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Educate nephrology
community about new Pre-
ESRD classes and current
pilot programs in the
greater Houston area
At the end of this presentation the
reader will be able to answer
• Why Kidney Education is important in Chronic Kidney
Disease or CKD
• What is a community-based education program
• What information is included in CKD education program
• How does early CKD education program benefit patient
outcomes and the physician’s practice
• What patients say about early CKD education
• How one can participate or set up a program
Chronic Kidney Disease in the US
• Over 20 Million Americans have some degree of renal
insufficiency….1 in 8 people.
2008
African Americans Develop ESRD at
a Younger Age
New Conditions of Coverage
• ESRD Medicare Reform
– Medicare Improvements for Patients and Providers Act of 2008 (HR 6331 –
MIPPA)
– CKD education is recognized by CMS
– Reimbursement to nephrologists who provide chronic kidney disease
education
• Physicians Must Educate CKD Patients on:
– Kidney disease
– Access choices and issues
– ESRD Treatment options
• Physician performance is based on
– Influenze vaccine
– Blood Pressure control
– Referral for an AV fistula
– Laboratory values – Ca, PO4, PTH, Lipid profile
*Best physicians educate on much more.
Why Educate?
• Why…Educate? And When? The earlier the better….Start
education by stage 2 or 3 to have the biggest impact.
• One reason is we must. The new cfc regulations are requiring pt
education on kidney disease, treatment options, accesses. I don’t
think this man had his “Save my vessels” class information or he
would not allow anyone to stick him up and down both arms.
• Another reason: It is smart use of patients time and energy. Pts
who use this information stay healthier longer and start dialysis in a
better place both physically and mentally. If they come to us
healthier – they start healthier in ESRD with better Outcomes, more
choices and better quality of life.
• They make better choices: more open to dialysis options when
starting dialysis not an emergency. When pt education is done
ahead of starting dialysis Home dialysis is chosen more often.
What is community-based education?
• Patient education program that includes:
– Multidisciplinary coaching program
– Stage-specific education
– Easy education referral process
– Follow-up with patients and physicians
– Sessions are free for patients and guests
Find a comfortable location and time.
Location • The course does not need to be held
in Maui, although it would be nice. A
church down the street with a large
conference room works fine.
• Experience with renal treatment
options training reveaed we would
gain more patients in a non-medical
location.
• And our participants have reinforced
that concept.
• The Houston Community-based CKD
program sponsored by DaVita, known
as EMPOWER, has had nearly 200
pts/family/friends
• The patient feedback is very positive
What is Community-Based Education?
Multidisciplinary Coaching
Multidisciplinary coaching
program
• Inform patients about their
kidney health
• Improve quality of life
• Preserve renal function
• Help patients identify the best
treatment choice for their
lifestyle
• Tools to organize and track their
health care
• Health Diary
Multidisciplinary education
• Multidisciplinary coaching program can make a difference.
• A nurse, a dietitian and a social worker attend each class to present the
information and answer questions.
• The goal is help patients learn as much as they can about kidney health.
• CKD education helps patients to identify the best treatment choice for
their lifestyle and reinforce early fistula placement.
Benefits of early intervention and
education
• Delay or prevent the worsening of cardiovascular
disease, hypertension and diabetes
• Delay or prevent the progression to chronic
kidney disease
• Improve outcomes if kidney replacement therapy
ever becomes necessary
• Psychologically prepare one for kidney disease
• Reduce health care costs
• Keep people employed and out of the hospital
Tools Provided
• An initial postcard and quarterly e-newsletters
• Valuable tools from a well-regarded website,
http://davita.com
– GFR calculator and tracker
– 500 CKD recipes
– DaVita Diet Helper
– CKD videos
– More.
• The health diary is a tool given to each CKD patient and
is designed to help organize and track their health care.
We recommend that patients utilize their Health Diary
for all provider visits to maintain continuity of care.
TOOLS FOR BETTER CARE
Health Diary
Resource for the patients
• Patient information
• Healthcare phone numbers
• History and Physical
• Medication list
• Lab work
• Diabetes and Hypertension
• Glossary
The health diary
• Both the patients and the doctors really like this diary.
• Not only is it a great resource but it gives the patients a
central location to keep their valuable health information.
• They just ask for copies and file it away.
• When they go to any health professional, they have it.
• Even with Hurricane Ike – pick it up and go.
• The doctors like it when they can see all the information.
• Best from patients is the questions to ask the doctor.
• Reminds them of the importance of the medication, BP or
lab results.
