By, Jackson Williams, Government Affairs Director for Dialysis Patient Citizens

For more than a decade, officials in Washington, DC have been experimenting with ways to reorganize Medicare to deliver better care at lower costs. Several of these “demonstration projects” have involved ESRD patients. Now, the largest such program for dialysis patients has kicked off at 13 locations across the U.S. It’s called the ESRD Seamless Care Organization, or “ESCO,” model. This article describes what one of these projects, Philadelphia-Camden Integrated Kidney Care, is doing to improve care for its patients.

Philadelphia-Camden Integrated Kidney Care covers about 2,000 patients at DaVita clinics in the Philadelphia area. Patients do not enroll in an ESCO; they are assigned to one by Medicare based on where they go to dialyze. Once the patient is assigned, the ESCO is responsible for the total cost of care for the patient—not just dialysis and other services associated with kidney care, but for emergency room visits and inpatient hospitalizations that make up the bulk of treatment costs for ESRD patients.

The ESCO agrees to actually lower its patients’ costs relative to the national average. To do so, it must keep patients’ health stable and avoid preventable complications that send patients to the hospital.

To accomplish this, Philadelphia-Camden Integrated Kidney Care deploys an additional staff of 20 clinicians and care coordinators. These teams aim to provide a “total care package,” says Bridget McCoy, a nurse practitioner who leads one of them. McCoy, who was previously assigned to regular duties in a dialysis facility, recalled that in that role, “there were things I wanted to for my patients that I couldn’t do before,” because clinics are organized to provide only the renal treatment specified by Medicare.

Under the regular system, accountability is fragmented; dialysis clinics and nephrologists are responsible for kidney care, primary care physicians are responsible for other illnesses such as diabetes, and hospitals are responsible for the care provided within their walls. Under the ESCO system, the ESCO team commits to filling “holes in care.” “Most patients like it,” says McCoy. “It feels like a concierge.”

Like a concierge at a hotel, ESCO care managers use their special knowledge and contacts to provide a smooth, hassle-free experience to clients. But instead of securing dinner reservations or theatre tickets, the care manager is on the phone making doctor appointments, getting answers from pharmacists, or cutting through red tape with dentists or state assistance programs. And the stakes are higher, because a missed appointment or medication dosage can snowball into a trip to the hospital. “The extra step makes the difference,” says McCoy.

Among the key tasks that Philadelphia-Camden Integrated Kidney Care undertakes are:

Transitions from the hospital to the community. A key goal of the care team is understanding why a patient was hospitalized and intervening to prevent another one. Often dialysis clinics have difficulty obtaining discharge summaries from hospitals, but the ESCO’s dedicated care coordinators are able to build relationships that expedite sharing of information.

To completely follow through on items in a discharge summary can take up to three hours of work, says McCoy, and many patients can be so overwhelmed at the prospect that they throw up their arms and give up. Follow-up items typically include changes to existing medications, prescriptions of new medications, and referrals to new specialists. ESCO care managers are able to explain the new medication regimen to the patient, make sure new prescriptions are filled, identify specialists who are taking new Medicare patients, make appointments, and arrange for transportation if necessary.

Medication reconciliation. A pharmacist is part of Philadelphia-Camden Integrated Kidney Care’s ESCO team and is available to consult on issues of “polypharmacy”—too many medications that may have interactions or serious side effects. One patient who was asked to bring in his prescriptions for reconciliation arrived with a “bucket of medications,” says McCoy. With the help of the pharmacists, the team was able to eliminate four prescriptions from the patient’s regimen.

Managing co-morbidities. The Philadelphia-Camden team has found that many patients whose kidney care has been stable have neglected managing their diabetes. ESRD patients are seen continuously by their kidney care team but do not always visit their primary care physicians regularly. As a hub of holistic care for ESRD patients, the ESCO team tries to coordinate care of comorbidities like diabetes, when necessary providing referral options for primary care physicians experienced with ESRD, or nudging patients to get eye and foot examinations. Occasionally, the Philadelphia-Camden team has had to track down a doctor who has moved to a new office since the last time the patient visited.

Involving clinicians at the dialysis facility. The Integrated Care team regularly meets with the team at each facility to review patients’ lab results, discuss any issues or barriers that individual patients may be facing, and identify patients most at risk for hospitalization. Working together they can reinforce each other’s messages to patients.

Engaging patients in their care.  Dialysis patients assigned to an ESCO are informed by a letter, telling them that “The goal of an ESCO is for your dialysis facilities, nephrologists, and other health care providers to communicate closely with your other health care providers, so they can deliver high-quality care that meets your individual needs and preferences.” Patients are told they will now have a specially trained nurse available to them who “will work with you, your family, dialysis team, doctors and care partners, both inside and outside of the dialysis center, to help you better understand and manage your ESRD.” Patients are also reminded that they can still choose any dialysis facility, doctor, or hospital. The letter is followed by an individual consultation with the nurse practitioner.

While the ESCO team takes on many tasks, improved outcomes can’t be achieved without the active cooperation of the patient. For many patients this can involve a real commitment, such as agreeing to additional time on dialysis when it’s necessary to remove fluids. At the Philadelphia site, about seventy percent of patients are fully engaged in the program, and very few have declined to participate at all. But the clinical staff is aware that ESRD patients already have a rigorous treatment regimen to follow, and are “not looking for additional opportunities to engage the health care system,” as McCoy put it. “You pick your battles.” Another nurse practitioner, Karol Eccles, says that patients are receptive, if not always immediately. “It takes time to build trust with patients.”One hiccup that ESCOs face is that rules in the Medicare program prohibit providers from channeling patients to specific doctors or facilities, even if they’re part of an informal network cooperating in the care of a group of patients.

Medicare does not pay extra for the ESCOs. Each ESCO, which is a partnership between a dialysis organization and a nephrology practice, must invest its own money in hiring the integrated care team and providing additional time on dialysis. If the ESCO “beats” cost of serving the average dialysis patient by keeping its patients well, the dollars saved are shared between the Medicare program and the ESCO. The Philadelphia-Camden Integrated Kidney Care ESCO is reasonably confident it will succeed financially because DaVita’s integrated care subsidiary, Village Health, has used many of the same techniques in its partnerships with insurance companies, including its own Special Needs Plan that it operates for Medicare in Southern California and Nevada.

What does the future hold for this new model of care?  DPC believes all ESRD patients deserve a better healthcare experience and improved quality of life that integrated care can provide.  However, the challenging economics and stringent rules that Medicare imposes on the ESCO program have scared away potential participants. Many kidney care advocates, including DPC, strongly support integrated care for all ESRD patients and legislation that would enable a far greater number of ESRD patients to receive the gift of integrated care. The ESRD Integrated Care Program, contained in legislation currently being drafted by Members of Congress, would deliver the same care coordination as ESCOs, provide enhanced benefits, and address the main challenges ESCOs face in expanding to more service areas.