Network of New England 20 th Annual Meeting Where We Have Been and New Challenges in the Care of ESRD Patients Douglas Shemin, M.D. Jenny Kitsen October.

Network of New England20th Annual Meeting

Where We Have Been and New Challengesin the Care of ESRD Patients

Douglas Shemin, M.D.

Jenny Kitsen

October 16, 2008

Sturbridge, MA

Clyde Shields, first patient in the United States on chronic hemodialysis, Seattle, 1961

Who shall live? Who shall die? Shana Alexander, Life Magazine 1962

Hemodialysis Patients before 1972

Dialyzed in some community, nonprofit centers and hospitals

Pilot programs in the VA and USPH systems United Auto Workers members after 1971 Predominately working aged men free of vascular

disease and diabetes No children or adolescents

Arguing for Public Law 92-603

“How do we explain that the difference between life and death is a matter of dollars? How do we explain that those who are wealthy have a greater chance to enjoy a longer life than those who are not?”

Sen. Vance Hartke, (Indiana), 1972

Arguing for Public Law 92-603

“60 % of them (prospective dialysis patients) with only a minor degree of retraining, and 40 % can return to their original employment with no retraining whatsoever.”

-Sen. Vance Hartke, (Indiana), 1972

ESRD: 1972 vs. 2005

1972 2005*** % on home HD 40 %** < 1 % % diabetes 5 %** 45 % Male/Female 2.7** 1.2 Mean age 44** 58 % Caucasian 91 %* 62 % High school graduate 73 %* Married 95 %* 2 year mortality rate 17 %** 36 %

* Evans, JAMA 1981 ** Lowrie, NEJM 1973 *** USRDS

ESRD: 1973 vs 2005

1973* 2005 ** Dialysis patients 10,000 350,000 ESRD Medicare costs 283 million 20 billion Total Medicare costs 14 billion 350 billion ESRD/Medicare costs 2 % 7 % Reimbursement $ 607*** $131

* Levinsky, NEJM 1981 ** USRDS

*** adjusted for 2005 dollars

ESRD Network Organization

ESRD Medicare Program Public Law 92-603 in 1972. Medicare coverage for ESRD began July 1973 ESRD remains the only disease based Medicare based

entitlement in the United States ESRD Network Coordinating Councils (32 areas)

established in 1978, consolidated to 18 networks in 1988 ESRD Networks were chartered by Congress to examine

and insure quality in ESRD care, which is ultimately funded by United States Medicare beneficiaries and taxpayers.

ESRD Network Organization

Network Organizations are independent contractors. Performance evaluated by CMS annually. 2/18 networks now administered by QIOs 16/18 administered by fulltime staff committed to and knowledgeable about ESRD, and supported by volunteer dialysis professionals living and working in the geographic area they represent

Contracts renewed every 3 years based on performance. Network of New England, Inc. (not-for-profit corporation)

has held the ESRD Network contract for 31 years. Most recent CMS contract effective July 1, 2006 for three

years.

What do the Networks do? Manage data (demographics, comorbidity, mortality information)

on > 400,000 patients in > 4000 facilities

Quality assessment: identify QI needs on a local level, institute and administer QI projects, offer assistance to underperforming facilities

Respond to grievances, complaints, concerns by patients, families, and facilities.

Disaster Planning Coordination (new)

Special projects

Kidney Community Emergency Response (KCER) Coalition

www.KCERcoalition.com KCER is a national coalition formed in 2006 to ensure that

national resources are in place to assist state and local response efforts in the event of a disaster.

Comprised of partners in renal community representing:– patient and professional organizations– practitioners, such as nurses, technicians, dietitians, social

workers, and physicians; – providers, including independent dialysis facilities, large

dialysis organizations and transplant facilities; – hospitals; – suppliers; – ESRD Networks; – state emergency and survey representatives– federal agencies, including the FDA, CDC, NIH and

CMS.

New England Provider

Distribution

Patients with ESRD, Network 1December 31, 2007

  Center HD Home HD PD Total

Connecticut 2,926 17 523 3,466

Maine 860 16 70 946

Massachusetts 4,671 60 444 5,175

New Hampshire 676 2 76 754

Rhode Island 891 3 28 922

Vermont 277 6 12 295

Total 10,301 (89 %) 104 (1 %) 1,198 (10 %) 11,588

Most Significant Medical Challenges in our Future

Disease burden

Hospitalizations

Transplants for patients

Unadjusted rates of diabetes in the U.S. population, by age

Data from the National Diabetes Surveillance System, at http://www.cdc.gov/diabetes/statistics/prev/national/figage.htm.

Incident counts of ESRD patientswith diabetes as primary diagnosis

Incident ESRD patients.

