Advancing American Kidney Health

CKD: Detecting CKD, Slowing Progression, and Managing Transitions

New tools and workflow transformation will be needed to better address CKD. This will require moving to team-based models that include the patient (4), clinical optimization, care coordination, and self-care, all steps DaVita is supporting in helping clinicians improve precision and effectiveness of CKD care.

Clinical optimization requires population health and decision support tools embedded in the electronic health record to inform patient risk stratification and population trends. Such data, when used by physician-led, multidisciplinary teams, enhances team and patient communication and shared decision-making (5). Ideally, such tools also support care pathways and practice resource allocation. The most challenging part of transformation may be changes in workflow, i.e., how nephrologists deliver care. This will require potentially new team members, additional infrastructure, and more efficient use of technology.

The payment models in the AAKH initiative though an impetus for practice transformation do not overtly support it. The Current Procedural Terminology codes for chronic care management (99487, 99489, and 99490), transitional care management (99495 and 99496), dietary counseling (97802–97804), and the proposed principal care management services (GPPP1 and GPPP2) cover many of the multidisciplinary services necessary for success in the proposed models but are transactional for direct services. Practices will still need to consider additional investment to support clinical optimization and care coordination.

New tools for CKD management and patient engagement are not easily implemented by small or medium-sized practices, although partnerships with health systems or kidney care providers could make this easier. DaVita has deployed patient-centered education through Kidney Smart and Start Smart programs and, in collaboration with nephrology practices, CKD practice support tools. Patients educated through Kidney Smart are six times more likely to start on a home modality and patients in our CKD program were significantly more likely to have a nephrologist at transition to ESKD, with 72% of ESKD transitions being outpatient. These could be cornerstones of CKD care if and when waivers are introduced to enable us to extend them to nephrologists.

Home: Novel Ways to Expand Care Delivery to Patients on Home Dialysis

United States patients appear to lack access to home dialysis, even though patients with ESKD on home dialysis have the potential to experience a higher quality of life, better preservation of residual kidney function on peritoneal dialysis, less risk for cardiac stunning, and a slower rate of cognitive decline (6). Home hemodialysis offers patients better solute and volume control, better BP control, fewer episodes of hypotension, and stabilization of cardiac structure. Home hemodialysis allows physicians to individualize the dialysis prescription to meet the patient’s clinical needs and control risk factors.

A recent home dialysis conference sponsored by the National Kidney Foundation and Kidney Disease Outcomes Quality Initiative examined barriers to home dialysis (7). Conference participants supported a systematic change in CKD education, a shift in the approach to initiating dialysis, additional incentives for home dialysis, and breakthroughs to simplify home dialysis modality performance. The AAKH initiative advances those conclusions by advocating for a significant increase in home dialysis for patients with ESKD. Average United States home dialysis penetration ranges between 10% and 12% because of various factors, including program size; clinical competence of the medical director, nephrologists, and nurses; patient loss rates; and lack of predialysis education. The last is exceedingly important given the benefits of educating patients with CKD about home dialysis and the positive perception of home dialysis by many patients. To reach the objectives of the AAKH initiative, it will require adopting a “home first” culture, multitouch patient education, physician competency in home dialysis modalities, increased conversions to home dialysis modalities, a reduction in patient losses from home modalities, consistent patient-centered training, and root-cause analyses of hospitalizations and complications.

DaVita has been a leader in home dialysis, with >25,000 United States patients on home dialysis modalities. DaVita has invested significantly in a technology platform to transform the experience for patients on home dialysis with Home Dialysis Connect, a technology suite designed to improve patient experience and outcomes. Home Dialysis Connect includes DaVita Care connect (a patient-centered mobile application supporting multiway video visits, customized education, scheduling, reminders, secure texting, and image sharing), home remote monitoring (Bluetooth-enabled devices to transmit patient biometrics, health status via tablet-based questions, and device treatment data), telehealth (virtual visits with the patient, physician, and health care team [nurse, social worker, dietician, and care manager]), and artificial intelligence predictive analytics. Virtual monitoring of care enhances patient experience and proactively allows the care team to address problems that may occur outside of the traditional monthly visit cadence. Finally, newer approaches to education whether training patients, increasing nursing skills, or educating physicians will ensure program capabilities regardless of size.

Transplant: Working Upstream of the Transplant Center

As a kidney care provider, it is always our objective to have each patient reach the quality of life that they desire. We believe that kidney transplantation is the best modality for patients with ESKD. The AAKH initiative outlined steps to increase kidney transplantation, focusing on the supply side of the transplant equation, transplant rate, and post-transplant outcomes. Features in the concurrently announced payment models also supported kidney transplantation. The Kidney Care First and Comprehensive Kidney Care Contracting (CKCC) models included payments for patients transplanted who have a kidney transplant maintained 3 years. Finally, in the CKCC models, transplant providers are required participants in addition to nephrologists.

DaVita can educate and care for patients with ESKD with their nephrologists to prepare patients for transplantation with novel educational programs to explain the transplant process (Transplant Smart). We hope to be able to extend this information to patients with CKD in settings where they can interact with their physician and outline a personalized plan for transplantation if and when they approach ESKD. We also have piloted waitlist management support programs with transplant centers to facilitate communication between patients, providers, nephrologists, and transplant centers for critical patient information. A feature of this program has been to provide patients with the same data that the transplant center receives. In that way, all stakeholders can review the same information related to the patient’s status. Finally, providers can be an essential partner working with the nephrologist and the transplant center to help evaluate, monitor, and treat comorbid conditions for patients awaiting transplantation. This is an area in which DaVita has demonstrated expertise with its involvement and contributions to the success of the Comprehensive ESKD Care model (8).

These efforts emphasize where providers working with nephrologists can encourage patients to explore transplantation, consider living donor transplantation, and support patients in remaining healthy while they are on the waitlist. This should positively affect the demand side of the transplant equation and allow organ procurement organizations and transplant centers to enact their changes to positively affect the supply side.

Summary

Although aspects of the AAKH initiative are subject to debate, the initiative is a once-in-a-generation opportunity to positively address the kidney care continuum from CKD to dialysis and transplantation. As a kidney care provider, we see DaVita’s emphasis on innovation combined with its unremitting focus on quality of care expanding beyond dialysis and supporting the continuum of care for patients with kidney disease in partnership with nephrologists. We believe this is very much aligned with the administration’s effort to change the outcomes of patients with kidney disease. A modest delay in implementation to create consensus-driven changes in the mandatory model may help it achieve many of its stated goals. Moreover, the Kidney Care First and CKCC models can benefit from the lessons learned from the Comprehensive ESKD Care model by providing certainty of performance targets/measurements and flexibility in participation options for the structure of new models.

Disclosures

Dr. Becker and Dr. Nissenson are employees of and own stock in DaVita.