Patient Centered Care in the ESRD Network System

1. Patient Centered Care in the ESRD Network System Jenna Krisher Executive director Southeastern kidney council

2. Southeastern Kidney Council, Inc. Who’s Who in the Network System Congress CONTRACT HHS/CMS CMS Network 6 ESRD Networks Patients SOW

3. Congress • 1972: Extended Medicare coverage to Persons with ESRD • 1977: Amended Social Security Act (The Act) to establish ESRD Network Program • 1986: Amended the Act to expand Network responsibilities, add language to fund Networks at 50 cents per dialysis treatment

4. Congress’ List of Network Responsibilities • Encourage use of treatment settings most compatible with rehabilitation of the patient and the participation of patients, providers of services, in vocational rehabilitation programs • Develop criteria and standards relating to the quality and appropriateness of patient care and with respect to working with encouraging participation in vocational rehabilitation programs; • Develop Network goals with respect to the placement of patients in home therapies, and in-center self-care settings and undergoing or preparing for transplantation • Evaluate the procedure by which facilities assess the appropriateness of patients for proposed treatment modalities • Implement a procedure for evaluating and resolving patient grievances • Conduct on-site reviews of facilities as necessary, utilizing standards of care established by the Network to assure proper medical care

5. Congress’ List of Network Responsibilities • Collect, validate, and analyze such data as are necessary to assure the maintenance of the registry • Identify facilities and providers not cooperating toward meeting Network goals and assist such facilities and providers in developing appropriate plans for correction and reporting to the Secretary on facilities that are not providing appropriate medical care • Submit an annual report to the Secretary on July 1 of each year which shall include a full statement of the Network’s goals, data on the Network’s performance in meeting its goals including data on the comparative performance of facilities and providers, identification of those facilities that have consistently failed to cooperate with Network goals, and recommendations with respect to the need for additional or alternative services or facilities in the Network area in order to meet the Network goals, including self-dialysis training, transplantation, and organ procurement facilities.

6. § 405.2112 ESRD network organizations. • (a) Developing network goals for placing patients in settings for selfcare and transplantation. • (b) Encouraging the use of medically appropriate treatment settings most compatible with patient rehabilitation and the participation of patients, providers of services, and renal disease facilities in vocational rehabilitation programs • (c) Developing criteria and standards relating to the quality and appropriateness of patient are and, with respect to working with patients, facilities, and providers of services, for encouraging participation in vocational rehabilitation programs. • (d) Evaluating the procedures used by facilities in the network in assessing patients for placement in appropriatetreatment modalities. • (e) Making recommendations to member facilities as needed to achieve network goals. • (f) On or before July 1 of each year, submitting to CMS an annual report that contains the following information:

7. ESRD Network Contract SOW • Improve the quality and safety of dialysis-related services provided for individuals with ESRD. •  Improve the independence, quality of life, and rehabilitation (to the extent possible) of individuals with ESRD through support for transplantation, use of self-care, and in-center self-care, as medically appropriate, through the end of life. •  Improve patient perception of care and experience of care, and resolve patients’ complaints and grievances. •  Improve collaboration with providers and facilities to ensure achievement of goals 1 through 3 through the most efficient and effective means possible, with recognition of the differences among providers and the associated possibilities/capabilities. •  Improve the collection, reliability, timeliness, and use of data to measure processes of care and outcomes; to maintain a patient registry; and to support the goals of the ESRD Network Program. CONTRACT

8. Don Berwick Triple Aims SOW • Better care for individuals • Safe  Effective • Patient-centered Timely • Efficient Equitable • Better health for populations, by attacking upstream causes such as • poor nutrition • physical inactivity • substance abuse. • Reducing per-capita costs by improving Quality CONTRACT

9. 18 ESRD Networks • Each entity contracts with CMS • All have the same Statement of Work and Goals • Current contract through June 2012 • Most are small, non-profit companies • Our area is ESRD Network area #6

10. Non-profit organization, based in Raleigh, NC • Hold the contract with CMS for ESRD Network 6 • Volunteer, multi-disciplinary Board of Directors • Consumer Committee • Medical Review Board • Finance Committee • Nominating Committee • 14 paid staff members

