Tele-Dialysis Care

Charles Zachem, D.O.Eugene Springfield Nephrology Associates

4/11/13

Eugene-Springfield Nephrology Associates

5 Physician Single-Specialty Nephrology Private practiceServing : Lane, Douglas, Coos and Curry counties.Qualicenters Coos Bay Dialysis:

25 Chairs; 3 shifts 6 days per week (6AM-6PM)Provides dialysis/ESRD care to >100 patients.Opened in 1994Owned by Fresenius (For-Profit National chain)ESNA- Medical Directors and providers to unit.

Coos Bay, OregonQualicenters Coos Bay Dialysis:

Provides dialysis/ESRD care to >100 patients.25 Chairs; 3 shifts 6 days per week (6AM-6PM)Owned by Fresenius (For-Profit National chain)Opened in 1994ESNA- Medical Directors and providers to unit.

Bay Area Hospital172 bedsRegional Center of CareDistrict hospital

Experience in Tele-Dialysis:Described in Upper Peninsula of Michigan- based out of

Marquette General Hospital. Journal of Telemedicine and Telecare 2008;14:75-78

Program quite successful, but shut down due to CMS re-affirming that dialysis unit could not be origination site.

Recently, 2 programs described in Indiana and via Geisinger Clinic (Pa.) Renal Business Today Nov. 2012, Vol. 7 Issue 8, pp 18-20

Goals of ProgramQualicenters Dialysis

Improve Quantity presence in unitImprove Quality of presence in unit

Bay Area Hospital Initiate inpatient dialysis programEnable chronic stable ESRD patients to stay in their own

community for acute care hospitalizations.

Goals of Program cont.Eugene- Springfield Nephrology Associates

Improved Dialysis interaction quality for Outpatient ESRDExtend service area to BAH to provide community need.Improved Productivity ESRD service revenue.Decreased inefficiency of care delivery.Increased interaction with Dialysis care team.

Medicare ESRD programCapitated payments for outpatient dialysis care2004- CMS changed to a payment bundle based on face

to face vists with patients; based on large international study showing correlation between number of F2F visits per month and outcomes. (DOPPS)

Visit breakdown: 1 visit, 2-3 visits and 4 visits per month. Comprehensive visit each month by physician F2F/in-person.

Our Journey:Began in 2009 with discussions with CMS to see if we could obtain

permission for dialysis unit as origination site.Worked with Noridian and subsequently CMS Region X .2010 BAH first approached us regarding possibility of a nephrology

presence within their institution.2011 BAH broke ground for their new tower for ICU and Cardiac

services7/6/12- first Tele-dialysis management within BAH9/12- Live Tele-dialysis rounding at Qualicenters Coos Bay.

Barriers:Regulatory- CMS did not allow Tele-health origination site

in a for-profit free standing dialysis unit.Credentialing/Privileging- BAH did not have

credentialing/privileges for Telehealth MD’s to give orders within the institution

Hardware/Connectivity- Main issues were regarding the quality/reliability of connection with Qualicenters unit.

CULTURAL changes (Nursing, Physician, Patient)

SolutionsCMS Region X- John Hammerlund: Regional Administrator

gave permission for use in Coos Bay as a Medically Underserved Area (MUA)

Credentials for BAH developed and advanced through Medical Staff process

GCI Connect MD set up secure encrypted conferencing using Vidyo conferencing with T1 line form dialysis unit.

Stakeholder interviews: Nursing at Dialysis unit, BAH inpatient units, BAH Physician leaders, Nephrologists within ESNA, BAH Administration and Patients at dialysis unit

Cultural Change:Multiple meetings with all stakeholders- Nursing staff at

Hospital, Dialysis unit Staff, Medical Staff at BAH, not the least of all my partners.

Delineate: needs, wants, desires and fears for the process and the associated changes.

Describe/Map all the steps within the new necessary process; create written processes to achieve processes and test and re-design as needed. (PDSA cycles).

Educational meetings with Nursing staffGrand Rounds/ MEC attendance at BAHPatient concerns/fears addressed 1:1

Outpatient Dialysis Unit:

Fresenius QualicentersCoos Bay

ESRD Outpatient process:Dialysis Charge nurse moves Telemed cart around room; 3-way

communication with RN, Patient and MD.MD in office has Fresenius EMR live in side by side screen format, for

lab, dialysis treatment and medication review.Family at chair-side can also participate if needed.Quality of interaction is vastly superior- much more private and

intimate 1:1 review with patient of their status and concerns.On the spot review of Dialysis Plan of Care for patient; review MSW

and Dietician notes.Rounding on Outpatient shift of 18-20 patients approximately 90-

120 minutes. 3 shifts daily, 6 days per week.

Inpatient Dialysis

BAH Process:ESRD patients being admitted to hospital via ER- Nephrologist

contacted to confirm appropriateness of patient for Tele-dialysis as inpatient.

Nephrologist has Veto authority on appropriateness decision.Coordinate treatment time for team interaction.Tele-Med interaction: Patient, Dialysis RN, Floor RN and

Nephrologist; often with Hospitalist- live huddle, briefing and treatment plan.

Nephrologist has live side by side screen of BAH EMRNephrologist dictates interaction note/treatment plan into BAH

EMR.

BAH Results to date:Live- 7/6/12To date: 16 unique patients and 29 inpatient dialysis

sessions at BAH.Diagnosis for hospitalization: Cellulitis, Pneumonia,

Failure to Thrive, Cholecystectomy, ORIF lower extremity fracture and BKA for PVD.

Future:Florence Dialysis Unit- 9 station unit opening 5/1/13;

currently not within a MUA therefore may not be viable origination site.

Coos Bay- Delineating a methodology for feasible outpatient interactions/ follow-up.

Curry County Medical District- Curry General Hospital: discussions regarding dialysis unit associated with the

hospital for outpatient dialysis.

Thank You

Questions??