New Program for Kidney Disease Patients Stresses Personalized Care

Bon Secours Mercy Health is launching a new program for roughly 8,000 patients in Ohio living with chronic kidney disease or end-stage kidney disease that uses technology and multidisciplinary teams to improve chronic care management.

Bon Secours Mercy Health is launching a new program aimed at improving care management and coordination for an estimated 8,000 patients in Ohio who are living with chronic kidney disease (CKD) and end-stage kidney disease (ESKD).

In a partnership with Denver-based Strive Health, the Cincinnati-based health system, which includes 50 hospitals across several states, will use a technology platform and “Kidney Heroes” interdisciplinary care teams composed of nurse practitioners, dietitians, pharmacists, care coordinators and licensed clinical social workers to create a personalized care plan for patients. Among other things, the platform will allow care providers to chart the progression of the disease and the patient’s risk for hospitalization.

The program brings new technologies and strategies to bear on chronic care management, and builds on the idea of extending care outside the hospital, clinic or doctor’s office and into the home, where the patient and care team can collaborate on services. This includes using AI-enhanced technology to design a holistic profile of the patient and identify care needs and gaps.

In an e-mail Q&A with HealthLeaders, Chief Population and Community Health Officer Jean Haynes explains how the program will work.

Q. How will clinical care be delivered under the new model of care?

JH: Strive will deliver additional, specialized clinical services to Mercy Health’s kidney disease patients as an extension of the care already provided by the Mercy Health care team and physicians. The goal is to move upstream in the kidney disease journey and help patients better understand and manage their conditions to slow progression of disease. Chronic Kidney Disease (CKD) affects more than one in seven American adults and 90% do not know they have kidney disease. One in three adults is at risk for developing CKD, making early diagnosis and treatment intervention critical to helping patients stay healthier longer.

Q. How is this different from the "old" model of care?

JH: Technology-enabled data insights allow us to identify and intervene earlier in a patient’s kidney disease journey. … We will be able to identify patients needing earlier outreach and support services including nutrition education, social work services, complex medical coordination, and more.

Q. How will this improve clinical outcomes?

JH: [The} care model combines technology-enabled earlier identification coupled with robust clinical support services to address each patient’s individual, whole-person care needs. By helping to educate patients about their kidney disease and the care options available to them, we can address barriers to medical access that often go unmet, resulting in both an unplanned and unnecessary hospitalization. By reaching patients sooner, we can slow progression of disease, help patients navigate transplant programs, help patients select renal replacement therapies at the right time and increase home dialysis utilization, while helping them to manage other medical conditions. {The] care team is available 24/7 and can meet with patients in their preferred setting (in-person, virtual, telephonic). 

Q. What does this mean for the health system? How does it help your doctors and nurses (i.e. workflow changes)?

JH: Bon Secours Mercy Health has been focused on value-based care for many years, and our relationship with Strive helps us elevate our ability to reach patients in their communities and homes to continue delivering care at the right place and the right time. Mercy Health’s physicians and clinical care team coordinate and deliver care through a seamless continuum for their patients, working closely with Strive’s Kidney Hero care team. Strive adds both scale and specialized focus to our already strong primary care network capabilities.

Q. Will new technology (digital health, telehealth, RPM) play a part in this new model of care?

JH: Wherever possible, we will implement technology to be more efficient and provide care in a setting that meets patients’ needs. Bon Secours Mercy Health has been investing in digital strategies for years, and the pandemic highlighted the need to bring them to our patients as quickly as possible. We’ve been using telehealth, digital health, and remote patient monitoring, and we would expect to utilize these tools with our kidney disease patients wherever it is appropriate and desired.

Q. What are the challenges you're addressing in implementing this model?

JH: Early identification of patients with CKD: Technology-enabled data insights allow us to identify and intervene earlier in a patient’s kidney disease journey. … We will be able to identify patients needing earlier outreach and support services including nutrition education, social work services, complex medical coordination, and more.

Preventing crash starts for dialysis: Unfortunately, across the country, over 50% of dialysis starts are unplanned. The majority of ESRD patients receive dialysis treatments in a dialysis center. Our goal is to ensure that every patient who has the desire and meets the criteria for home dialysis is provided that opportunity.

Q. How will this platform evolve?

JH: Our initial focus is with the Medicare population, with the intention to expand.

Q. Do you anticipate using this model or applying this strategy to other chronic care populations?

JH: Yes, we currently do this today. We support eight ACOs/CINs across four states. Each of these CINs provides whole person care for populations which include commercial, Medicaid and Medicare. Focusing on whole person care has provided great outcomes and experience for the patients we serve.

Q. What one piece of advice (non-vendor-specific) would you give to other health systems considering this model of care?

JH: Health systems can and should play a critical role in the redesign of how care is provided for patients with kidney disease. [The Centers for Medicare & Medicaid Services] has been very clear that kidney care as a specialty will be a focus area for the Innovation Center moving forward, as evidenced by programs like CKCC (Kidney Care Choices) and ETC (ESRD Treatment Choices). Second, we believe there is a great opportunity to partner to quickly build and scale these new clinical capabilities.