurrent review nurses, etc) Nurseline Member self-identification (including HRAs); and Practitioner referral. Identification Logic At lease two medical claims greater than 7 days apart with the principal or secondary diagnosis of CKD Administrative specifications for identifying those with kidney disease ICD-9-CM diagnosis codes used for identification can be found in Attachment A of the Program Specifications for CKD Management Program. Patients with a kidney transplant are excluded from the program. Exclusion codes can be found in Attachment A of the Program Specifications for CKD Management Program III. Clinical Guidelines for Chronic Kidney Disease/End Stage Renal Disease The clinical guidelines for the program are based on those developed by the National Kidney Foundation. All Coventry Health Care members identified as having chronic kidney disease, in addition to routine preventive and follow up care, the following preventive and therapeutic services: Patients with chronic kidney disease should be evaluated to determine: Diagnosis (type of kidney disease) Comorbidities Severity of kidney disease, assessed by level of kidney function Complications, related to level of kidney function 4

Risk for loss of kidney function Treatment of chronic kidney disease should include: Evaluation and management of comorbidities Slowing the loss of kidney function Prevention and treatment of complications of decreased kidney function Preparation for kidney failure and kidney replacement therapy (dialysis and/or transplant) Patients with chronic kidney failure should be referred to a nephrologist if their GFR<30mL/min/1.73m 2 All Coventry Health Care members identified as having end stage renal disease, in addition to routine preventive and follow-up care, the following preventive and therapeutic services: Early placement of vascular access if on, or planning to go on, hemodialysis Outpatient placement of vascular access and outpatient de-clotting of grafts Dialysis as ordered Early testing (two weeks prior to initiating dialysis) of hepatitis status Blood pressure monitoring (goal is <130/80mmHg) Calcium, Phosphorus, Parathyroid, Vitamin D, LDL, Hgb/HCT, Ferritin and Potassium monitored at least annually IV. Providing Complex Case Management Services to Members with Chronic Kidney Disease Conduct an assessment located in NavCare Develop a clinical action plan depending on kidney disease stage: Stage 1 Diagnosis and treatment, treatment of comorbidities, slowing progression of disease Stage 2 Estimating progression Stage 3 Evaluating and treating complications Stage 4 - Preparation for dialysis or transplant Stage 5 Dialysis or transplant Monitor GFR and proteinuria Discuss diet/fluid restrictions Facilitate referral to nephrologist or dialysis centers as indicated Review medications and discuss with member to determine level of understanding and educational opportunities Encourage member to discuss flu and pneumonia vaccines with his/her physician Members who have not completed all of the clinical measures will receive a personalized reminder letter (e.g., no claim for laboratory tests, etc.) Upon identification, members will also receive a new member welcome kit as well as may receive newly identified call. Members will also receive quarterly educational mailings, based on Plan/Group election. 5

V. Providing Complex Case Management Services to Members with End Stage Renal Disease Conduct an assessment located in NavCare Verify placement of access and early testing of hepatitis status Discuss dialysis schedule with member to ensure understanding Monitor blood pressure to meet goal <130/80 Discuss diet/fluid restrictions Review medications and discuss with member to determine level of understanding and educational opportunities Encourage member to discuss flu and pneumonia vaccines with his/her physician Members who have not completed all of the clinical measures will receive a personalized reminder letter (e.g., no claim for laboratory tests, etc.) Upon identification, members will also receive a new member welcome kit as well as may receive newly identified call. Members will also receive quarterly educational mailings, based on Plan/Group election. 6

VI. Clinical Process and Outcome Measures for Chronic Kidney Disease/ End Stage Renal Measures Labs Proteinuria Calcium, phosphorus, parathyroid, vitamin D, Ferritin, Potassium Hgb/Hct Serum creatinine Vaccines Influenza Physician Visit Physician visits annually Diet Protein: protein intake at the discretion of the nephrologist if not on dialysis Sodium: individualized, 1-3g/day Potassium: individualized based on lab results Dialysis Access AV fistula Percutaneous catheter Peritoneal dialysis catheter Hospital Utilization Hospital admits per 1000 Hospital readmissions per 1000 Outpatient visits per 1000 Emergency Department visits per 1000 Process -# Members Identified -Stratification Levels and counts -#Mailings -% High Risk Members that were assessed -% High Risk Members eligible for CCM (Cancer patients, members no longer eligible, etc will be removed from eligible count) -% High Risk Members managed in CCM Frequency (Source) Annually (Med Claims) Annually (Med Claims) Annually (Med Claims) Each Assessment not measurable via system Nursing Assessment not measurable via system Annually (Med Claims) Annually 7

VII. Evaluation of the Chronic Kidney Disease Complex Case Management Program A. Determining the quantitative results Use the measures listed in Section VI to identify the quality indicators and compare with the baseline or previous year measures. A statistical test can be conducted to determine if there were any differences. The quality indicators can also be evaluated by risk level. For example, the number of members in complex case management who are on control medications can be reviewed. B. Evaluating the impact of the Program 1. Evaluate the results. A group of staff and practitioners, who are closest to the program, evaluate the results comparing baseline with post-intervention measures. The baseline should be the results from the year prior to the interventions being implemented. The group can include the disease manager, case manager, QM Director, HS Director, Medical Director, and a network practitioner. 2. Compare results with other Coventry Plans, regional and national rates. 3. Identify best practice. Ask Coventry Plans, who have high rates, for information about their interventions. Identify opportunities from the literature. 4. Identify root cause. The group looks at each result and discusses the potential impact the intervention may have had or not have had on the results. For example, the visit rate to the PCP after ER care did not change when only mail reminders were sent. Potential causes are members need more or different type of reminders, practitioners need to remind members, access issues, and misinformation about benefit. 5. Identify opportunity for improvement. Team discusses the results and identifies potential interventions to improve the rates based on best practices and root cause analysis. If the measure has had a statistically significant increase and many reminders and other interventions were implemented, consider implementing fewer in the following year. Additional questions to be addressed by the Team: Which costs could be decreased and not impact the clinical outcomes? Were there barriers to the members receiving the needed care? Were high-risk members identified and referred as early as possible? Did high-risk members have many admissions? Could a modification to the program prevent these? 8

Did members receive the mailed reminder? How many were returned? Would a telephone reminder, which is less costly, have a similar impact? Do repeat reminders need to be sent or telephoned? Are practitioners aware of the program and the guidelines for the condition? Which guideline(s) are not being followed? 6. Implement the intervention The team develops a plan to develop the tools, training and materials needed to implement the intervention. VIII. Population Health Management Reports Population Health Management Reports include the following measurements for kidney disease: The number of members identified Utilization statistics (i.e., ER/1000, admits/1000, days/1000, ALOS and readmits/1000); Compliance statistics (percentage of members who had annual lab testing and annual physician office visit for kidney disease); The number of kidney disease educational mailings mailed and number of telephone calls made to members with kidney disease. Population Health Management Reports are available quarterly for clients who have our Disease Management Program. IX. Bibliography Chronic Kidney Disease: A Guide to Select NKF KDOQI Guidelines and Recommendations 2006. Nephrology Pharmacy Associates, Inc., American Regent, Inc. and the National Kidney Foundation, Inc. 2006 X. Origination: September 2007 Revisions July 2008 November 2008 July 2009 January 2010 December 2010 October 2011 9