It takes a village: Integrated care team gives hope back to dialysis patient

(BPT) – Six years ago Francis Hogan was doing what he loved most: playing golf. After his usual game, his ankle was swollen and painful. When he visited the doctor, he discovered the swelling wasn’t because of an injury. Something was seriously wrong.

Hogan’s kidneys were failing. He was diagnosed with focal segmental glomerulosclerosis, a condition that scarred his kidneys, leading to end stage renal disease (ESRD). He needed to start dialysis or receive a transplant to survive. After a failed transplant, Hogan began dialysis treatments.

Hogan spends about 12 hours a week on a dialysis machine that cleans his blood. At one point, he had to track over 20 pills a day – a common daily average for dialysis patients. Also, Hogan’s risk for hospitalization increased: Most dialysis patients spend about 11 days a year in the hospital.

‘Dialysis patients are some of the most medically fragile in our health care system,’ said Bryan Becker, MD, chief medical officer of Integrated Kidney Care (IKC) at DaVita. ‘They need a tremendous amount of support managing their condition to reduce the risk of repeated hospitalization.’

Fortunately, Hogan qualified for treatment at an ESRD Seamless Care Organization (ESCO), a Comprehensive ESRD Care Model administered by the Centers for Medicare and Medicaid Services. ESCOs are groups of dialysis centers, nephrologists and other providers who join together to coordinate care for Medicare beneficiaries with ESRD. The ESCO model encourages providers to think beyond their traditional care delivery roles to provide patient-centered care that addresses health needs inside and outside of the dialysis center.

Hogan’s ESCO is one of several run by DaVita. His care team includes a dedicated nurse practitioner and registered nurse in addition to his nephrologist and DaVita center staff. The increased resources and focus on care coordination have made a big difference for Hogan.

The care team reduced Hogan’s daily pills in half by coordinating with his other specialists to create a better prescription plan. And, after a recent surgical procedure, the team not only managed his transition back to DaVita but also recognized something was different about him.

‘He wasn’t interested in conversation and wouldn’t say his usual ‘Good morning!” said Debbie Abbonizio, Hogan’s nurse practitioner. ‘He often lost his words, wasn’t hungry and couldn’t walk short distances without stopping.’

The team met consistently until the root cause of Hogan’s symptoms was identified. After ruling out several possible diagnoses, the team found his recommended post-treatment target weight was too high. Extra fluid was accumulating in his body and toxic waste was gathering in his bloodstream, causing his symptoms.

Hogan’s target weight was adjusted and the extra fluid slowly decreased from his body. He soon regained his health and began to greet his care team with a cheerful ‘Good morning!’ again.

‘I feel fortunate to have a team observing and supporting me daily,’ Hogan said. “It gives me confidence to better manage my condition.”

Hogan also is grateful to feel better so he can spend quality time with the love of his life, Carol, his wife of 57 years.

‘Currently less than 10 percent of dialysis patients on Medicare have access to IKC programs,’ said Dr. Becker. ‘Yet these programs can make a significant impact on patients’ health-related quality of life. Why not make them available to all Medicare patients on dialysis?’

To learn more about DaVita’s IKC programs, visit VillageHealth.com.

The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.

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