11. The Patients We Serve • 3 States • 38,500 people on dialysis • 11,000 people with a transplant • 10% of the US ESRD Population • 68% African American/30% White • Average age: 59 years • 72% dialyzing in-center • 8% at home • 20% with a transplant

12. The Patients we Serve • 590 Facilities • FMC: 34% • DaVita: 33% • All others: 33% • 10% of all facilities nationally

13. Network Contract by the Numbers SOW • 5 Tasks • Task 1: Quality Improvement • Task 2: Outreach and Patient Services • Task 3: Administration • Task 4: Information Management • Task 5: CROWN Web • Funding • CMS collects 50 Cents per treatment • SKC receives 26 Cents per treatment • 14 SKC Staff members CONTRACT

14. To improve the lives of people with or at risk for end stage renal disease by promoting and advancing quality of care.

15. Quality of Care Commitment Each Facility agrees to… • Cooperate with the Network, participate in Network activities and pursue Network goals to fulfill the terms of the current Network Statement of Work. • Identify a Governing body that receives and acts upon Network recommendations. • Provide the highest quality of care to every patient we treat by striving to meet Network Quality Goals using a data-driven quality assessment and performance improvement plan. • Provide timely and accurate data and information to support the national ESRD registry, to facilitate measurement and improvement of care and to resolve patient complaints.

16. Quality of Care Commitment • Cooperate with the Network Medical Review Board (MRB) on all QI activities including QI Projects and Focused Review, including submission of information and responding to MRB recommendations. • Cooperate with the Network in prevention and resolution of patient concerns, complaints and grievances. This includes educating patients on the Network’s role in complaint and grievance resolution, posting the Network address and phone number and notifying the Network at least 30 days prior to involuntarily discharging a patient. • Share educational information with patients as requested by the Network and helps educate patients on the role and services of the Network. • Follow all CMS/HIPAA rules for secure transmission of data.

17. Quality of Care Commitment Southeastern Kidney Council agrees to… • Provide educational resources and technical assistance to facilities and to patients to help improve the quality of care. • Provide comparative feedback reports that facilities can incorporate into local QI projects. • Provide education, tools and technical assistance to assist facilities and patients to: • Prevent and resolve conflict between patients and providers • Improve the quality of care • Ensure data submission is accurate and timely • Oversee all Network activities through the multidisciplinary Board of Directors and its committees to ensure projects are effective, reasonable and appropriate for patients and providers in the Network 6 area and that activities are conducted in an environment free from conflict of interest.

18. Task 1: Quality Improvement • Increase fistula use • Decrease catheter use • Improve anemia management • Improve adequacy • Increase immunizations • Reduce health care infections

19. Task 1 by the Numbers • 52.8% of Patients Dialyzing via AV Fistula • 7.2% of Patients Dialyzing via Catheter > 90 Days • 28% of Patients Dialyzing via AV Graft

20. Vascular Access in Network 6 Area

21. Catheter Use By Network Dec 2010

22. AVF Use by Network Dec 2010

23. Facility AVF Rates Dec 2010 <40% 41-50% 51-65% 66% Opportunity to Improve - QAPI 62 11% 164 30% 255 46% 71 13%

24. Improving AVF Rates for Better Care • All Facilities • Resources • Technical Assistance • Workshops/Education • Data Feedback

25. Improving AVF Rates for Better Care • 66%: Great job! • 51-65%: Include in your QAPI; call us for help • <50%: Complete box and return We reviewed this report at our QI meeting on __/__/__ Signed: Medical Director _________________ Nurse Manager ___________________ We (Check one) ___ Confirmed data is correct ___ Corrected the data in the corporate systems and with the Network We (check one) ___ Have an AVF QAPI ___ Do not have an AVF QAPI We plan to increase the # of AVFs each month as follows: _____in 30 days ___ in 60 days ___ in 90 days • <40%: Focused Review

