Bruce R. Gordon M.D. The Rogosin Kidney Care Alliance ESRD Seamless - PowerPoint PPT Presentation

Bruce R. Gordon M.D. The Rogosin Kidney Care Alliance ESRD Seamless Care Organization (ESCO) **Prospective from a small dialysis organization (SDO)

ESCO Participants – 4 Organizations* 13 ESCOs Small Dialysis Orgs (SDOs) < 200 units 1 sided risk The Rogosin Non-profit ~1,600 8 units 1 ESCO Institute patients Large Dialysis Orgs (LDOs) > 200 units 2 sided risk DCI Non-profit 14,800 233 units 3 ESCOs patients Fresenius For profit 178,337 2,312 units 6 ESCOs patients Davita For profit 174,300 2,173 units 3 ESCOs patients *As of 2016; In 2017 new ESCOs likely added

The Rogosin Institute Non-profit kidney care provider in NYC Affiliated with NewYork-Presbyterian Health System/Weill Cornell Medicine 8 dialysis units in Brooklyn, Manhattan, and Queens CKD clinic and clinical research Center for Health Action and Policy - Outreach, education, outcomes research, policy

Rogosin Kidney Care Model Health Promotion and Disease Prevention CKD 1,2,3 CKD 4,5 ESRD Primary Care Intensive education Transplant Hypertension Multi-disciplinary In-center care team hemodialysis Diabetes control Emphasis on PD/home hemo Nutrition preparation and Medical management Physical activity treatment choices Healthy living Better Care, Lower Costs, Better Outcomes, Improved Quality of Life

ESCO: Why Did Rogosin Participate? • Improve clinical outcomes, quality, and decrease cost • Participate in the national health care discussion • Competitive advantage • SDO will have more roots in the local community compared to LDO

Challenges for an SDO The application: Defining our approach, getting partners and owners, agreements. Help from DCI, CDC and NKCA. Getting started: Forming the LLC, finalizing agreements, creating web site, educating staff and partners Running the ESCO: Time/effort, EHR (using Darwin/DCI), Data analytics/interpreting financial reports, Quality reporting Cost: Achieving the minimal savings rate without aggregation. Allocate funding to infrastructure and projects that we needed to do independent of ESCO

Investment Considerations Start Up Costs • RKCA began in Fall 2016 with 400 aligned beneficiaries, 300 actively managed Direct Start Up Costs ( approximate ) Salaries & Benefits - 2 Care Coordinators (1 month) $20,000 ESCO Administration (4 months) $25,000 Legal Fees $8,000 Compliance Program $2,000 Total Direct Start Up Costs $55,000 Note: Excludes Compliance Officer, Quality Director and ESCO Management

Investment Considerations Direct Annual Costs ( approximate ) Salaries & Benefits - 2 Care Coordinators $200,000 ESCO Administration $75,000 Medication Therapy Management $25,000 Care Management Platform $15,000 Patient Education iPad Program $15,000 Data Analytics $25,000 Travel $10,000 Legal Fees $3,000 Compliance Program $2,000 Total Direct Annual Costs $370,000 Note: Excludes Compliance Officer, Quality Director and ESCO Management

Focus: Reduction of Patient Admissions and Readmissions • Provide upstream CKD education outside ESCO • Provide in-patient education and counseling among pre-ESRD and ESRD patients • Create partnership with local emergency department to manage our ESRD patients • Target high risk patients via dedicated nurse care coordinators • Enhance health literacy of patients, families, and care partners

PEAK Program for Education In Advanced Kidney Disease • Goal is to establish relationship between kidney disease patients and care team early in care process • Target Group: CKD Stage 4 and 5 • Patient Care Team: Nurse practitioner, nurse educator , nutritionist , and social worker • Facilitate informed decision making on renal replacement options with an emphasis on transplant and home dialysis • Conservative medical care when appropriate • Encourage AV access placement before starting dialysis

ESCO Field Welcome to Rogosin Stadium Dietitian Nurse Social Practitioner Worker Nurse Educator

PEAK Statistics May 2015 - August 2016 Number of Patients Percentage Total New Patients Enrolled in Program 192 Started Dialysis 33 17% Referred to Vascular Surgeon 119 62% Vascular Access Placed 106 55% Start HD with AV Access (26% 2014) 19/33 58% Referred for Transplant evaluation 141 73% Started dialysis in the home 2 6%

Hospital In-Patient Program Target groups: Patients who “crash” into dialysis • Patients with eGFR <20 who are approaching dialysis • Patients on hemodialysis who have catheters • Educator: Nurse Practitioner with experience as a dialysis nurse Education regarding: dialysis modalities • access type (if HD) • urgent home dialysis start (if “crash start”) • placement of AV access in hospital if appropriate •

Role of Care Coordinator • Target high risk patients based on daily printout created by EHR (Darwin/DCI) • Medication reconciliation post discharge • Integration of RoundingWell program to assist care coordinator • Role is evolving • Recruiting the right talent is critical

Health Literacy • Definition: The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions • According to the Department of Education, only 12% of Americans are proficient in Health Literacy

Factors Impacting Health Literacy Culture, language, diversity • In the NY metropolitan area, there are over 190 • languages spoken in households Patient demographics, educational attainment • Communication skills and context • Complexity of healthcare system, demands on • healthcare systems, new technology, advances in scientific discoveries

Rogosin’s Health Literacy Strategy Work upstream with patients prior to dialysis • PEAK program (CKD education) • Hospital education program • Work with current ESRD patients • iPad education • Peer to peer learning • Patient interviews • Work with Rogosin staff • Health literacy training • Work in the community • Kidney health and transplant education with community-based • partners including senior centers, schools, faith-based organizations, and recreational facilities

Work with Current Patients • iPad Education Program • Interactive educational e-books on topics including coping with dialysis, access management, nutrition, transplant, treatment modalities • E-books include videos, text, images, PDFs, and web links • Link to National Kidney Registry sign-up • KDQOL completion • Apps for therapeutic purposes (including meditation apps, coloring apps, games)

Work with Current Patients • Peer to peer learning • Videos with patients discussing their experiences • Support groups • Roundtables • Events bringing together experts from around the country on topics impacting our patients to develop pilot projects • Past: health literacy, mental health, nutrition • Upcoming: transplant • Interviews to collect patient voice and experience

Work with Rogosin Staff • Hosted a health literacy staff training in January 2016 with representatives from all Rogosin facilities • Skills taught: Teach-back, Plain Language, Universal Precautions • Formation of “health literacy champions” team • Currently developing in-service to spread training topics to all Rogosin staff

ESCO - Next Steps • Broader provider participation/engagement • Increase focus on home dialysis • Advocacy for inclusion of kidney transplantation in the CEC model • Enhanced end-of-life care and planning • Analysis of financial data • Work toward aggregation with new participant SDOs in 2017 • One-sided risk 2017, two sided risk 2018?

Discussion and Questions Thanks!