End-stage renal disease patients have complex clinical needs and face unique challenges impacting patient quality of life. ESRD care can be fragmented due to multiple specialists managing multiple conditions across multiple care settings, often without continuous communication. This can result in patients struggling to navigate the complex health care system on their own.

Over the past decade, the Centers for Medicare & Medicaid Services established several demonstration programs that work to address care delivery to these patients. The Comprehensive ESRD Care (CEC) Model demonstration, launched in 2015, introduced the first CMS disease-specific accountable care organization—the ESRD Seamless Care Organization (ESCO). The ESCOs allow nephrologists, dialysis centers, and other providers to partner to test a new care delivery model aimed at improving clinical outcomes and patient experience under a shared savings payment structure. DaVita currently has three ESCOs in place as part of the CEC demonstration:

  • Phoenix-Tucson Integrated Kidney Care (Phoenix)
  • South Florida Integrated Kidney Care (Miami)
  • Philadelphia-Camden Integrated Kidney Care (Philadelphia)

Integrated kidney care and innovation in the ESCOs

DaVita has developed a model of care with its nephrology partners that transformed clinical performance, using multiple years of experience in ESRD Chronic Condition Special Needs Plans (C-SNPs). The model focuses on a holistic approach: delivering personalized interventions to patients across the care continuum.

The C-SNP model features multiple components:

  1. Patient risk stratification to account for potential changes in patients’ functional and medical status
  2. Individualized care plans that take into account unique patient needs
  3. Care management
  4. Frequent face-to-face patient engagement by a nurse
  5. Regular education updates for care team members
  6. Shared clinical and outcome data to physicians on an ongoing basis

This experience shaped the foundation of DaVita’s ESCO care model. The ESCO interdisciplinary care team includes nurses, social workers, dietitians, care coordinators, and nephrologists, who interact with patients either in person or telephonically at various critical points (see Figure 1) in the patient’s care continuum. The model utilizes the dialysis center as the patient’s primary location of care to ensure continuity. This approach enables multiple licensed professionals to continually provide targeted interventions to patients in a coordinated manner—instead of the interventions being triggered only by a patient’s hospitalization or missed treatment. DaVita prioritizes innovation in these settings to allow integration with existing clinical programs and newly developed practice tools and programs.

In each ESCO market, nephrologists bring their leadership and expertise to the evolving model of care, while also utilizing key insights to develop local innovative programs to address patient needs based on market dynamics and practice patterns. In addition, DaVita implemented a robust data and analytics function for population-level assessments, clinical decision support tools, and standard reporting for the ESCO teams and physicians. These programs and capabilities include:

A pilot aimed at providing patients more days at home. The ESCO works with the local hospitals and clinics to guarantee a dialysis spot after discharge, meaning when a patient leaves the emergency room (as long as he or she is stable and the attending physician agrees to the discharge), the patient can dialyze at a center. Once a patient is admitted, DaVita partners with the health system, the hospitalist, and the case management team using daily alerts to monitor patient progress while in the hospital and during the discharge planning phase. This facilitates a smooth transition back to outpatient dialysis. In addition, the hospital team provides information to help schedule the last dialysis treatment in an outpatient center, helping to reduce the patient’s length of stay.

Communication tools adopted from DaVita’s C-SNP model of care, such as regular hospitalization calls. These calls engage the patient’s care management team and nephrologist, all of whom are aware of the patient’s condition and location. They review the cause of hospitalization and outline specific steps in care and social support to prevent recurrent hospitalizations.

These care team interventions resulted in patients spending over 2,600 more days at home in the last six months, when compared to the first six months of the ESCO program. Additionally, the DaVita ESCOs achieved a 37% reduction in hospital readmissions.

ESCO framework allows for local input

As noted above, one benefit of the ESCO model is the flexibility to innovate locally through the guidance of the ESCO governing body. DaVita recognizes the importance of nephrologist leadership in the ESCO efforts. DaVita continues to explore opportunities for nephrologists to lead improvements by piloting new practice tools and spearheading efforts to expand patient communication.

