October 10, 2017

Staying Out of the Hospital: How Care Coordination is Helping Patients with End Stage Renal Disease

ESRD_Chantaylor &Diane

Diane Goodwin, RN, sits with patient Chantaylor during one of her dialysis appointments. Goodwin oversees around 50 patients enrolled in the Brigham and Women’s Hospital ESRD program.

There are more than 32 million people in the United States living with chronic kidney disease—that’s more than double the populations of New York, Los Angeles, and Chicago, combined. Kidney Disease, most often caused by diabetes or uncontrolled high blood pressure, can lead to anemia, weak bones, poor nutritional health, and nerve damage. As the disease progresses kidneys are less able to filter wastes and excess fluids from the blood, which means dangerous levels of fluid, electrolytes, and wastes can build up in the body. Once the kidneys have reached this point, called End Stage Renal Disease or ESRD, there’s no turning back. Patients must receive a treatment called dialysis, which helps replace the functions of the kidney, for the rest of their life or receive a kidney transplant.

“Chronic kidney disease is really a spectrum and there are various interventions you can do at various stages,” says Mallika L. Mendu, MD, MBA, a Brigham and Women’s attending physician specializing in nephrology and Assistant Medical Director of Specialty Care at Center for Population Health. “But chronic kidney disease can be very progressive and debilitating. Patients who progress to end stage renal disease have really poor health outcomes, they develop complications, and they end up in the hospital frequently.”

The problem with progression to ESRD is that it’s complex and multilayered. Not only are patients required to receive dialysis three times a week from an outpatient clinic, they are likely suffering from other chronic conditions like diabetes or vascular disease, as well as serious, acute complications related to those diseases. Since patients receive care in multiple settings from multiple clinicians—primary care doctors, emergency department staff, hospital inpatient staff, and a variety of specialists like nephrologists and endocrinologists—it can make their care very fragmented. This can easily lead to gaps in communication between doctors, overlapping or redundant treatments, and stressed and overwhelmed patients.

To address these issues, Brigham and Women’s Hospital (BWH) began a care management pilot program for ESRD patients that creates unifying care plans and links patients with designated care coordinators to help navigate patients’ care. The goal is to increase patients’ health outcomes by finding a treatment plan that works for them while reducing costs for both the patient and the hospital by avoiding unnecessary emergency visits and inpatient stays. The program is supported by the strong commitment of the staff, leadership, and infrastructure of the established BWH high risk care management program (iCMP).

*As of 10/2/17

Initial ESRD Care Coordination Impact   

52 Patients Enrolled
14 Serious Illness Conversations Completed Six Palliative Care Referrals
22 ED Visits Avoided $26,400 savings (Cost per Visit $1,200)
12 Admissions Avoided $120,000 savings (Cost per Admission $10,000)
2 Patients with Successful Transplants Cost of transplant breaks even two years after surgery

After first two years,$45,600 annual cost savings

10-year survival rate post-transplant

 Estimated Cost Savings to Date* $164,400  in short-term cost savings

$729,600  additional long-term savings

Diane Goodwin, RN, is the Nurse Care Manager that oversees around 50 patients enrolled in the program. From her home-base at Brigham and Women’s Faulkner Hospital, Goodwin visits four dialysis units in Boston and Foxboro to meet with her patients in-person. She keeps an eye out for complications with the patient’s vascular access sites (the “hook-up” in their arm for dialysis) and any new or worsening symptoms like a persistent cough or elevated blood pressure. Once a month she has the patient bring in all their medications to do an in-depth medication review. She will also make calls on behalf of the patient to help coordinate appointments and transportation.

Dr. Mendu explains that these patients are already committing so much of their life to dialysis that it can be challenging to go to another doctor or pick up the phone and make another appointment. She says, “These patients are going and sitting in a chair for four hours, three days a week, and during that time Diane goes and sits with them face-to-face and works through their issues. I think that’s powerful.”

Goodwin’s biggest challenge is keeping her patients out of the hospital. ESRD patients frequently get admitted, so Goodwin works with the emergency department to identify patients when they come in to see if they can be treated in outpatient settings like urgent care centers or their primary care office. She also works with the inpatient team to see if they can facilitate changes to treatments so that patients don’t end up back in the hospital.

“I follow one patient, a 29-year-old woman named Chantaylor*, who at the start of her enrollment was in the hospital more than she was out of the hospital,” says Goodwin. “She was going into the hospital with gastroparesis (a complication from diabetes in which the stomach cannot empty itself of food). She was staying for two, three, four weeks, then discharged without a clear and concise plan in place. When she was home she would continue to have symptoms making it difficult for her to keep her dialysis schedule and other appointments.”

But with a lot of collaboration and a lot of hard work, Chantaylor has made great strides in her health. In addition to her usual day-to-day check-ins, Goodwin started focusing more on Chantaylor’s unique issues. Goodwin coordinated with a gastroenterologist to evaluate Chantaylor’s gastroparesis, asked a social worker to join the care team to address issues in Chantaylor’s personal life, and developed a clear care plan for emergency department (ED) visits. Within a few months, Chantaylor’s inpatient stays plummeted. She transitioned from staying multiple times a month, to once a month, to no inpatient stays over the course of 3 months.

“I think because she knew that somebody would be watching her, somebody was there for her, even to answer questions, she stopped going to the hospital. And she started listening to us. She started to pay attention and said okay I need to do this,” says Goodwin.

If Chantaylor needs to go to the ED, she is no longer given a cocktail of drugs and automatically admitted. There is now a playbook for which medications are appropriate for her specific case, monitoring dietary choices, and instructions that she should be discharged when possible to avoid prolonged admissions. Goodwin also collaborates with the dialysis unit to involve them in the care plan and keep them updated and informed.

Chantaylor herself has noticed a big difference. “I’ve been in the hospital a lot less. I’ve, gone through more of a consistent period of being able to say ‘this is what’s wrong’ and being able to get it done rather than having to chase my tail around,” she says. “Everything is in progress but I feel like once we got on the same page with communication it’s really doing well now, it’s working.”

Since March 2016, the ESRD program estimates approximately $894,000 in savings from both short- and long-term costs from the health system. This includes avoidance of emergency visits and inpatient hospital admissions, and improvements in care coordination processes for  transplant evaluations or palliative care services. With the success of the program, the ESRD team is planning to enroll all eligible Brigham and Women’s Hospital ESRD patients covered under the Partners Accountable Care Organization (ACO) by the end of 2017 and expand to  eligible Massachusetts General Hospital ACO patients by mid-2018.

“Diane has really had a major impact and we’ve gotten a lot of positive feedback from primary care providers, nephrologists, and patients about how impactful the program has been,” says Dr. Mendu. “The goal was to take these patients who are really complicated, high utilizers of care with traditionally poor health outcomes and try to make the system work better for them. I think we’re accomplishing that.”


*Last name is not included to protect patient privacy.

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