Transcript 2014 ANNUAL FORUM: STEP UP TO THE PLATE Hit a Home Run …

2014 ANNUAL FORUM:
STEP UP TO THE PLATE
Hit a Home Run in ESRD Care!
Demetra Denmon, MA, WSD
ESRD Network 7 Executive Director
Jeffrey J. Sands, MD, MMM
ESRD Network 7 Board of Directors Chair
The Florida ESRD Network
Today’s Lineup
Top of the Inning
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Network 7 Changes
Demographics
Down the Stretch
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Mortality
Hospitalization
Vascular Access
Quality Indicators
ESRD Costs
Triple Play
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Quality and the Network
Patient and Family Engagement
Learning and Action Network (LAN) Quality Improvement Activities (QIAs)
and Campaigns
The Florida ESRD Network
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What We Do As the Network
• Oversee the quality of dialysis care
• Encourage patients engagement in their ESRD care
• Provide technical education and assistance to ESRD
facilities
• Assist in the administration of the ESRD program
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ESRD Network Ownership 2014
Data Source: 2013 Network Annual Reports
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*Transplant Prevalence as of 12/31/2012
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Network 7 Changes
Demographics
TOP OF THE INNING
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Network 7 Changes
• Florida Medical Quality Assurance, Inc.(FMQAI) will
become Health Services Advisory Group (HSAG)
• July 2014 office moved to 3000 Bayport Drive, Suite
300, Tampa, FL 33607
• Staffing Changes
 New Executive Director—Demetra Denmon
 New QID—TBD
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Florida ESRD Demographics
*VR increase from 654 in 2012 appears related to facility usage of CROWNWeb
Source: 2013 ESRD Facility Survey
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Florida Prevalence by Race
Source: 2013 ESRD Facility Survey
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Florida Modality Treatments
Source: 2013 ESRD Facility Survey
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Mortality
Hospitalization
Vascular Access
Quality Indicators
ESRD Costs
DOWN THE STRETCH
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National Incident & Prevalent
Patient Counts by Modality
Source: USRDS 2013 ADR
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Total Medicare Expenditures Per
Person Per Year, by Modality
• Total Medicare ESRD costs from claims data
• Includes Medicare as primary claims
• Period prevalent ESRD patients
Source: USRDS 2013 ADR
The Florida ESRD Network
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Mortality in Prevalent Dialysis
Patients
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Adjusted all cause mortality rates in period prevalent hemodialysis patients,
by vintage
Adjusted for age, gender, race, and primary diagnosis
Incident hemodialysis patients, 2010, used as reference cohort
Source: USRDS 2013 ADR
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All-Cause & Cause-Specific
Mortality – Year 1
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Source: USRDS 2013 ADR 14
ESRD Hospital Admissions and
Hospitalized Days
Period prevalent ESRD patients.
Adj: age/gender/race/primary diagnosis; ref: ESRD patients, 2010.
Source: USRDS 2013 ADR
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Change in All-Cause & CauseSpecific Hospitalization Rate
• Period prevalent ESRD patients
• Adjusted for age, gender, race, & primary diagnosis
• ESRD patients, 2010, used as reference cohort
Source: USRDS 2013 ADR
The Florida ESRD Network
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Cause-Specific 30-Day Rehospitalization
by Index Hospitalization
• Period prevalent dialysis patients, all ages
• Unadjusted; includes live hospital discharges
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Source: USRDS 2013 ADR
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Network 7 & National AVF/LTC Rates
Prevalent rates based upon November 2014 FFCL Data from the NCC
Source: November 2014 FFCL Data from NCC
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Network 7 & National AVF/LTC Rates
Prevalent rates based upon November 2014 FFCL Data from the NCC
Source: November 2014 FFCL Data from NCC
The Florida ESRD Network
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Florida AVF Rates by County
Source: CROWNWeb
The Florida ESRD Network
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Florida LTC Rates by County
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Source: CROWNWeb
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Vascular Access at 1st Treatment
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Source: USRDS 2013 ADR
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Mean EPO Dose per Week After
Hemodialysis Initiation, by Year
Source: USRDS 2013 ADR
The Florida ESRD Network
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Mean Monthly Hemoglobin,
Hemodialysis
• Period prevalent hemodialysis patients.
• Patient distribution by mean monthly hemoglobin (g/dl)
Source: USRDS 2013 ADR
The Florida ESRD Network
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Mean Monthly Hemoglobin,
Peritoneal Dialysis
• Period prevalent peritoneal dialysis patients
• Patient distribution by mean monthly hemoglobin (g/dl)
The Florida ESRD Network
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Source: USRDS 2013 ADR
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Quality Indicators
Percentage of patients meeting clinical & preventive care guidelines.
Source: USRDS 2013 ADR
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Quality and the Network
Patient and Family Engagement
LAN QIAs and Campaigns
TRIPLE PLAY
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Quality and the Network
• Improve vascular access placement rates
 Fistula First and Catheter Reduction Focus Groups
• Reduce Healthcare-Acquired Infections
• Decrease Standardized Mortality Rate
• Decrease Involuntary Discharges and Involuntary
Transfers
• Facility vascular access reporting
• Support for the ESRD Quality Incentive Program (QIP)
and performance improvement
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Patient and Family Engagement
• Support engagement at facility, Network, and
national levels
• Recruit patients to serve as Network 7 Patient
Subject Matter Experts
• Convene Patient Engagement LAN
 Implement a QIA
 Implement at least two campaigns
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LAN QIA and Campaigns
• Patient Engagement LAN QIA
 2013: Increase the number of patients invited to attend a
scheduled plan of care meeting
 2014: Establishing peer to peer support in the dialysis
facility
• Patient Engagement LAN Campaigns
 Campaign 1: What’s your plan?