26. Focused Review to Improve Care • Letter to Medical Director and Clinical Manager with Agreement of Expectations • Data-driven QAPI • Send us your progress data • SKC will help with tools and feedback • Training manual • Educational materials • Sample templates • MRB reviews data and provides feedback • Possible site visits • When facility hits goal, released and asked to share best practices

27. Focused Review to Improve Care

28. Focused Review to Improve Care • Using March 2010 vascular access data, ranked all providers by catheter use (all catheters) • Selected the 15 facilities with at least 40 patients that had the highest catheter rates • Selected the 5 facilities with < 40 patients with the highest catheter rates • 8 Facilities continued from last year

29. Focused Review to Improve Care

30. Increasing Immunizations for Better Care 9% 100% 53% >90%

31. Increasing Immunizations for Better Care

32. Increasing Immunizations for Better Care

33. Decreasing Anemia for Better Care

34. Increasing Adequacy for Better Care

35. Quality Improvement on the Horizon • Healthcare Acquired Infections • Transplant • Formed a coalition to study and remove barriers to transplant • Increased patient / provider education • Collaboration of transplant centers • Increase donors • May include transplant measures in future screening

36. Quality Improvement on the Horizon 81 (18%) had more than Expected 377 (82%) Facilities had fewer Transplants than Expected

37. Better Care • 1,256 more AV Fistulas in use • 571 fewer catheters in use • 322 fewer long-term catheters in use • 1,125 more patients receiving adequate dialysis • 2,680 more patients with anemia managed

38. Educating Patients for Better Care • New Patients receive NEPOP • Introduce CMS, Network, State Surveyors • Educational materials • All Patients receive newsletters • All Patients receive annual Calendar • Developed by Consumer Committee • Each month, facility receives supporting packet

39. Educating Patients for Better Care • 39,665 Calendars mailed in December 2009 • Survey/analysis conducted in June 2010 • 29% of respondents knew ”Network 6” • 82% knew “Southeastern Kidney Council” • When asked for future education topics • Nutrition – 31% • Treatment Options – 26% • Emergency Preparedness – 12% • When asked how • Video – 34% • Facility distribution – 27% • Mail materials to home – 25% • Workshop/meeting – 13%

40. Educating Providers for Better Care • Network Annual Report • Regional and National patterns of care • Information on Network QI projects • Information on the importance of immunization • CQI Materials • Dialysis Facility Report • VISION, CROWN information

41. Assisting Patients/Providers for Better Care • Identify providers for transient dialysis • Assist users with Dialysis Facility Compare • Assist with procedures to assess patients for treatment modalities • Assist providers in developing rehabilitation goals • QI Plans / QAPIs • Assist in disaster planning and recovery • Assist with community education programs • Help patients and providers resolve issues

42. Resolving Issues For Better Care • 287 complaints in 2010 • 9% of all the complaints in the US • 5.06 complaints per 1000 patients • Other calls • 101 Beneficiary inquiries • 191 Facility concerns • 451 Facility inquiries • 1,720 Calls regarding

43. Resolving Issues For Better Care

44. Resolving Issues For Better Care • 37 Involuntary Discharges in 2010 • 32 Averted

45. Resolving Issues For Better Care • What to do if SKC calls you with a complaint • Think positive: you’ve done a good job educating patients to call us • Keep an open mind • Send us documentation that helps us understand the situation • Know the conditions for coverage • If IVD – 30 day notice and complete IVD packet • Keep the patient central to your actions

46. Maintaining the Registry for Better Care • 11,000 CMS 2728 Forms entered in 2010 • 1,760 had to be returned for correction • 88% on time, accurate • 7,700 CMS 2746 Forms entered in 2010 • 230 had to be returned for correction • 94% on time, accurate • 6,732 NPAR forms with 47,124 events entered • Clinical Data • Fistula First – monthly • Elab – annual • Immunization – annual

47. Maintaining the Registry for Better Care • Medicare uses data to determine eligibility • Clinical indicators profiled to identify trends in care to be addressed • Registry allows us to know where patients are dialyzing and help with placement in emergencies • Data analyzed and reported in journals to improve the science of care • Descriptive / demographics help us understand the population served

48. Questions?