DaVita also acknowledges the important role that practice administrators in the participating nephrology groups play in the success of the ESCO. They ensure seamless communication with their nephrologists and help reallocate time and resources accordingly, which proves to be an important lever in affecting patient outcomes.

Additionally, through access to Medicare claims data, the analytics team provides each ESCO with insights into the major causes of hospitalization, as well as predominant sites of care (acute and post-acute) in each local market. These insights allow the team to implement ESCO-specific improvement plans, ranging from helping nephrologists assess the appropriateness and ongoing need for home health, to identifying the highest quality post-acute environments. All three ESCO-specific improvement plans at the three DaVita sites have shown improvement in clinical measures (see sidebar).

Insights through practical application of the ESCO demonstration model

Integrated care already exists in health care for many primary care patients and is increasingly seen as a solution to manage complex, high-need and high-cost patients. Models such as the ESCO allow providers to develop, test, and implement new processes that can improve overall care for ESRD patients. As with any type of demonstration program, there are features that encourage additional innovation, sharing of lessons learned, and the identification of gaps and challenges with the model.

Quality measures. Medicare Shared Service Program (MSSP) ACOs originally reported on 33 quality measures. While ESCOs have fewer quality measures, they focus on several categories meant to capture a patient’s experience of care within the ESCO, improvement in care coordination, and patient health outcomes. Yet the connection between the quality measures, ESRD patient health, and medical cost reduction is not direct and linear. Given the lead time for chronic conditions in many ESRD patients, it may not be as straightforward as simply expanding quality measures to look at secondary prevention as a means of overcoming this disconnect. It may be appropriate to incorporate different measures related to patient frailty, treatment, expanded screening beyond just mental and behavioral health conditions, and using multiple sources of patient-reported data to bolster the relevance of the quality measures in the ESCO program.

The impact of market and geography selection on ESCO program success. ESCOs are structured similar to the MSSP. As such, one might anticipate a similar trajectory over time: early cost savings in geographies where market-level costs are traditionally high, followed by later improvements in quality. However, not all markets are created equal, and shared savings models work the best where there is greater opportunity for improvement. Geographies where integrated care innovation has taken place prior to the launch of the ESCO model are disadvantaged because those historically significant improvements will not be rewarded or captured in the CEC Model. In addition, markets with healthier populations and lower overall utilization of health care services have much less room for improvement in medical cost reduction and generation of shared savings. Given the high economic hurdles of the ESCO model, this unfortunately excludes many different markets across the country from being considered viable.

Create alternate options for broader partner participation. In the ESCO model, nephrologists are required to take financial risk. If there is a desire to scale the ESCO model more broadly, future models should create flexible options for nephrologist and other provider participation, given large variations in practice sizes and the limited capital available for investment by smaller practices across the country. In addition, DaVita believes that bringing multiple practices and providers together, regardless of size, to pursue better patient outcomes is at the core of integrated care. Other mechanisms might still successfully engage nephrologists who may not possess the same risk tolerance or resources as ESCO partners, but who do possess the energy and creativity to contribute to innovative ESRD care. Similarly, alternative models that either incentivize performance or provide a risk-adjusted regular payment, similar to Medicare Advantage plans, can enhance the likelihood of broader patient care management as opposed to a primary focus on acute events alone.


ESCO-specific improvement plans

Innovations to reduce volume overload-related admissions. In the Philadelphia-Camden ESCO, DaVita, together with physician partners, focused on volume overload as a driver for hospitalizations. The physicians in the ESCO developed an approach for evaluating patients who presented with fluid issues in the emergency department setting. Additionally, they determined the next step in care delivery for the patient, including dialysis in an observational setting or dialysis back in the dialysis center. From a prevention perspective, the nephrologists modified their dialysis rounding schedule to spend more time with each patient in the center, focusing specifically on fluid-related issues. Dr. Roy Marcus from Clinical Renal Associates LTD in Philadelphia observed that “the time spent reviewing individual patients and their volume issues was not as much as anticipated, and the yield was far better for patients as we could customize their treatments better and prevent them from showing up in the hospital.”