Hospitalization Rates

Cumulative incidence of infectious hospitalizations at 36 months

Incident dialysis & first-time, kidney-only transplant patients with Medicare as primary payor, 1995–2002 combined.

Adjusted Five-year Survival, by First Modality

Wait list counts & listings

Patients listed for kidney or kidney-pancreas transplant on December 31 of each year.

Most Significant ESRD Program Challenges

Increased Medicare costs for ESRD Program

Lack of professionals to care for ESRD patients

New ESRD Conditions for Coverage = Medicare certification as provider of service

Distribution of Medicare Patients and Cost

Medicare Improvements for Patients and Provider Act (MIPPI) Passed in 2008

By 1/1/2011 Medicare will have a fully bundled payment system for ESRD including drugs

Providers must meet specific standards for quality of care based on case mix adjustments. If not, reduction in payment to providers

Adjustment in payment for geographic areas and unique patient population

Educational outreach for patients with Chronic Kidney Disease

New Conditions for Coverage*Key Provisions

Patient safety– Infection control– Water and dialysate quality– Reuse of hemodialyzers and bloodline– Physical environment

*Available on Network website plus final interpretive guidelines www.networkofnewengland.org

Key Provisions

Patient care– Patients rights– Patient assessment– Patient plan of care– Home care– Quality assessment and performance

improvement (QAPI)– Special purpose dialysis facilities

Key Provisions

Administration– Personnel qualifications– Responsibilities of the Medical Director– Medical records– Governance

§494.80 Patient Assessment

Criteria for assessment– Current health status– Appropriateness of dialysis prescription, blood pressure and fluid

management needs– Laboratory profile, immunization and medication history– Anemia management– Bone disease management– Nutritional status– Psychosocial needs, including family and other support systems– Access type– Patient goals including modality and setting (home vs. in-center)– Suitability for transplant– Evaluation of physical activity level– Evaluation for referral to vocational and/or physical rehabilitation

services

§494.90 Patient Plan of Care

Required components of plan of care– Dose of dialysis– Nutritional status– Mineral metabolism– Anemia– Vascular access– Psychosocial status– Modality

– Home dialysis– Transplantation status

– Rehabilitation

§494.110 QAPI

Program scope must include, but not be limited to, the following:– Adequacy of dialysis– Nutritional status– Mineral metabolism and renal bone disease– Anemia management– Vascular access– Medical injuries and medical errors identification– Hemodialyzer reuse – Patient satisfaction and grievances– Infection control

§494.150 Responsibilities of the Medical Director

Responsible for the delivery of patient care and outcomes of the facility

Accountable to the governing body Responsibilities include

– QAPI program– Staff education, training and performance– Oversight of development, periodic review and

adherence to of facility policies and procedures

Effective Dates

New Conditions for Coverage6 months

10/14/2008

Life Safety Code and Separate room for HBsAg+ patients

300 days

2/9/2009

Certification of technicians hired after 10/4/2008 18 months from hire

Certification of existing technicians24 months 4/15/2010

Electronic Data Submission

As of 2/1/2009, every facility must electronically submit data on all patients, including data on clinical performance measures to CMS.

Release of final Interpretive Guidelines– October 3, 2008

Provider Training for CROWNWeb (one day training)– 6 Sessions

1/12/2009, 1/13/2009 & 1/14/2009 (Westborough, MA)

1/16/2009, 1/19/2009, 1/20/2009 (Nashua, NH)

CMS Deployment Plan

Technical Assistance ProgramNetwork of New England

on Conditions for Coverage

November 13th 2008

9:00AM to 1:00PM

Limited Space

5 Diamond Patient Safety Program

ESRD Network of New England (Network 1)Mid-Atlantic Renal Coalition (Network 5)

Objectives

To promote patient safety values To create an awareness of patient safety issues To help dialysis units learn more about specific

areas of patient safety To build a patient safety culture in every dialysis

unit

Components

Hand Hygiene Flu Vaccination Slips, Trips and Falls Medication

Reconciliation

Emergency Preparedness

Sharps Safety Decreasing Patient &

Provider Conflict

Under Development

Staff Adherence to Procedures Dialyzer Set-up Errors

Patient Safety Principles (required)

Components

Each topic is a complete educational module Tools and resources are located on the Network of

New England and MARC websites Required and optional activities PowerPoints for staff in-service presentations Posters for display Games and activities to engage patients

Recognition

5 Diamonds Completed Acknowledged in Network Newsletter Listed on Website Special recognition at Annual Network Meeting 2 free passes to Annual Meeting $75.00 gift certificate for entertainment material

for patients Plaque to display in unit

Congratulations Diamond Providers!Facilities who have completed at least one module and

have achieved diamond status

(20 Providers enrolled)

Congratulations!

Network Patient Advisory Committee (PAC)

10 Years of Service to the Network and Fellow Patients

Questions are the Answer