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Joy McGee-Cory - Senior Vice President, Advanced Plan for Health & Barbara Rutkowski, EdD, MSN, CCM - Vice President, Clinical Operations, Advanced Plan for Health

Members who are in chronic kidney disease at Stage 3 or 4 need to be approached about their plan of treatment. At this point the member may be in denial or unable to determine if they would like to be listed for a transplant, but it is not too early to start the process. The member needs to know about the importance of an early transplant listing decision, because it takes eligible individuals 24 months or longer on the transplant list to get a kidney. They can always change their minds and remove themselves from a transplant list, or list with more than one Center of Excellence to improve their chances for receiving a kidney.

First, it’s important to determine if the member is a candidate for transplant by reviewing their age and health conditions. It’s also essential to coordinate a possible transplant with the stop loss carrier by identifying Centers of Excellence for Kidney Transplant, and coordinating the transplant referral, evaluation, contract, etc. The care manager will also help work through issues with the member about possible donors (live donor or cadaver), and more.  The average wait time after being listed at a transplant center for a cadaver donor may be 24 months or longer, but this varies by transplant center.  

People with chronic kidney disease (CKD) are also more likely than the general population to develop heart and blood vessel disease such as clogged, hardened arteries or myocardial infarcts.  It’s critical that they follow their physician’s treatment plan, control lipids like cholesterol (blood fats), keep blood sugar below 7, and limit liquid intake to avoid fluid overload. Good health habits, like a healthy diet, exercise, adequate rest and sleep, positive attitude and blood pressure regulation, are essential. People with hypertension and CKD, who cannot be managed by diet and exercise may need to take a blood pressure medication. Those with abnormal cholesterols or triglycerides may also need medication to normalize lab values and slow damage from clogged and hardening arteries.

Staying in the best possible health is important when the individual has a complication like an acute illness or an infection, because it makes a difference in how they avoid and / or weather health problems. Debility greatly increases health plan costs.

Due to these factors, the case manager needs to be fully engaged with each member who has CKD to educate them on the importance of complying with the physician’s treatment plan regarding nutrition, lifestyle activities, employment, weight, heart, diabetes and blood pressure care and other chronic condition management. Advanced Plan for Health’s Poindexter advanced and predictive analytics platform enables case managers to monitor various metrics and member behaviors to reduce expensive hospitalizations and emergent care for cardiac events, diabetic complications, hypertension, anemia, electrolyte imbalances or problems related to infections or dialysis. 

Once the member is on track with prudent care for chronic conditions and an optimal lifestyle, the case manager can reduce the frequency of intervention, but still needs to receive regular updates from the provider and member contact to promote best health practices. They also need to deliver extra oversight when adverse changes or increased costs occur. 

Beginning Dialysis

Permanent kidney failure is a critical point in the process –  a game changer.  At this time, it’s important to revisit the transplant decision, because the individual needs to start the listing process if this has not been done previously. When kidney failure is permanent, kidney dialysis needs to be initiated.  Dialysis is the process of removing - by artificial means - excess water, solutes and toxins from the blood in those whose native kidneys have lost the ability to perform those functions.

Dialysis patients can work, travel and participate in life by pre-planning and having access to needed resources. Nurse care managers can help members access these requisite services and resources.

Members feel best right after their blood is cleansed of toxins and replaced into their bodies, and then may feel depressed when waste builds up before a treatment. For those attending a center for hemodialysis, changing work shifts can be a solution to getting treatment three times each week, seeing specialists and remaining employed.

Most people are on hemodialysis, but some qualify for home dialysis, which is less expensive, and provides members with more flexibility and control over their schedule. More details on the different dialysis types and sites of care are below.


Dialysis Types

There are two types of dialysis – hemodialysis and peritoneal dialysis.

Hemodialysis

While some plan members may be on temporary dialysis until their acute kidney failure resolves, the individuals we are addressing here are those who are near or at Stage 5 with permanent kidney failure (ESRD). Most individuals with ESRD travel to a hospital or free-standing facility for hemodialysis three times a week. A few may qualify for home dialysis – that is a decision between the member and physician.

The first step in preparing for hemodialysis is for a surgeon to create a fistula (usually in the arm, where an artery and vein are connected), or insert an artificial tube (graft), which serves as an access site for hemodialysis sessions.  

Hemodialysis is the process of filtering blood from an individual’s blood vessels through a manmade filter (dialyzer) to remove extra fluid, waste products and to correct any electrolyte imbalance. After the blood circulates through the dialyzer, it is slowly pumped back into the body. A dialysis session takes from 3 to 5 hours. The nephrology team does periodic tests to ensure that dialysis is cleansing the blood adequately. When dialysis is not clearing wastes properly, the provider may need to adjust the access site, or the dialysis procedure.

The individual is weighed before and after each dialysis session to assess for fluid retention. Regular lab tests are drawn to monitor anemia and electrolytes. Calcium, phosphorus and parathyroid hormone levels are tested to evaluate bone health. 

High blood phosphorus levels result in loss of bone calcium, which may result in weak bones that break easily (osteoporosis). Diabetes, hypertension, cardiovascular disease, and other health conditions need to be closely watched through laboratory testing. Anemia is very common, but can be treated with erythropoiesis stimulating agents and an adequate iron intake that encourages the body to produce red blood cells.

Members with ESRD need to work with a dietician and nurse care manager to eat a balanced, healthy diet that limits phosphorous, liquid intake and potassium. Succeeding in promoting a healthy lifestyle and eating plan requires consideration of means, access to healthy food and attention to cultural practices that work for each individual.

Imagine the adjustment that people with ESRD must make to center their lives and well-being around being tethered 3 times weekly to a dialysis machine and having their blood filtered and cleansed for hours at a time. People vary in their response to permanent dialysis, and need ongoing help from multiple team members - including a nurse care manager - to ease the adjustment, assist them through acute complications from dialysis or other health conditions and help them access needed resources to optimize essential life functions. Health plans need this medical management intervention and support to prevent and manage complications and avoid preventable costs.

Peritoneal Dialysis

There are two types of peritoneal dialysis – Continuous Ambulatory Peritoneal Dialysis (CAPD) and Automated Peritoneal Dialysis (APD). According to the National Kidney Foundation® CAPD is the only type that does not require a machine, and can be done at home. CAPD is a method where about two quarts of dialysate are placed into the abdominal cavity through a catheter several times each day, and then drained and discarded. The advantage is that the individual on CAPD can engage in usual life activities because CAPD is performed during waking hours, often at meals and bedtime. A CAPD cycle takes about 30 to 40 minutes. APD requires a special home-based machine that performs exchange cycles during the night when the person sleeps. Each cycle is completed in about ninety minutes.


The Criticality of Case Management Support

Case managers should not discount the importance of ongoing professional intervention and support as a member adjusts to the major life changes inherent to being on dialysis. Case managers can provide emotional support during the daunting and depressing experience of requiring life-long dialysis and / or potential kidney transplantation. They may also help the member access needed community, financial and medical resources at a time when income and functional capabilities may be reduced. A case manager can also help the member create a plan for optimizing life and health.

Failure to case manage and closely monitor these members can lead to a myocardial infarct or Coronary Artery Bypass Grafting (CABG) bypass surgery, which will bump members off the transplant list for 12 months before they can reapply to become eligible again. That is a huge price to pay for the member and the health plan.

To learn more about how Poindexter and the APH team of expert analytics and clinical experts can help you identify and address Kidney Disease as early as possible, please contact us here and we’d be happy to connect to learn more about your needs.

This is a multi-part blog series.
Part three will cover the costs of dialysis, where Medicare fits into the picture and best practices.