Personalization remains key to improving outcomes in value-based care
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Personalization is a key aspect of value-based care for patients with chronic kidney disease and end-stage kidney disease.
Both are complex health care challenges affecting millions of people worldwide.
In the United States, an estimated 37 million adults are living with CKD, according to the CDC.
The range of comorbidities and complications such as diabetes, hypertension and anemia require a complex, multiphase treatment approach with high levels of coordination and communication among all participants, including the patient. Yet, the long-established fee-for-service payment model has discouraged such coordination by prioritizing volume over value, leading to duplication and overutilization of services, rising costs and suboptimal outcomes.
The need for more efficient care, driven by initiatives to reduce Medicare and Medicaid expenditures, has led to the development of value-based care models that reward providers based on the quality of care delivered, patient satisfaction, positive patient outcomes and cost-effectiveness. It is an approach that has proven especially valuable in the treatment of complex, long-term conditions such as CKD.
To overcome the challenges associated with adopting a value-based approach for a medically complex kidney population, many health entities have partnered with third-party companies that specialize in population management of patients with CKD and ESKD. In this article, we look at the key elements of value-based care, which are essential to a successful kidney population health management program. When implemented, this approach results in improved care, outcomes and experiences for patients living with CKD and ESKD, while also lowering total medical costs and benefiting providers and health plans.
Care plans, interventions
As noted, personalization is a key aspect of value-based care; each patient with CKD and ESKD is unique and care plans must be tailored to meet their individual needs. When developing care plans, clinicians should consider the following:
Risk stratification – Personalized care begins with risk stratification to identify those at risk of disease progression and adverse medical events. Early identification of at-risk individuals and prompt interventions to control comorbidities can help slow CKD progression in its early stages.
Treatment plans – Once risk is assessed, health care providers can develop personalized treatment plans that consider factors such as comorbidities, lifestyle and preferences. This results in more effective and efficient care.
Medication management – Personalized care includes careful medication management to ensure patients are adhering to medications proven to slow CKD progression while also avoiding nephrotoxic agents and staying clear of certain drug interactions or contraindications. Additionally, medication management ensures patients are receiving medications at the correct dosages given their kidney function.
Dialysis options – Too many patients still initiate dialysis in an unplanned fashion, unprepared and unaware of their options. To optimize this transition, patients should receive comprehensive renal replacement therapy education beginning at stage 4 CKD. The patient-provider team selects the most appropriate option that best suits the patient’s lifestyle, preferences and clinical needs, and begins preparing the patient for treatment well in advance.
Transplant evaluation – As part of their renal replacement therapy education, patients should be informed about the benefits of kidney transplantation, specifically living donor transplantation. An individually tailored plan can expedite transplant evaluations and ensure timely access to donor kidneys.
Multiple providers
Management of patients with CKD and ESKD usually involves multiple providers, including nephrologists, primary care physicians, endocrinologists, cardiologists, dietitians and others. Value-based care can be achieved only in the absence of treatment silos. That includes communication among providers. Value-based care models prioritize effective communication among various health care providers who share patient information, test results and treatment plans to ensure that everyone involved is informed and on the same page.
Timely transitions among providers facilitates smoother care transitions for patients. For example, when a patient is transferred from an acute care facility back to his or her home and requires ongoing dialysis treatments, those transitions must be communicated effectively between all providers on the patient’s care team.
Holistic care
Holistic care acknowledges that CKD and ESKD affect not only patients’ physical health but also their emotional, psychological and social well-being. It contributes to improved outcomes through patient-centered priorities. Holistic care prioritizes the patient’s preferences, values and goals. It involves open communication between providers and patients to develop a care plan that aligns with each patient’s individual needs.
A diagnosis of CKD or ESKD can have a profound impact on a patient’s behavioral health and mental well-being and can be associated with anxiety and depression, which can hinder effective care for the patient. Psychosocial support for patients with holistic care includes behavioral health counseling and coordination with support or peer groups to address the emotional challenges patients face.
Healthy diet and lifestyle choices also play a critical role in CKD and ESKD management. Holistic care involves collaborating with dietitians to develop personalized dietary plans that meet the specific nutritional needs of each patient along with counseling to educate and support healthy choices and habits, such as smoking cessation and exercise.
Social determinants of health
Recognizing that social determinants of health can adversely impact the clinical outcomes of patients with CKD and ESRD, a value-based approach closes care gaps by addressing factors such as:
Socioeconomic status – Patients with limited financial resources may struggle to access care and adhere to treatment plans. Value-based care systems provide financial counseling and assistance programs to mitigate these barriers.
Access to health care services – Some patients with CKD and ESKD face challenges related to transportation, access to specialist care and affordable medications. Value-based care models work to improve access by coordinating transportation services and telehealth options.
Nutrition and food security – Given that proper nutrition is essential for managing CKD and ESRD, food insecurity can be a significant barrier to achieving optimal health. Holistic care includes dietary support and connections to food assistance programs in local markets.
Housing and environmental factors – Stable housing and a healthy living environment are critical for a patient’s overall well-being. Addressing housing instability and environmental factors that exacerbate health issues is vital to value-based care.
It is evident that screening all patients for social barriers to care is essential to optimizing a patient’s health. If a social barrier to care is identified, the next step is connecting patients with the appropriate community-based social organizations or service professionals who can help overcome barriers related to treatment, access, transportation, nutrition and more.
Outcomes and cost savings
A value-based approach to CKD and ESKD care yields several notable benefits, including improved quality of life. By addressing psychological, social and emotional needs, patients are better equipped to cope with the challenges of their condition.
Early identification and intervention, risk stratification and personalized coordinated care help prevent complications and reduce the need for unnecessary, costly and disruptive hospitalizations. Appropriate and timely interventions can slow the progression of CKD and potentially delay the onset of ESKD, which includes the need for dialysis or transplantation. This not only improves patient outcomes but also reduces long-term costs. Personalized care includes ongoing preventive measures, such as blood pressure control, glycemic management and lifestyle modifications, required to reduce the risk of complications and the need for intensive treatments. Lastly, a well-educated patient is more willing and able to actively participate in care, adhere to the treatment plan, and make better food and lifestyle choices.
- For more information:
- Stephanie Toth-Manikowski, MD, MHS, is a national medical director of Healthmap Solutions and can be reached at stephanie.toth-manikowski@healthmapsolutions.com.
- John Danziger, MD, is an assistant professor of medicine at Harvard Medical School/Beth Israel Deaconess Medical Center and a national medical director of Healthmap Solutions. He can be reached at john.danziger@healthmapsolutions.com.
- Howard Shaps, MD, MBA, is the chief clinical officer at Healthmap Solutions and can be reached at howard.shaps@healthmapsolutions.com.
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