Early Detection & Prevention of Progression of Chronic Kidney Disease

Transcription

1 Early Detection & Prevention of Progression of Chronic Kidney Disease Portfolio Overview NELHIN & the Health Professional Advisory Committee Chronic Disease Prevention Management Team October 14, 2011 Lise Corriveau RN, BScN, MBA Regional Director, ORN North East Region

2 Presentation Outline ORN s Mission & Vision / Core Values Major Milestones / Provincial Priorities North East Regional Renal Programs & Satellites Range of Services North East Regional Renal Steering Committee Early Detection & Prevention of Progression Background Strategy - 3 Pronged Approach o Screening, Management, Shared Care o Proposed Projects / Pilots Closing Remarks 2

3 ORN s Mission & Vision OUR MISSION Working together to improve the life of every person with kidney disease OUR VISION By 2015, the ORN will: Be funding patient-based care to drive equity and access to CKD care across Ontario Support excellent evidence-based CKD patient care across Ontario Enable leading CKD knowledge generation, research and innovation 3

4 ORN s Core Values Patient-focus We will make decisions in the best interest of patients and the community Transparency We will adopt a transparent approach to sharing performance-related information and foster a culture of open communication with colleagues, partners and the public Equity We will ensure fairness across regions in the development of a strong provincial renal network Evidence-based We will make decisions and provide policy advice based on the best available evidence Performance oriented We will advance new ideas, promote change and take action toward quality improvements in chronic kidney disease Active engagement We will consult widely and collaborate with other organizations and service providers in order to achieve our goals Value for money We will use public resources wisely and promote the efficient use of these resources across the provincial renal network 4

5 Major Milestones - Regional Leadership 14 Regional Directors Patricia Dwyer Elaine Chemeris (A) Peter Varga Rick Badzioch Carol Rhiger Nancy Webster Jill Campbell Melanie Tremblay Jay Wilson Julie A. Gordon Connie Twolan Marni Van Kessel Lise Corriveau Julia Salomon jan feb mar apr may jun jul aug sep oct nov dec jan feb mar apr may jun jul aug sep oct nov dec Through monthly meetings of the Provincial Leadership Forum (PFL), our RD s act as conduit between the ORN and regions, and as implementation arm of key ORN priorities. 5

6 Major Milestones - Regional Leadership 14 Regional Medical Leads Dr. Al Kadri Dr. Norman Muirhead Dr. Tom Liu Dr. Christian Rabbat Dr. Hitesh Mehta Dr. Gordon Wong Dr. Phil McFarlane Dr. Andrew Steele Dr. Ross Morton Dr. Peter Magner Dr. Derek Benjamin Dr. Malvinder Parmar Dr. Paul Watson jan feb mar apr may jun jul aug sep oct nov dec jan feb mar apr may jun jul aug sep oct nov dec Medical leads in each region are integral to the Regional Renal Steering Committee and provide clinical guidance grounded in local issues. 6

7 Major Milestones Deeper Engagement with Stakeholders Ontario Renal Council Ontario Association of Nephrologists Renal Administrative Leader s Network of Ontario Kidney Foundation of Ontario ORN Medical Leads Hospital Liaison Committee Primary care leader (via the OCFP) CCAC leader (via the OACCAC) Local Health Integration Networks jan feb mar apr may jun jul aug sep oct nov dec jan feb mar apr may jun jul aug sep oct nov dec Broad stakeholder representation in a more transparent and inclusive advisory structure. 7

8 Major Milestones Provincial Medical Leadership Dr. Judith Miller Early Detection & Prevention of Progression Dr. Andreas Pierratos Independent Dialysis Dr. Louise Moist Vascular Access Dr. David Mendelssohn Research & Innovation Dr. Peter Magner Funding Group jan feb mar apr may jun jul aug sep oct nov dec jan feb mar apr may jun jul aug sep oct nov dec Establishment of provincial medical leadership to guide the development and implementation of key clinical improvement strategies, including recently established provincial aboriginal portfolio lead, Dr. David Berry 8

9 Major Milestones Ontario Renal Reporting System jan feb mar apr may jun jul aug sep oct nov dec jan feb mar apr may jun jul aug sep oct nov dec Monthly capture of minimum data on all prevalent patients (~10k), ORRS complies with highest standard data quality framework. 9

10 Major Milestones Regional Summary Reports Quality & Performance Measures Home dialysis by modality Vascular access by type Volumes and funding Missing data jan feb mar apr may jun jul aug sep oct nov dec jan feb mar apr may jun jul aug sep oct nov dec Year long review by each Regional Renal Steering Committee, the Regional Summary Report provides baseline and trend data on CKD program activity and select performance and quality indicators. 10

