Walking the walk or just talking the talk: how do we make progress?

1. Walking the walk or just talking the talk: how do we make progress? RichardFluck Date: 16th March 2016

2. The strategic challenge • Numbers requiring RRT are growing • Population is older with more comorbidities • Home therapies are in decline – especially PD • Economic downturn has implications for healthcare expenditure Home Therapies Richard Fluck

3. Figure 2.2. Growth in prevalent patients by treatment modality at the end of each year 1997–2012 UK Renal Registry 16th Annual Report Home Therapies Richard Fluck

4. Falling PD Figure 2.9. Modality changes in prevalent RRT patients from 1997–2012 UK Renal Registry 16th Annual Report Home Therapies Richard Fluck

5. Rise in home HD Figure 2.10. Detailed dialysis modality changes in prevalent RRT patients from 1997–2012 * Scottish centres excluded as information on satellite HD was not available UK Renal Registry 16th Annual Report Home Therapies Richard Fluck

6. Variation Figure 2.8. Percentage of prevalent haemodialysis patients treated with satellite or home haemodialysis by centre on 31/12/2012 ∗Scottish centres excluded as information on satellite HD was not available. No centres in Northern Ireland have satellite dialysis units UK Renal Registry 16th Annual Report Home Therapies Richard Fluck

7. Home Therapies Richard Fluck

9. Ambitions • 3. Self-management: All people with kidney disease are offered as much information as they would like in order to understand and manage their condition. • 4. Person-centred care: Care is centred on the person, taking into account individual needs and preferences, quality of life, symptom burden and the presence of co-existing medical conditions. Home Therapies Richard Fluck

10. 6. Preparation and Choice: All people approaching end-stage renal disease, or moving from one type of treatment for end-stage renal disease to another, understand and are given sufficient time and support to prepare for a treatment that is suitable for them, chosen from the full range of options. Home Therapies Richard Fluck

11. The House of Care Home Therapies Richard Fluck

12. Commissioning of RRTThe base

13. Key principles • Ensure patient pathway integrity • Enable CCGs to better allocate their resources efficiently • Move to accountability linked to population outcomes • Improve financial incentives for commissioners and providers • Offer value across the system and to individuals Home Therapies Richard Fluck

14. Simon Stevens, April 2014, Newcastle But at all times our guiding principle will be: walk in the shoes of the people we serve. Think like a patient, act like a taxpayer

15. Reimbursement • Short term • Mitigate short term issues • Long term • Process of internal and external consultation • Review of pricing engine • Challenge re reference costs • Renal specific – strategic review of reimbursement structure • Incentives? Home Therapies Richard Fluck

16. Service specifications • Modality specific • Clear pointers to shared care • CQUIN re shared care • Better metrics Home Therapies Richard Fluck

17. Specialised status • Advantages • High costs and complexity • Disadvantages • Reimbursement structure • One aspect of patient pathway • Collaborative solution • Reintegrate patient pathway • Plan A, B and C • Reestablish provider networks driven by peer review Home Therapies Richard Fluck

18. Patient participationThe left hand wall

19. Engaging the patient on multiple levels Carmen, Health Affairs Feb 2013 32:232 Home Therapies Richard Fluck

22. Integration

23. Education, self-awareness, changing beliefs about patient‘s role, self-management support, skills development Skills, knowledge and confidence matrix Interventions High CSPAM scores (Clinician support for patient activation) Changing beliefs about clinician’s role, leadership, skills training e.g. MI, communication, coaching Low Low High PAM scores (patient activation) Home Therapies Richard Fluck

24. Measurement and improvement:the ceiling

25. Data • Numbers • Organisational process • Outcomes • Clinical • Patient centred • Value Home Therapies Richard Fluck

26. Survival by Dialysis Modality—Who Cares? All-cause patient mortality rates, overall and by modality, US Renal Data System ESRD Database, 2011. Adjusted for age, sex, race, and primary diagnosis. HD, hemodialysis; PD, peritoneal dialysis. Home Therapies Richard Fluck CJASN 2016 ePub Martin B. Lee* and Joanne M. Bargman†

27. Value The Renal Alliance: UKRR, PHE, CVIN, RightCare and Commissioning for value Home Therapies Richard Fluck

28. Recovery time after HD Lindsay Clin J Am Soc Nephrol. 2006 Sep;1(5):952-9. Home Therapies Richard Fluck

29. Home therapies: Patient Quality Markers - Restless legs and depression Jaber Clin J Am Soc Nephrol 6: 1049–1056, 2011 (FREEDOM study group) Home Therapies Richard Fluck

30. The right hand wall:professionals

31. What do the professional stakeholders need to offer? • Leadership: vision, courage and commitment • Individual • Organisational • Expertise • Drive improvement – e.g. quality improvement Home Therapies Richard Fluck

32. Home therapies QI • KQuiP • Stakeholder led • RA, BRS, BKPA, NKF, KRUK, BTS • NHS England and home nations • Strategic alliance to foster QI Home Therapies Richard Fluck

33. Improving the pathway • Establish an MDT to assess new starters • Consider legibility • Shared decision making – • ?Physician led PD insertion • Training • Late presentation Perit Dial Int. 2013 May-Jun; 33(3): 233–241. Dialysis Measurement, Analysis and Reporting (DMAR: Oliver Medical Management, Toronto, ON, Canada) Home Therapies Richard Fluck

34. Home haemodialysis Home Therapies Richard Fluck

35. Summary Home Therapies Richard Fluck

36. Home Therapies Richard Fluck