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  • Jul 31, 2018

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

Dr. Griffin Rodgers, Director of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) has published a short video that is a good introduction to understanding individuals at risk for developing chronic kidney disease (CKD). It was developed to be shared with members at an educational moment.

It is time to disrupt the business-as-usual paradigm of waiting until a member “triggers” for medical management intervention because they use the emergency department excessively, take high cost medications, have a hospital admission or have high dollar claims. 

Early intervention is the key to slowing or stopping chronic kidney disease (CKD), improving the quality of lives for those at risk and containing health plan costs. Avoiding dialysis for just one member represents a health plan savings of $350,000 to $700,00 per year, which more than pays for the CKD program by itself.

A well-reasoned, proactive kidney disease management program
is a necessity, not a luxury.

As detailed in our recent “Cost of Dialysis and TPA and Medical Management Best Practices” blog, once dialysis starts, the employer or Plan will pay these costs for 33 months after outpatient dialysis is initiated. After that time period, Medicare takes over if the individual member has made a timely application.

Who should be tested for possible CKD? According to the NIDDK video mentioned earlier, those with diabetes, hypertension, family history of kidney disease or heart disease are at higher risk of developing CKD. Obesity is also a contributing factor, but blood pressure control is one of the most critical factors in controlling kidney damage. The risk for CKD is also magnified for those of African American, Hispanic or Indian descent.

Finding at-risk individuals early is critical, since CKD does not have any discernible symptoms until kidney disease is advanced. By the time, symptoms appear, there is often permanent and severe kidney damage.

Early Detection and Aggressive Management is Vital

The American Kidney Fund published an overview of which tests show that kidneys are not working properly. A simple urine test is done to check for protein or blood, which indicates that there is an acute or lasting problem with your renal system. Providers will also draw blood to check creatinine levels, to show how kidneys are filtering waste from the blood. Blood pressure will also be tested to see how hard the heart is working to pump blood throughout the body and through the organs. High blood pressure can be caused by kidney disease and likewise kidney disease can cause high blood pressure. Blood sugar will also be evaluated, since diabetes control helps kidney function. 

Once these test results are in, a good consumer-facing reference tool on interpreting test results is available from the National Kidney Disease Education Program (an initiative of the National Institutes of Health (NIH)).  Their very simple handout for use in helping individuals understand the tests for kidney disease is called: How Well are Your Kidneys Working: Explaining Your Kidney Test Results”. 

Spotting the Symptoms and Finding the Individuals with CKD

More than 30 million people in the USA are living with chronic kidney disease – which is defined as lasting kidney damage that worsens and ultimately may end in kidney failure. 

When the kidney failure is permanent, the individual must be on dialysis or have a kidney transplant to live. When kidney damage is severe, there may be symptoms because of the waste and extra fluid building up in the body. These symptoms include: Itching; Muscle cramps; Nausea and Vomiting; Swollen feet or ankles; Sleeping difficulty; Loss of appetite; Excessive or diminished urine output and Trouble breathing.

Did you know that damaged kidneys can also cause anemia, poor bone health, heart disease and fluid accumulation causing a whole host of other health problems that create human misery, loss of productivity and high health plan costs?

Advanced Plan for Health (APH) has Poindexter, an advanced and predictive analytics system that assists client clinical resource professionals such as Nurse Navigators and Nurse Health Coaches in finding persons with metabolic syndrome, diabetes, heart disease and kidney disease so they may address predicted risks and close care gaps to improve financial and clinical outcomes. 

By intervening early to control blood sugar, weight and blood pressure, and by encouraging a healthy lifestyle and compliance with the physician’s treatment plan – individuals will be able to stabilize and improve health and quality of life which can help to avoid progression of kidney disease. Some individuals can reverse their kidney disease, whereas others will be able to delay the progression of kidney failure.

The Art and Science of Nurse Navigation and Coaching Intervention

The National Institute of Diabetes and Digestive and Kidney Diseases has published a five-part series on chronic disease nutrition and management training for Nurse Navigators and Nurse Health Coaches working with the at-risk population to avoid or slow the progression of end stage renal disease (ESRD). This series is highly recommended as a basis for understanding CKD, helping at-risk individuals, and having useful tools and tables that apply to all stages of the disease. 

The key is controlling risk factors, modifying the lifestyle and nutritional patterns, and closely monitoring disease progression so that targeted intervention is possible. The program is divided into five modules, as follows:

  • Module I provides an overview of chronic kidney disease which includes a great review on how to determine kidney health, adverse symptoms, tests and disease progression. This module is foundational in understanding CKD at its various stages. ​

  • Module II includes detail on slowing the progression of chronic kidney disease. Nurses coaching those at risk for CKD will benefit from reviewing this module.​ 

  • Module III details what Nurse Navigators and Nurse Health Coaches need to know about detecting and managing CKD in concert with the individual’s physician and other members of the health team. The discussion also includes tables and examples of complications that worsen with diminished kidney function.​​

  • Module IV provides an indepth discussion of nutrition and how it has to be modified for each individual, and also as CKD progresses. This module details calories, beverages, protein needs, balanced diets, and the impact of salt, potassium and phosphorus – all of which require control for individuals with CKD. Cooking methods are also emphasized because of the need to reduce Advanced Glycation End (AGE) products. Because so many individuals eat processed foods – which can impact CKD with hidden chemicals, sugar, salt and fats – good and ill-advised food preservatives and additives are also addressed and cannot be ignored.

Getting nutritional aspects of CKD right at various stages of kidney disease is so important that health plans should strongly consider offering periodic consults with a dietician as an integral program element.

  • Module V explains the dietary changes needed for individuals with kidney failure, which differ depending on the type of dialysis used and whether they have had a kidney transplant.

Other helpful tools include the consumer handout called “Eating Right for Kidney Health: Tips for People with Chronic Kidney Disease CKD”, which is a simple, effective tool from the National Kidney Disease Education program for individuals trying to address their CKD.

Proactive Intervention to Minimize Risk and Cost

Since End Stage Renal Disease (ESRD) and dialysis can be so expensive ($350,000 - $700,000  annually per individual on average), and the health plan is the primary payor for 33 months after outpatient dialysis is initiated, we believe it’s possible to delay ESRD and increase quality of life by catching those in the early stages of chronic kidney disease and getting them on a renal diet and closely monitoring blood pressure and diabetes.

Get started by seeing if there is a nephrologist and dietician who would be willing to help the Nurse Navigator start a comprehensive CKD program.  Having support from endocrinology and cardiology would also be a good idea.

The good news is that for APH’s clients, Nurse Navigation has proven to also reduce heart disease, improve diabetic control and optimize the health of participants. This proactive intervention impacts financial outcomes related to lower acute care stays, as well as other resource utilization rates. After all, health plan costs are a result of resource utilization multiplied by the times a particular resource is utilized. Consider also the value of having employees regain their health and vitality so that they can be contributing, productive team members.

Steps in getting started are just a matter of:

  • Getting Prepared

  • Obtaining administrative support

  • Having an easy-to-use intelligent system to measure care gaps, health patterns and access predictive analytics to find at-risk individuals, and then help participants bend the trend by reversing or slowing the risk drivers that placed them in the high predictive risk category

  • Measuring the program baseline, outcomes and individual compliance

  • Providing personalized, individualized clinical support that encourages people to become motivated in making critical life changes vital to their well-being and that of the health plan

What a difference delaying dialysis for just one person makes to both the individual and the health plan!


To learn more about what APH’s Poindexter analytics system is delivering to clients in CKD visibility, or to learn more about our Nurse Navigation programs, contact us here or call (888) 600-7566.