11 Major Milestones Quarterly Quality Review Cycle Q1 - Vascular Access - Home Dialysis - Early Detection - Data quality Q2 - Volumes - Vascular access - Data quality Q3 - Early Detection - Volumes - Data quality Q4 - Volumes - Home dialysis - Data quality jan feb mar apr may jun jul aug sep oct nov dec jan feb mar apr may jun jul aug sep oct nov dec Establishment and initiation of regional quarterly quality review cycle to monitor and support improvements in each LHIN. 11

12 Major Milestones Ontario Renal Plan A plan that integrates the best ideas of our partners to drive quality improvements in the CKD care system. 12

13 Ontario Renal Plan Patient Centered - System Focused Early Identification & Management Patient Experience Pre Dialysis Dialysis Access (Body/Vascular) Transplant Facility Based Dialysis Home Dialysis Symptom Management & Palliative Care Research 13

14 Ontario Renal Plan Development Process Ontario Renal Council Provincial Engagement Ontario Renal Plan System Level Priorities Supporting Business Cases Communication Activities Regional Engagement Synthesis (ORN Staff) 14

15 Major Milestones Refining ORN s Strategy Alignment with ECFAA Vision & Mission Provincial Priorities Enabling Strategies Core Values jan feb mar apr may jun jul aug sep oct nov dec jan feb mar apr may jun jul aug sep oct nov dec ORN strategy map aligned to the Excellent Care for All Act (ECFAA) is the blueprint for improvement. 15

16 Major Milestones jan feb mar apr may jun jul aug sep oct nov dec jan feb mar apr may jun jul aug sep oct nov dec Iteratively incorporating feedback from stakeholders, partners and patients & family, the new ORN web space will evolve to meet the needs and interests of the broad CKD community. 16

17 Major milestones Capacity Planning Capital project review process with LHINs and Capital Branch jan feb mar apr may jun jul aug sep oct nov dec jan feb mar apr may jun jul aug sep oct nov dec Ongoing engagement with CKD programs via Regional Directors and LHINs to ensure evidence-based planning and decision making associated with system capacity needs. 17

18 2011 Dialysis Capacity Summary North East Region 363 prevalent hemodialysis patients 140 independent dialysis patients 119 hemodialysis stations (operational) 131 hemodialysis stations (built) 18

19 Hub-and-Spoke Service Delivery Model Regional Centres (26) Provides administrative, programmatic and clinical expertise to support patients at all levels of care and full continuum of care Tertiary Centres Satellite A Regional Centre: The HUB of the network for defined geographic region and maintain linkages with tertiary centres, satellites, and IHFs IHF Satellite B 19

20 North East Regional Renal Programs & Satellites Regional Programs North Bay Sault Ste. Marie Satellite Locations Elliot Lake Kapuskasing Kirkland Lake Little Current New Liskeard Parry Sound Sudbury Timmins 20

21 Regional Program Range of Services Clinics pre-dialysis and treatment options, nephrology and follow-up Education regarding options in End Stage Renal Disease Assessment of patients for renal transplantation Training for patients who wish to perform their own Peritoneal Dialysis or Hemodialysis PD catheter insertion Maintenance of patients on PD Chronic and acute HD Maintenance of patients on HD Access creation (AVF, AVG, PermCath) Vascular access support including vascular surgery and interventional radiology Pre work-up and follow-up renal transplants in association with Transplant Centers Home visits by nursing and technical personnel Service availability 24 hours per day, seven days per week 21

22 North East Regional Renal Steering Committee Membership Chairperson: Lise Corriveau, Regional Director, ORN LIHN 13, Sault Ste. Marie Vice-Chairperson: Dr. Malvinder Parmar, Clinical Lead, Division Head, Nephrology, Timmins North Bay Dr. Darren Saunders, Nephrology Division Head Nancy Jacko, Vice President Medicine Care Debbie Thomas, Program Manager Sault Ste. Marie Dr. David Berry, Medical Director, Nephrology Brenda Lynn, Clinical / Administrative Director Oncology & Renal Programs Linda Mizzi, Interim Manager, Algoma Regional Renal Program Sudbury Dr. Goluch, Division Head, Nephrology Lisa Lee Smith, Director ER & Ambulatory Care Programs Judy Chaperon, Clinical Manager, Nephrology Mary Catherine Coady, Supervisor, Nephrology Programs & Satellites Stephanie Cranston, In-centre Supervisor 22

