NATIONAL HARBOR, MD—With its complexities and comorbidities, chronic kidney disease (CKD) is a particularly good match for a collaborative approach to care, speakers said in presentations here at the National Kidney Foundation 2012 Spring Clinical Meetings.
“The philosophy should be that we provide a consistent, longitudinal, regular form of care with an interdisciplinary team providing evidence-based, collaborative practice between specialties and liaising primary care so we are all delivering the same message to the patient,” said Marianna Leung, PharmD, clinical pharmacist in a collaborative care network in Vancouver, British Columbia, during her presentation.
While collaborative care has been successful in Canada, both in terms of patient outcomes and system savings, it has been slow to catch on in the United States, in part due to structural barriers in this country.
In a historical prospective review of a cohort of 340 CKD patients referred to a multidisciplinary clinic in Halifax, Nova Scotia, for example, clinic attendance was associated with improvements in metabolic and blood pressure control (Nephrology Dialysis Transplantation 2005;20:2385–2393).
Another study of 500 randomized patients compared a nurse coordinated model of care with usual care of Stage 3–4 CKD (Can J Nurs Res 2008;40:96–112). While there was no difference in targets or clinical endpoints, the study found a significant reduction in hospitalized days and cost-effectiveness with the nurse coordinated model of care, according to Dr. Leung.
The system in which Dr. Leung participates includes a nephrologist, nurse, unit coordinator, dietitian, pharmacist, and social worker. The number of professionals in each category varies with patient load.
* The nephrologist assesses patients, discusses renal replacement therapy options, and consults with other providers to come up with the best overall plan for the patient. Between clinics, the nephrologist analyzes blood work with nurses, reviews new patient symptoms, and reorders medications.
* The nurse provides the patient's physical assessment, educates the patient on how to manage CKD, and sets up the renal replacement session reviewing the different available modalities with the patient. In between clinics, nurses act as case managers.
* The unit coordinator ensures the correct flow of patient appointments.
* The dietitian provides dietary advice and recommendations for phosphate, potassium, sodium, and metabolic control.
* The pharmacist conducts medication reconciliation, assesses patients and resolves drug-related concerns, and develops medication protocols for anemia management outside the clinic.
* The social worker performs psychosocial assessment and counsels patients.
US Reimbursement System
Unlike Canada, the framework for health care reimbursement in the United States has not been especially friendly to collaborative care models.
“The challenge is our payer system,” said meeting session Chair Wendy St. Peter, PharmD, Professor at the College of Pharmacy at the University of Minnesota, during a phone interview. “We have multiple payers—commercial, Medicare, Medicaid. A lot of the systems are fee-for-service systems, where care is paid for in different buckets. This is a big problem. If you reduce the cost in one bucket and you can't seize the cost savings from another bucket, there is no incentive to reduce the cost from your bucket.”
There is no question, though, that the current system must be transformed, said Adam Whaley-Connell, DO, Associate Professor of Medicine at the University of Missouri School of Medicine, describing a system of flawed spending.
“The need for system change is evident just in the simple economics of how we practice,” Dr. Whaley-Connell said in a phone interview after the meeting. “The system is weighted toward acute- and long-term care that is, on a ground level, based on the premise that we currently practice complaint-, symptom-driven care rather than preventative, chronic management in a clinic setting.”
The United States spends more on health care than other countries, but that has not bought better care, Dr. Whaley-Connell noted.
He mentioned the medical home model, which has led the movement from a complaint-driven model of care to a team-based preventive model, and outlined Medication Therapy Management (MTM), a partnership of the pharmacist, patient or caregiver, and other health professionals that promotes the safe and effective use of medications.
Dr. Whaley-Connell is currently implementing MTM in Missouri with the Missouri Health Net. Preliminary data suggest that enrollment of patients in this program can lead to system savings of approximately $17 million and meet requirements in the CKD and diabetic populations, he said. And, it is not difficult to set up.
“Engage the administration and pharmacy up front not only to gauge interest but also to understand compliance issues,” he explained in his presentation.
“Once a team has been assembled, it is incumbent to set up a collaborative practice agreement, CPA. These are one to two pages, keeping in mind local/state and federal laws, and specifically outline team members, what medications will be instituted, and what clinical skills will be employed.”
In order for collaborative care efforts to become widespread, though, some things still must change.
“Until reimbursement rates reach a level that drives the change, individual systems and practice groups won't follow,” Dr. Whaley-Connell said.
There is also a problem for the pharmacist in the current US system because they are not paid under Medicare as independent practitioners.
“If a dialysis unit would like to add a pharmacist because a pharmacist can identify and solve drug-related problems and potentially reduce costs down the road, they would have to support the whole salary line of the pharmacist themselves,” Dr. St. Peter said.
Although these bumps in the road exist, the benefits of collaborative care models are beginning to be recognized in the United States.
“I think we are turning the ship around,” Dr. St. Peter said. “It's like the Titanic. You don't turn around a payer system like this on a dime and expect everything to be perfect. From my perspective in Minnesota, I am seeing all of our major health care systems within Minnesota turning and transitioning to a medical home model, and there are several health care systems in Minnesota that are becoming accountable care organizations.
“The Centers for Medicare and Medicaid Services is putting incentives out there to look at these types of models, and people are responding to these incentives.”
There is no doubt in the mind of collaborative care supporters that such a system will continue to succeed.
“I believe very strongly that when you have a team of practitioners that are utilizing their expertise together for the patient you will come up with a better outcome,” Dr. St. Peter said. “With any individual patient, one patient may need one type of care depending on the needs, and with this care model, you can focus the individual practitioner to the needs of the patient.”