Renal Care Coordination
Chronic kidney disease (CKD) is a major global health problem that affects more than 1 in 7, or 37 million, adults in the United States. In addition, 9 in 10 adults do not know that they have CKD and 2 in 5 adults do not know that their CKD has progressed into later stages.
Although studies show that care coordination for patients with chronic kidney disease (CKD) is effective in improving treatment outcomes and reducing costs, many patients in the United States with CKD do not receive care coordinated treatment. This may lead to poor outcomes for patients, with an increased cost of care.
Panoramic Health, an integrated value-based care provider led by physicians, is a leader in the industry because they understand that patients with CKD and ESKD have complex health needs that require holistic coordinated care across organizations and medical professionals. Panoramic Health offers patients care coordination as a foundation of their value-based care platform.
Key Facts:
•The aim of renal care coordination is to facilitate the appropriate healthcare services at the right time and in the right setting to improve overall patient care and reduce costs.
•Holistic care coordination can improve outcomes and quality of life for patients with CKD and ESKD.
•CKD is a large contributor to overall U.S healthcare costs and improvements must be made to achieve better patient outcomes.
•The aim of renal care coordination is to facilitate the appropriate healthcare services at the right time and in the right setting to improve overall patient care and reduce costs.
•Holistic care coordination can improve outcomes and quality of life for patients with CKD and ESKD.
•CKD is a large contributor to overall U.S healthcare costs and improvements must be made to achieve better patient outcomes.
What is Care Coordination?
Care coordination in kidney care facilitates the delivery of the appropriate healthcare services at the appropriate time and in the right setting. This, simply put, is the integration of healthcare delivered to a patient by multiple providers and specialists.
Care coordination is comprised of the following:
•Access to care/Evaluation
•Diagnostic resources
•Care plan/education
•Follow-up/Post care
Successful care coordination includes the following elements:
1.The patients are given access to a variety of healthcare services and providers.
2.Efficient and effective care are put in place with satisfactory communication between providers.
3.The central focus is on the overall and complete health care needs of the patient.
4.The information is presented in a manner that is clear, concise and comprehensible by the patient.
Health care providers implement care coordination throughout the entire continuum of care; primary, acute, and long-term/post-acute care coordination. The participants involved in a patient's care include family caregivers, social workers, physicians, pharmacists, nurses, the patient, and other medical and support professionals. The number of people involved in a patient's care generally increases the more complex the patient's needs become.
Care coordination in kidney care facilitates the delivery of the appropriate healthcare services at the appropriate time and in the right setting. This, simply put, is the integration of healthcare delivered to a patient by multiple providers and specialists.
Care coordination is comprised of the following:
•Access to care/Evaluation
•Diagnostic resources
•Care plan/education
•Follow-up/Post care
Successful care coordination includes the following elements:
1.The patients are given access to a variety of healthcare services and providers.
2.Efficient and effective care are put in place with satisfactory communication between providers.
3.The central focus is on the overall and complete health care needs of the patient.
4.The information is presented in a manner that is clear, concise and comprehensible by the patient.
Health care providers implement care coordination throughout the entire continuum of care; primary, acute, and long-term/post-acute care coordination. The participants involved in a patient's care include family caregivers, social workers, physicians, pharmacists, nurses, the patient, and other medical and support professionals. The number of people involved in a patient's care generally increases the more complex the patient's needs become.
Why Care Coordination is Essential in CKD
For many patients, their diagnosis of CKD often occurs later in the disease progression, with only half of stage 4 CKD and 7.7% of stage 3 CKD patients knowing that they have the disease. The rate for patients starting dialysis within a year of seeing a nephrologist is also very low at 27.9%. Advanced CKD patients’ needs are often more complex, as they usually have comorbidities and require care from multiple professionals within and over an array of clinical settings.
The progressive nature of chronic kidney disease, and end-stage renal disease, makes the continuum across the care complex. Often, the transition for patients is fragmented. For example, many patients only receive a referral from primary care to a nephrologist late in the progression
of CKD.
of CKD.