23 North East Regional Renal Steering Committee Membership Timmins Joan Ludwig, Clinical / Administrative Director Lorna Green, Manager Nephrology Francoise David, Renal Nurse Clinician LHIN Erika Espinoza, CKD LIHN Representative, LHIN 13 KFOC Shirley Pulkkinen, Representative, KFOC Aboriginal Representative: TBD Diabetes Representative: TBD 23

24 North East Regional Renal Steering Committee Purpose: To ensure optimal functioning of the RR Steering Committee, with respect to the delivery of CKD services in the LHIN. o Administrative Accountability for resources allocated Accountability for implementation of ORN programs Selection of representatives to sit on key ORN committees o Patient Outcomes Seamless integrated access to resources Maintenance of patient outcomes in accordance with ORN guidelines To establish and maintain effective and collaborative working relationships between and among the stake-holders, care-providers, and decision-makers throughout the regional CKD programs within each LHIN, as well as in the province. To ensure that the principles and guidelines for CKD care delivery and data collection regarding patient care are in accordance with ORN guidelines and standard 24

25 North East Regional Renal Steering Committee Responsibilities Review summary data from regional CKD programs. o Identify problems, solutions, and issues arising from that data Review key issues in the delivery of quality CKD services in regional CKD programs as they arise, and develop collaborative solutions. Ensure that the CKD regional program budget development and planning processes are in accordance with ORN guidelines and standards. Provide input to ORN initiatives and guideline development. Review financial reports of the CKD regional programs, planning documents, and outcome/statistical reports. Identify CKD regional program operating (care delivery) issues and devise a communication mechanism to ensure ORN is fully informed. Review levels of CKD service, quality of care, outcome measurements and reports based on reports generated from the ORN database. Identify issues and provide a venue for discussion, strategy development, and implementation. Ensure that appropriate resources for infrastructure are available for activities essential to the delivery of CKD services, identify short-falls to ORN to determine or leverage resources as needed. 25

26 EARLY DETECTION & PREVENTION OF PROGRESSION 26

27 Early Detection & Prevention of Progression Background There are an estimated 1,500,000 individuals in the province who are categorized as early CKD 6 out of 14 regions have expressed that early CKD detection and prevention of progression is the top priority in their region Early CKD detection and management can prevent crash dialysis starts ORN s Early Detection and Prevention of Progression has identified a threepronged strategy: o o o Screening Management Shared Care 27

28 Early Detection & Prevention of Progression Moving the Bar Upstream At risk of CKD ESRD 28

29 Strategy 3 Pronged Approach To broaden CKD screening uptake & early detection of CKD patients Metrics: - Increased CKD screening rates for atrisk populations To prevent the progression to ESRD through early management of CKD Metrics: - Improved CKD management & associated outcomes To create a provincial shared care model between primary care providers and nephrologists which will ultimately improve CKD care Metrics: - Decreased crash dialysis starts - Appropriate and timely referral to nephrology 29

30 PROJECTS GOAL Early Detection & Prevention of Progression A Goal-Oriented Plan To broaden CKD screening uptake & early detection of CKD patients To prevent the progression to ESRD through early management of CKD To support a range of shared care models between primary care providers and nephrologists which will ultimately improve CKD care Primary Care EMR Integration Identification of patients for screening Flow sheet InScreen Targeted Identification Campaign management Aboriginal Community Screening Primary Care Education Toolkit Toolkit for regions to educate primary care practitioners Aboriginal Community Pilots Coordination of CKD and related chronic disease management Early CKD Shared Care Clinic Pilots Coordination of CKD and related chronic disease management 30

31 CKD Current State Analysis Purpose & Description: Understand the current state of CKD screening and management practices in the province through lab data analysis, jurisdictional scans, patient and provider focus groups, etc. o E.g. Working with ICES to investigate SW LHIN lab data to provide insight into CKD screening practices Data to be used to help in the development and execution of projects related to early CKD and other ORN streams of work Objectives: o E.g. Streamlining and packaging CKD guidelines; Shared care models Provide a current state analysis of CKD in the province from both the patient and provider perspective Obtain global best practice guidelines through jurisdictional scans Provide feedback and recommendations on CKD guidelines in Ontario Research and understand the current patient data available in Ontario as it related to CKD, with a specific emphasis on lab data Evidence summary for CKD screening 31

32 Strategy Proposed Projects Primary Care EMR Integration Identification of patients for screening Flow sheet Primary Care Education Toolkit Toolkit for regions to educate primary care practitioners Primary Care Shared Care Models InScreen Targeted Identification Case based screening Provider Reports Early CKD Shared Care Clinic Pilots Coordination of CKD and related chronic disease mgmt Aboriginal Community Screening Aboriginal Community Pilots Coordination of CKD and related chronic disease mgmt. 32