What stage am I?
This is the question most patients ask. We review kidney function and the stages of
kidney disease. We review how this calculation works and that is based on both
kidneys. We discuss that the stages are generally progressive but that patients can
impact or slow the progression of kidney disease with diet, medications and healthy
behaviors. Patients need to be informed and ask lots of questions of their health care
team and physicians.
• Traditional cv risk
factors
• Non traditional risk
factors
How Can You Protect Yourself Against Heart Disease And High
Blood Pressure?
• Smoking
• Cholesterol
• Obesity
• Family History
Non Traditional Risk
Factors
• Inflammation
• Mineral-bone
disorder
• Anemia
ACEs and ARBs
• These drugs are critical to care starting in Stage 1 and 2
• ACES and ARBs have a compound effect on blocking
the renin-angiotensin system.
• The goal is to lower the blood pressure to 120 mm Hg
and to titrate proteinuria.
• Contraindications include allergy and bilateral renal
artery stenosis
• Potassium levels should be monitored closely when
patients are on ACES or ARBS
• (Beta blockers, NSAIDS, ACES and ARBS can raise serum
potassium)
Blood Pressure Is Poorly Controlled in
Patients With CKD
Inflammation
• Associated with CKD
• Atherosclerosis
• Vascular calcification
• Statins not helpful in CKD5
• CRP not diagnostic
• MIA
Exercise And Kidney Care
Class reinforces
bone and
heart healthy diet.
Stage 3
RBC
RBC PRECURSOR
Acidosis
• Increased protein catabolism of amino acids
• Inhibition of protein synthesis can cause a low
albumin
• Accelerates renal osteodystrophy
• Modulates vitamin D and parathyroid hormone levels
• Evokes insulin resistance
Albumin Synthesis
DIET IS IMPORTANT!!!
Chronic Kidney Disease
And Mineral Bone Disorder
• Vitamin D level
• Parathyroid hormone level
• Ergocalciferol over the counter
• Vitamin D is probably for everyone –regargless
of stage
• At later stages you might need an active form of
vitamin D
• Exercise and diet management
• The doctor may want to check for vascular
calcification
What Effect Can Chronic Kidney Disease Have On
The Body?
• Heart disease
• High blood pressure
• Vitamin D deficiency - bone and mineral
disorder
• Anemia
• Malnutrition and low serum albumin
• Acid buildup
Recommendations
• Understanding Insurance– state and federal insurances and when to apply for secondary insurance especially if want transplant due to medication
cost. We have saved patients money by assisting with insurance questions.
Modality Choice
• PD - 7% of population
– Preference values higher than for HD 74-69
– Physicians in practice 11 years along more likely to refer to PD
– More likely recommended to men, people with residual function,
with weight less than 200 lb and the absence of diabetes
• Hong Kong
– Half the mortality
– 5 staff for 300 patients
– Less mortality because residual function preservation
– Loss of residual function is a cardiovascular risk factor
Stage 4 – Medical focus
• Modalities – Incenter and Home Dialysis,
Transplant or Conservative therapy
• Referral for access – Vein mapping and surgery
• Serum Albumin – Prevent malnutrition
• Continue other therapies – ACE or ARB
• Anemia – Erythropoietin therapy
Stage 5 – but not yet on dialysis
Empower Team
– Call patient
– Schedule class
How the program works
• The CKD community-based process begins and ends with the office team
• First, the office will need to identify patients who are Stage 3, 4 and 5 that need CKD education.
• Next, refer those patients for education by completing and faxing the referral form (show form).
The patients are notified, enrolled in a class and called to remind them of class approximately 1
week prior. The day of class, patients will complete an attendance form and evaluate the class.
This data will be recorded at the call center.
• The recorded data allows the educators to provide the office with information affecting patients
and practice. We can extract the number of your patients who have attended a class, which class
they have attended, their stage of CKD, access preparation for dialysis, type of access, modality
choice just to name a few of the components.
• Ultimately, the goal is help patients to take control of their CKD and, if dialysis is needed, that they
begin dialysis healthier and prepared.
Communication is crucial
Success Stories…
Success Stories
• Patients need information and change can happen
– Pt went from stage 4 to stage 3 and thanked us for the
class….
• Office staff tell of a pt they were dreading to tell about
time to start dialysis
– Pt said “It’s OK, I know about it”. The office nurse was
amazed.
• Access placements before starting dialysis
– As they should be
• Insurances saved or supplemental insurance obtained
before ESRD.
The End