Results: Because of this new process, patients in two of the major participating practices saw a reduction in volume-overload-related admissions of over 40%.ii

Innovations to reduce vascular access-related admissions: Central venous catheter (CVC) issues are a prominent cause for hospital admission in the ESCOs. DaVita conducted an in-depth review of vascular access claims data, hospitalization information, and patient outcomes. Acknowledging that physician relationships and traditional patterns of patient service delivery are often nephrologist-dependent, DaVita presented the vascular access information to ESCO-participating nephrologists on a regular basis for their review and discussion. This resulted in an overall central venous catheter rate of 10% throughout the ESCOs.iii This means more patients were able to get the safer fistulas placed instead of the more infection-prone catheters.

In the South Florida ESCO, specific physician groups also pursued additional strategies to lower vascular access-related admissions. They undertook actions within their own practice to work more closely with vascular access surgeons to reduce hospitalizations related to access procedures.

Results: The Coastal Nephrology & Hypertension Center has seen a 49% decline in vascular access-related admissions in their patients during the first year of the ESCO in South Florida.iv

Innovations to reduce septicemia-related admits: In the Phoenix-Tucson ESCO, DaVita worked with physician partners to analyze the underlying causes of the bloodstream infections. A consensus-driven intervention plan was developed for patients deemed to be high-risk for potential infection. The ESCO was also able to leverage existing DaVita programs addressing central venous catheter removal (Cathaway™) and infection prevention (Wipeout™).

Results: Dr. Rajiv Poduval, one of the ESCO partners from Southwest Kidney Institute, describes how his practices used innovative approaches to reduce septicemia-related admits. “By committing to a multidisciplinary approach, focused on dialysis access placement, immunization, fluid management, post-hospitalization medication reconciliation, patient education and more flexibility in accommodating unique patient needs, we have been able to reduce hospitalizations by 34%, and septicemia admits by 36%.v

In year one of the ESCO demonstration, DaVita focused efforts on partnering with clinicians and other health care providers in the ESRD patient care continuum to implement a model of care designed to deliver long-term improved quality of life for patients. In addition, DaVita identified causes and potential actions that could significantly influence and prevent hospitalizations. As a result, the ESCOs demonstrated success in lowering the readmission rate and providing patients with more time at home with loved ones.

Footnotes

  1. Metrics based on comparison between first 6 months of program (October 2015 through March 2016) and last 6 months of complete data (June 2016 through November 2016). Metrics are from internal analysis only using claims-based data.
  2. Metrics based on comparison between first 6 months of program (October 2015 through March 2016) and last 6 months of complete data (June 2016 through November 2016). Metrics are from Internal analysis only using claims-based data.

iii.    DaVita Internal clinical data analysis only.

iiii.    Metrics based on comparison between first 6 months of program (October 2015 through March 2016) and last 6 months of complete data (June 2016 through November 2016). Metrics are from Internal analysis only using claims-based data.

  1. Metrics based on comparison between first 6 months of program (October 2015 through March 2016) and last 6 months of complete data (June 2016 through November 2016). Metrics are from Internal analysis only using claims-based data.

 

Conclusion

All ESRD patients deserve their best chance at having a quality life, and this is achievable through integrated care. Less than 10% of Medicare patients can access integrated care through the models available today. DaVita is committed to providing long-term quality of care for the whole patient, anticipating that this will lead to both continued improvements in outcomes for the patients in the ESCOs today, and improved processes and programs for future patients.

Dialysis centers and providers are also committed to leading health care delivery reform for the chronically ill and will be ready to participate broadly and nationally if some of the current constraints and learnings from the ESCO structure are applied to the models of the future.

The statements contained in this document are solely those of the author and do not necessarily reflect the views or policies of CMS. The author assume responsibility for the accuracy and completeness of the information contained in this document.