Jai R adhakrishnan, Radhakrishnan, MD Columbia University

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1 Jai Radhakrishnan, MD Jai Radhakrishnan, MD Columbia University

2 1. The Patient-Centered Medical Home 2. CKD Clinic as the paradigm for PCMH? 3. Outcome data 4. The Columbia model 5. Limitations 6. Financial considerations

3 Scheduled appointment: (FU 99213: 15 mins) 75 year old patient with diabetes, R leg amputation, CKD (egfr 22ml.min) His BP is 200/100, 3+ edema He has run out of medications, (does not remember, nothing in the computer) You peep out in the waiting room You give him samples and call him back in 1 month

4 Renal Office

5 Planned follow up visit for CKD Arrives with home attendant with BP and blood sugar readings taken by VNS Vital signs have already been taken, meds updated by health tech. CKD-CDSS CDSS can be accessed online Epo and Influenza vaccine is prescribed-given by NP in Room 2 Total visit 30 mins

7 Frequently, the acute symptoms and concerns of the patient crowd out the less urgent need to bring chronic illness under optimal management Bodenheimer..JAMA. 2002;288:

8 A physician-directed practice that provides care that is accessible, continuous, comprehensive and coordinated and delivered in the context of family and community. The PCMH is a model of comprehensive health care delivery and payment reform that emphasizes a central role for primary care Health Aff (Millwood) 27 : , 2008

9 Coordinated care by incorporation primary care model and disease management model: reduced emergency department visits fewer hospitalizations less duplication and by incorporating increased use of the electronic medical record with the chronic care model onto a primary care platform Receive additional remuneration for coordinating all Receive additional remuneration for coordinating all of the patient's care, from diet to mental health to preventive measures.

10 Health Care Organization Community Resources Delivery System Design Self-management Support Decision i Support Clinical Information Systems Bodenheimer..JAMA. 2002;288:

11 Primary care physician (PCP) societies American Medical Association American Association of Retired Persons Labor and consumer organizations Corporations, including IBM and Merck

12 Blue Cross/Blue Shield United Healthcare Aetna Centers for Medicare and Medicaid Services (CMS) under Tax Relief and Health Care Act of 2006 to conduct a PCMH demonstration project beginning in January 2010

13 1. CKD / ESRD is a growing problem 2. Late referral e to nephrology ogy is not good 3. Nephrologists might do a better job 4. CKD/ ESRD is expensive

14 USRDS 2004

15 * * >20 years old Adapted from Coresh J, Selvin E, Stevens LA, et al. Prevalence of chronic kidney disease in the United States. JAMA. Nov. 7, 2007;298:17.

16 16

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18 Medicare: period prevalent general Medicare patients age 65 & older, with Medicare as primary payor, & not enrolled in Medicare Advantage. Medstat: period prevalent patients age 50 64, enrolled in a fee-for- for service plan. CHF, diabetes, & CKD determined from claims.

19 Early: > 12 months Intermediate: 4-12 months Late: <4 months Kinchen KS.Ann Intern Med 2002 Sep 17;137(6):479-86

21 Effectiveness of a chronic kidney disease clinic in achieving K/DOQI guideline targets at initiation of dialysis--a singlecentre experience Lee, W. et al. Nephrol. Dial. Transplant :gfl701v1-6; doi: /ndt/gfl701 Copyright restrictions may apply.

22 Effectiveness of a chronic kidney disease clinic in achieving K/DOQI guideline targets at initiation of dialysis--a singlecentre experience

23 PHYSICIAN New Consults Follow up consults with active issues Return from NP if active 3 SECRETARIES 1 BILLER Patient Volunteer NURSE PRACTITIONERS Straight CKD Chronic Stable GN Chronic Stable Transplant Hypertension FELLOWS Dedicated Vascular Surgeon Dedicated Interventional Nephrologist

24 Extensive use of online and paper diet sheets Patient helpline for drug assistance programs Patient volunteer and front desk staff are very efficient.

25 50% 40% 30% 20% 10% 0% 43% Column1 23% 7% 2% AVF PLACED AVF REFERRED PD FAILED ACCESS

26 Health Care Organization Community Resources Delivery System Design Self-management Support Decision i Support Clinical Information Systems Bodenheimer..JAMA. 2002;288:

27 Patient with CKD Identify patients with CKD Provider Note in EHR Monitors notes for CKD documentation CKD- CDSS Informs provider of CKD if Informs provider of CKD if documentation is lacking

28 JAMIA :

29 EHR Structured data Date Test Value 1/23/09 Creatinine /2/09 Creatinine 1.7 CDS CKD Unstructured data This is the first admission for a 74 year old man admitted with chronic renal insufficiency and shortness of breath 29

30 CDSS Promoting Early Recognition and Optimal Management of CKD Provider CKD Report Feedback [2] Patient CKD Report Renal Function Provider CKD Diagnosis A Anemia Mineral Metabolism... Patient CKD Report Note in EHR [1] CDSS Renal Function Anemia Mineral Metabolism... Notification [1] E Patient CKD Report Renal Function Recommendations [2] R Anemia Mineral Metabolism... Guideline-based reports Guidelines

31 Patient CKD Report Renal Function Anemia CKD e a Mineral Metabolism Cardiovascular Nutrition Parameter creatinine Most recent Value egfr, 40 ml/min/m / 2 U alb/creat Urine protein Parameter 2.3 mg/dl No value 3+ Ca, mg/dl 8.6 phos, mg/dl Most recent Value 5.4 PTH, IU 325 Vitamin D No value

33 ICD 9 Office Visit Billing Codes CKD Stage 1 (GFR > 90) CKDStage2(GFR ) CKD Stage 3 (GFR 30-59) CKD Stage 4 (GFR 15-29) CKD Stage 5 (GFR<15) 585.5

34 Office Visit Reimbursement Commercial Insurances reimburse NPs at 100% of MD charges Medicare only reimburses NPs at 80% of MD charges Medicare and a secondary insurance reimburses NPs at 100% of MD charges

35 Office Visit Reimbursement Commercial Insurances reimburse NPs at 100% of MD charges Medicare only reimburses NPs at 80% of MD charges if pt independently d seen Medicare and a secondary insurance reimburses NPs at 100% of MD charges

37 CPT ESA Billing Codes Epoetin alfa J0885 (Standard unit 1,000 units) Darbepoetin alfa - J0881 (Standard unit 1 mcg) Injection HemoCue Lab 85018QW

satisfaction reporting Cost analysis Proactive patient care

38 Multilingual communications Comprehensive electronic data systems Detailed case management Coordination of care Performance and satisfaction reporting Cost analysis Proactive patient care self-initiatives Preventive care measures Ongoing continuous quality improvement

39 Nephrologists would usually not wish to be designated as the medical home. Exceptions: dialysis or transplant recipients.

40 The financial and logistic burden of CKD/ESRD patients continue to increase CKD clinics with physician extenders are a logical next step. The PCMH model is probably an optimal one, but needs to be customized.

TREAT THE KIDNEY TO SAVE THE HEART. Leanna Tyshler, MD Chronic Kidney Disease Medical Advisor Northwest Kidney Centers February 2 nd, 2009

TREAT THE KIDNEY TO SAVE THE HEART Leanna Tyshler, MD Chronic Kidney Disease Medical Advisor Northwest Kidney Centers February 2 nd, 2009 1 ESRD Prevalent Rates in 1996 per million population December