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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 ” the 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 .
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