With a keen focus on developing ways to keep patients healthier and avoid hospitalizations, integrated care models are rapidly changing the paradigm for health care delivery systems in the dialysis setting. In this type of environment, the face of nutritional care likewise needs to be poised for change.
Fresenius Medical Services (FMS) has recently collaborated with accountable care organizations (ACOs) to implement an integrated care model for their patients receiving in-center hemodialysis treatments or home therapy treatments for end- stage renal disease. In this setting, both organizations are aligned to focus on the patients’ best interests and outcomes and thereby assume responsibility for a portion of the cost of treating ACO patients. It is in the best interest of both entities to keep their patients healthy, thereby avoiding, or at least minimizing, hospitalizations. A model of integrated care serves such a purpose.
A traditional approach to patient care (see Figure 1) necessitates that each member of the interdisciplinary team (IDT) assesses discipline-specific problems and then develops a plan of care. While there is some overlap in responsibility for various problems such as fluid overload, the IDT in a traditional care model may meet only monthly, or as infrequently as yearly, to discuss plans of care.
Figure 1. Traditional model of care
An integrated approach (see Figure 2) requires that the IDT, including the dietitian, nurse, social worker, case manager, and the physician share responsibility for treating various aspects of a patient’s care. In the FMS integrated care model, three key areas of focus, including malnutrition, incident patients, and recent hospitalization(s), define a starting point for the team to address. In addition, all members of the IDT play roles in each of eight focus areas, when any of those factors occur in a patient. Care playbooks, available for each of these factors, contain guidelines for each discipline’s interventional role in the attenuation or resolution of the problem.
The success of an integrated care model relies on collaboration from all dialysis team members to create an environment in which every patient benefits. In a malnutrition scenario, defined as a three-month rolling average albumin 3.5 g/dL or less, the physician places the order for protein supplements via FMS Oral Nutritional Supplement Program (ONSP) guidelines; the registered dietitian (RD) assesses the patient’s nutritional status, while the MD and RD perform root cause analysis of low albumin levels.
A “deeper dive” hypoalbuminemia analysis tool is available for RDs to use when the hypoalbuminemia root cause analysis is tenuous. The registered nurse (RN) assesses the patient for treatable contributors to malnutrition, while the patient care technician (PCT) reports issues and concerns to the IDT. The social worker (SW) investigates community resources that can improve nutrition; these can include a Meals on Wheels program, access to free or low cost supplemental nutrition, and free or low cost dental services. The integrated care model produces a greater level of accountability for each member of the IDT, working as a collaborative unit, and largely eliminating the possibility of an incomplete or fragmented approach to care.
Tracking patient progress
To that end, the IDT usually meets weekly to discuss care for each patient. The IDT reviews the status and progress of each patient. Dialogue regarding the nutritional care of a patient with a low albumin includes trending of the albumin, and patient intake of protein and calories from meals and supplements. Mitigation of psychosocial barriers to better nutrition, and resolution of factors that contribute to hypoalbuminemia, including infections and the presence of a dialysis catheter are also part of the nutritional care portion of an integrated care model. Additionally, the IDT updates the plan of care regularly and discusses outcomes at a higher level with integrated care team leaders who may suggest additional measures to resolve ongoing issues and concerns that, left untreated or unresolved, may lead to hospitalization.
Likewise, in an integrated care model, the RD performs functions in each of the other care pathway playbooks. For example, if the patient has issues with treatment adherence, the RD needs to provide education and support regarding the impact of missed treatments on nutrition and fluid management. If the patient is at risk of, or has, a blood stream infection, the RD screens the patient for nutrition supplements, and educates the patient on the importance of maintaining a high protein intake.
The success of any dialysis provider, such as FMS, is measured by outcomes. Specifically, the greatest measure of a successful outcome is not only survivability, but also achievement of the best quality of life possible for each patient. Nutritional health, in the guise of albumin outcomes, is a major player in that ultimate goal. RDs, along with the entire IDT, and by using an integrated care team approach, have the skills and resources available to make a significant difference in the nutritional outcomes of our dialysis population. It behooves insurers and dialysis care providers alike to consider that a paradigm shift toward a fully integrated care model may be a path well worth taking.
The impact of nutritional supplementation during the Medicare Disease Management Demonstration Project for ESRD
From 2006 to 2010, Fresenius Medical Care North America participated in a demonstration project that the Centers for Medicaid and Medicare Services (CMS) conducted to test the impact of disease management approaches and related clinical interventions in patients with end-stage renal disease (ESRD). Independent evaluation by the Arbor Research Collaborative for Health of the 2006-2008 cohorts is instructive when thinking about the impact of nutritional supplementation on the nutritional competence of ESRD patients.
The overall FMCNA demonstration results showed a 36% improvement in adjusted, one-year mortality and a 20% improvement on all-cause hospitalization over a two-year period compared to the Medicare fee for service case mix adjusted rates at a contemporaneous time.
One of the incorporated clinical interventions that drove the overall successful outcomes included the administration of oral nutritional supplements (ONS) for patients whose serum albumin was found to be below 3.8 g/dL. To evaluate the efficacy of the provision of ONS, Arbor conducted an attempt-to-treat analysis for one-year mortality. They found that among patients with the indication for ONS use, 16.2% of patients died within one year as opposed to 23% among the ESRD clinical performance measure (CPM) comparison group for the same year. After careful study, Arbor concluded that the oral nutritional supplement intervention was associated with significant and reduced mortality at one year, which is consistent with the findings from data reported in the American Journal of Kidney Disease on overall oral nutritional supplement use in patients with impaired nutritional competence.
The overall summary of the impact of oral nutritional supplements showed that patients on ONS were more likely to be female, have diabetes, be older and have a higher CMS-HCC risk score. ONS use resulted in an increase in serum albumin and although hospitalization at one year was found to be comparable to the ESRD CPM patients the reduction in mortality at one year corroborates the findings that maintenance and recovery of nutritional competence is critical in these high-risk populations of ESRD patients.
As providers move toward a health delivery system with full health responsibility for patients with ESRD, the management and maintenance of nutritional competence and the ability to recover nutrition following acute illness or hospitalization is critical in the overall maintenance of health and well-being of these patients. Further study on the type, timing and proactive supplementation of protein, with secondary attention to reduction of inflammatory states, becomes a necessary evolution of ONS programs to evolve from a reactive clinical intervention to a proactive intervention and preservation of nutritional competence in times of stressors on nutritional health of the ESRD patient.
–– Franklin Maddux, MD
Dr. Maddux is the chief medical officer for Fresenius Medical Services