 Campaign 2: Know your options
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How We Accomplish Our Goals
• Educate:
 Providers, patients and community partners with the
knowledge/resources to build QI practices into care delivery
• Communicate:
 Spread best practices and promising innovations
• Convene:
 Stakeholders, using LAN strategies, to work on the shared goal of
highest quality care
• Activate:
 Encourage all patients (and their families) to be fully engaged in their
care providing education and protecting rights
• Promote:
 Evidence based practices and care in a patient- and family-centered
environment
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Impact of Network Volunteers
• Support of the Executive Director and the Network
staff
• Network Board of Directors (BOD) and Medical
Review Board (MRB) and committees; Patient
Advisory Committee (PAC) and Network Council (NC)
• Unpaid medical professionals (physicians, surgeons,
RNs, SWs, dieticians, administrators) and patients
• Patients serve on both the BOD and the MRB
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About the QIO-QIN Program
Everyone with Diabetes Counts
QIO-QIN PROGRAM
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About the QIN-QIO Program
Sharing Knowledge, Improving
New Approach to improve
care for Beneficiaries, Families Quality Healthcare
and Caregivers
• Equips providers with the
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Goals are bolder
Patient-centered
All improvers are welcome
Everyone teaches and learns
Foster greater value
The Florida ESRD Network
knowledge and resources
• Spread best practices and
accelerate change
• Convenes communities of
practice to improve patient care
• Engages Medicare beneficiaries ,
families and caregivers to have a
voice in quality improvement
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Everyone with Diabetes Counts
Reducing Disparities in Diabetes Care
• African American
• Hispanic/Latino
• American Indian/Native American
• Asian/Pacific Islander
• Rural population
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Everyone with Diabetes Counts
Desired Outcomes
Task Goals
• Improve clinical outcomes for
HbA1c, lipids, blood pressure
and weight control
• Decrease lower extremity
amputations
• Improve health literacy of
Medicare and dual-eligible
beneficiaries with diabetes
• Increase adherence to clinical
guidelines by participating
practitioners for diabetes
utilization measures
• Establish a Focus Group to
determine feasibility of providing
free DSME classes to End Stage
Renal Disease Patients in Dialysis
Settings
• Complete Focus Group
Questionnaire
• Return Questionnaire to ESRD
registration table
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Reduce hospitalization
CHF prevention
Nutritional support
Preventing intradialytic hypotension and cognitive
decline
FUTURE OPPORTUNITIES
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ESRD Disease Management
Demonstration Project 2006-2008
Home weight monitoring
• Reduction in IDWG (p
<0.01); all cause and
cardiovascular
hospitalization and
mortality
Oral Nutrition Supplement
for Alb <3.8 decreased 1 year
mortality
• 16.2% (CI 11.8, 20.3) vs
23.4% (21.2, 25.4) in
matched CPM sample
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CMS Dec 8 2010
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Reducing Readmission with
Nutrition Management
• FMQAI Care Transitions Pilot Project (2010)
 Provided free meals to elderly patients upon
discharge
o
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Enrolled seniors received one month of meals and a
nurse’s visit
Readmission rate dropped from 23.0% to 2.7%
Meals alone dropped readmission rate by nearly 10.0%
Source: Beattie, S., & Burrough, B. (2013) Reducing Readmissions with Nutrition
Management, Briefing White Paper. PurFoods, LLC/Mom’s Meals NourishCare
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Intradialytic hypotension (IH)
• IH is frequent: 17.2% of Tx
 Varies by patient (0-100% Tx) and dialysis facility (11.1-25% Tx)
• IH frequency correlates with poorer survival, increased
hospitalization and hospitalized days
• Both facility and patient characteristics are independent
predictors of IH
The Florida ESRD Network
#Tx
Deaths/
100 pt yrs
Hospital
admissions/
pt yr
Hospital
days/pt yr
123
2460
8.90
1.10
8.90
1-35%
230
4600
8.9
(p=0.999)
1.21
(p=0.47)
9.02
(p=0.725)
>35%
93
1860
22.4
(p=0.036)
1.5
(p=0.04)
10.84
(p=0.0002)
Total
446
8920
11.69
1.24
9.31
% Tx
with IH
N
<1%
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Sands JJ et al; HDI 18:415-422 2014
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Preventing Brain Injury by Lowering
Dialysate Temperature (T)
• 73 incident patients randomized to 37°C dialysate vs dialysate
0.5°C below core body T
• Results
 37°C dialysate: Ischemic brain injury on serial MRI imaging
 Changes in brain white matter associated with hemodynamic
instability (p<0.05)
 0.5°C< core body T dialysate: Improved hemodynamic stability and
complete protection against white matter changes at 1 year
• Conclusion
 “….HD results in significant brain injury and that improvement in
hemodynamic tolerability achieved by using cooled dialysate is
effective at abrogating these effects. This intervention can be
delivered without additional cost and is universally applicable.”
Eldehni MT et al; cJASN 26 2014
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Network and National
Demographics
www.usrds.org/atlas.aspx
www.fmqai.com/ESRD.aspx
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It’s a Grand Slam!
The Florida ESRD Network
3000 Bayport Drive, Suite 300
Tampa, FL 33607
813-354-9111
This material was prepared by ESRD Network 7, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health
and Human Services. The contents presented do not necessarily reflect CMS policy nor imply endorsement by the U.S. Government.FL-ESRD-GR-11142014-01
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