33 Primary Care Projects Three main primary care projects: Primary Care EMR integration Intelligent triggers to identify patients who should be screened for CKD (i.e. patients with diabetes, hypertension, 55+ years old, positive family history etc.) Advanced CKD Flowsheet to assist with tracking management, referrals, etc. Pilot w/ four FHTs using the same EMR with plans for further roll-out to all EMRs upon successful proof of concept Primary Care CKD Education Toolkit ORN to develop a toolkit of educational materials, best practices, and paper and electronic tools relating to CKD Each region will be able to use the toolkit to develop their own unique curriculum for primary care Shared Care Model Shared care model between a nephrologist and primary care practitioners that would help with the screening and management of early stage CKD patients and improve appropriate referral to nephrology 33

34 Primary Care Projects Objectives: Increase screening for CKD by targeting high-risk population groups Provide primary care practitioners with more knowledge and tools when screening, managing and referring CKD patients and foster collaboration between the nephrology and primary care communities Assist primary care providers with identification and management of CKD with assistance through a shared care interdisciplinary model Develop an advanced CKD flow sheet that can be leveraged across all EMR s in the province Provide tools for regions to use for education of primary care providers relating to CKD Proof of concept pilot that can be scaled and implemented across the province 34

35 InScreen Targeted Early Identification Purpose & Description: InScreen is an existing CCO tool used to identify patients for screening (currently being used by the Colon Cancer Check program) Leverage existing tool for case-based screening of CKD based on specific criteria, with reports for rostered patients sent directly to providers InScreen will require new data source(s) and a screening algorithm for CKD purposes Objectives: Increase case-based CKD screening Leverage existing InScreen data, reporting, and algorithm functionality Enrich InScreen s data repository with additional Lab and Primary Care data Develop reports for Primary Care Providers and Specialist to support patient screening needs Provide data analysis and data mining capabilities for research and academic purposes 35

36 Aboriginal Community Program + Pilots Purpose & Description: The Aboriginal Community Program is intended to target communities that are geographically dispersed and lack medical facilities to help screen, manage and improve outcomes for CKD patients. Several barriers are faced in the Aboriginal community, such as distance to medical facilities, inadequate housing, and lack of proper resources such as a clean water and running electricity. This stream of work is targeted towards the specific needs of the Aboriginal community Specific pilot projects have not been scoped, but the intention is to work directly with the community to help develop targeted programs to help with screening and management of CKD There is an opportunity to leverage ongoing diabetes work in the area Objectives: Understand how the needs of the Aboriginal community differ from the larger population base of Ontario Understand how the needs of Aboriginal communities differ amongst each other Investigate and deploy pilot projects that will assist in improving CKD care in the Aboriginal community Improve overall CKD screening rates, management, and outcomes in Aboriginal communities 36

37 ORN Primary Care Lead Leverage CCO s existing provincial primary care engagement strategy ORN to hire a part-time primary care physician to assist with: o o Vertical Integration: Engaging the primary care community and working alongside committees and other organizations to bring the perspective of primary care to the ORN Clinical Integration: Developing solutions to key challenges facing the primary care community in the province o Functional Integration: Process of helping at the practice level, discovering what works and what does not work and helping to overcome barriers. CCO s Provincial Primary Care Engagement Strategy 37

38 Early CKD Shared Care Clinic Pilots Promoting early detection and appropriate management of early stage CKD through a shared care model : Shared care model between nephrology and primary care (e.g. consultation/access to a nephrologist via phone or pager, in-clinic case reviews, primary care education, etc.) Shared Care Model Knowledge and expertise to treat related chronic diseases that cause progression of progress CKD such as hypertension & diabetes Chronic Disease Management Early CKD Interdisciplinary Care An interdisciplinary team to manage CKD and related comorbidities (e.g. dietitian, social worker, pharmacist, nurse practitioner, etc.) Community Based Integrated within the community to have easier access to patients 38

39 RRSC Regional Renal Programs Closing Remarks We have numerous community programs which offer great opportunities to link the ORN Strategic Priority for Disease Prevention & Delay of Progression which can improve the screening, management of early stage CKD, and coordination of related chronic disease management. Stroke Network LTC Facilities CCAC Aging at Home Liaison Diabetes Education Centers RRSC / Regional Renal Programs Nursing Stations (6) Complex Diabetes Care Center Nurse Practitioner led clinics (6) Family Health Teams (31+5) Community Health Centers (5) 39

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