Care coordination is also essential in CKD patients that present with multimorbidity (two or more chronic medical conditions), such as diabetes or hypertension, as these patients often require care from multiple specialists with specific clinical practice guidelines and settings.
The challenges of implementing renal care coordination
Fragmented coordination often arises from inadequate communication and the failure to develop a unified and established care plan. Lack of care coordination is often the main barrier to adequate care for patients with ESKD. The main issues with collaboration among nephrology and palliative care clinicians are summarized by the following:
•65% reported that there was poor coordination of care and communication among providers and teams.
•39% reported that collaboration was impaired due to providers being situated at various locations.
•49% reported a reluctance of patients and their families to discuss prognosis, palliative care or hospice.
The Impact of Kidney Care Coordination
The impact of well-structured care coordination can provide a focused, committed care management approach that improves patient outcomes, streamlines patient care and reduces healthcare costs for both patients and providers. Care coordination for patients with ESRD has shown promising clinical results.
The Impact of Panoramic Health Renal Care Coordination:
•$872 average pmpm savings
•65% patient engagement
•56% reduction in hospital readmissions
•30% of at-home dialysis starts
•54% improvement in planned dialysis starts
•30% decrease in hospitalizations
•77% optimal dialysis rates (compared to the national average of 54%)
•35% pre-emptive transplant rate (compared to the national average of 17%)
The impact of well-structured care coordination can provide a focused, committed care management approach that improves patient outcomes, streamlines patient care and reduces healthcare costs for both patients and providers. Care coordination for patients with ESRD has shown promising clinical results.
The Impact of Panoramic Health Renal Care Coordination:
•$872 average pmpm savings
•65% patient engagement
•56% reduction in hospital readmissions
•30% of at-home dialysis starts
•54% improvement in planned dialysis starts
•30% decrease in hospitalizations
•77% optimal dialysis rates (compared to the national average of 54%)
•35% pre-emptive transplant rate (compared to the national average of 17%)
How Does Panoramic Health Provide Kidney Care Coordination
Panoramic Health has created an integrated value-based kidney care platform led by physicians to provide coordinated renal care to patients. The platform is the largest nephrologist provider platform in the U.S, with over 800 providers in 19 states. Panoramic Health's value-based kidney care platform also includes ambulatory surgery centers, increasing planned dialysis and transplants for patients.
As part of the value-based kidney care platform, the comprehensive care model and its ability to manage the total cost of care creates providers with a "plug-and-play" solution for patients in the CKD3-ESKD spectrum. Key aspects of the comprehensive care model include:
•Data platform and predictive analytics: Panoramic Health has the largest live, real-time CKD database of more than 600,000 lives, capturing more at-risk patients than traditional models. Plus, the platform utilizes automated reporting to enrich payers’ understanding of the attributed population.
•Holistic care management: The services and frequency are customized to the patient's disease stage and risk profile. Panoramic Health's comprehensive care model includes nutrition, pharmacy, Social Determinants of Health (SDOH) services, and PCP coordination.
•Provider decision and engagement support tools: Panoramic Health boasts 14 years of experience driving patient outcomes through data-sharing networks. Operationally integrated practices can expect seamless and frictionless provider experience and unmatched workflow automation.
•Patient education, engagement, and access. Patient engagement is increased with comprehensive access to patients in-home, in-facility, virtual, and in-clinic. Both patient and provider have a frictionless experience due to seamless operational integration.
Physicians and nephrology practices effectively coordinate and manage patient care with Panoramic Health's comprehensive practice management solutions. Key aspects of this solution are:
•Revenue cycle management
•Population health insights
•IT services
•Full-service practice management
•Credentialing services
•Finance and accounting
•Revenue cycle management
•Population health insights
•IT services
•Full-service practice management
•Credentialing services
•Finance and accounting
Considering how care coordination emphasizes providing patients with the right treatment at the appropriate time, in the right setting, Panoramic Health's value-based kidney care model improves the outcomes of patients whilst reducing costs for both patients and providers.
