The Florida ESRD Network

2014 ANNUAL FORUM:STEP UP TO THE PLATE

Hit a Home Run in ESRD Care!

Demetra Denmon, MA, WSDESRD Network 7 Executive Director

Jeffrey J. Sands, MD, MMMESRD Network 7 Board of Directors Chair

November 20, 2014 Gaylord Palms Hotel & Convention Center • Kissimmee, FL

2The Florida ESRD Network

Today’s Lineup

Top of the Inning • Network 7 Changes• Demographics

Down the Stretch • Mortality• Hospitalization• Vascular Access• Quality Indicators• ESRD Costs

Triple Play• Quality and the Network• Patient and Family Engagement • Learning and Action Network (LAN) Quality Improvement Activities (QIAs) and

Campaigns 11/20/2014

3The Florida ESRD Network

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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4The Florida ESRD Network

ESRD Network Ownership 2014

Data Source: 2013 Network Annual Reports *Transplant Prevalence as of 12/31/2012

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Network 7 Changes

Demographics

TOP OF THE INNING

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6The Florida ESRD Network

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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7The Florida ESRD Network

Florida ESRD Demographics

*VR increase from 654 in 2012 appears related to facility usage of CROWNWeb

Source: 2013 ESRD Facility Survey11/20/2014

8The Florida ESRD Network

Florida Prevalence by Race

Source: 2013 ESRD Facility Survey

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9The Florida ESRD Network

Florida Modality Treatments

Source: 2013 ESRD Facility Survey

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DOWN THE STRETCH

Mortality

Hospitalization

Vascular Access

Quality Indicators

ESRD Costs

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11The Florida ESRD Network

National Incident & Prevalent Patient Counts by Modality

Source: USRDS 2013 ADR

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12The Florida ESRD Network

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

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13The Florida ESRD Network

Mortality in Prevalent Dialysis Patients

• 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

Source: USRDS 2013 ADR11/20/2014

15The Florida ESRD Network

ESRD Hospital Admissions and Hospitalized Days

Source: USRDS 2013 ADR

Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; ref: ESRD patients, 2010.

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16The Florida ESRD Network

Change in All-Cause & Cause-Specific Hospitalization Rate

• Period prevalent ESRD patients • Adjusted for age, gender, race, & primary diagnosis • ESRD patients, 2010, used as reference cohort

Source: USRDS 2013 ADR

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17The Florida ESRD Network

Cause-Specific 30-Day Rehospitalization by Index Hospitalization

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• Period prevalent dialysis patients, all ages• Unadjusted; includes live hospital discharges

Source: USRDS 2013 ADR

18The Florida ESRD Network

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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19The Florida ESRD Network

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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20The Florida ESRD Network

Florida AVF Rates by County

Source: CROWNWeb

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21The Florida ESRD Network

Florida LTC Rates by County

Source: CROWNWeb11/20/2014

22The Florida ESRD Network

Vascular Access at 1st Treatment

Source: USRDS 2013 ADR11/20/2014

23The Florida ESRD Network

Mean EPO Dose per Week After Hemodialysis Initiation, by Year

Source: USRDS 2013 ADR

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24The Florida ESRD Network

Mean Monthly Hemoglobin, Hemodialysis

• Period prevalent hemodialysis patients. • Patient distribution by mean monthly hemoglobin (g/dl)

Source: USRDS 2013 ADR

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25The Florida ESRD Network

Mean Monthly Hemoglobin, Peritoneal Dialysis

• Period prevalent peritoneal dialysis patients• Patient distribution by mean monthly hemoglobin (g/dl)

Source: USRDS 2013 ADR11/20/2014

26The Florida ESRD Network

Quality Indicators

Percentage of patients meeting clinical & preventive care guidelines.

Source: USRDS 2013 ADR

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TRIPLE PLAY

Quality and the Network

Patient and Family Engagement

LAN QIAs and Campaigns

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28The Florida ESRD Network

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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29The Florida ESRD Network

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

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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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QIO-QIN PROGRAM

About the QIO-QIN Program

Everyone with Diabetes Counts

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34The Florida ESRD Network

About the QIN-QIO Program

New Approach to improve care for Beneficiaries, Families and Caregivers

• Goals are bolder• Patient-centered• All improvers are welcome• Everyone teaches and learns• Foster greater value

Sharing Knowledge, Improving Quality Healthcare• Equips providers with the

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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Desired Outcomes• 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

Task Goals• 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

Everyone with Diabetes Counts

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Reduce hospitalization

CHF prevention

Nutritional supportPreventing 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

CMS Dec 8 201011/20/2014

39The Florida ESRD Network

Reducing Readmission with Nutrition Management

• FMQAI Care Transitions Pilot Project (2010) Provided free meals to elderly patients upon

dischargeo Enrolled seniors received one month of meals and a

nurse’s visito Readmission rate dropped from 23.0% to 2.7%o Meals alone dropped readmission rate by nearly 10.0%

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Source: Beattie, S., & Burrough, B. (2013) Reducing Readmissions with Nutrition Management, Briefing White Paper. PurFoods, LLC/Mom’s Meals NourishCare

40The Florida ESRD Network

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

% Tx with IH

N #TxDeaths/

100 pt yrs

Hospital admissions/

pt yr

Hospital days/pt yr

<1% 123 2460 8.90 1.10 8.90

1-35% 230 46008.9

(p=0.999)1.21

(p=0.47)9.02

(p=0.725)

>35% 93 186022.4

(p=0.036)1.5

(p=0.04)10.84

(p=0.0002)

Total 446 8920 11.69 1.24 9.31

Sands JJ et al; HDI 18:415-422 201411/20/2014

41The Florida ESRD Network

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 201411/20/2014

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Network and National Demographics

www.fmqai.com/ESRD.aspx www.usrds.org/atlas.aspx

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43The Florida ESRD Network

The Florida ESRD Network3000 Bayport Drive, Suite 300Tampa, FL 33607813-354-9111

It’s a Grand Slam!

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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