For patients with end-stage renal disease (ESRD)—advanced chronic kidney disease that necessitates dialysis for survival—complications and hospitalization present a persistent threat. Often faced with comorbidities such as diabetes or vascular disease, ESRD patients require treatment from a patchwork of providers—which can result in fragmented, redundant care.

The challenge is a prime one for Partners HealthCare’s continued efforts to manage population health, embodied at Brigham and Women’s Hospital by the high-risk Care Management Program (iCMP). To harness cross-specialty providers into a cohesive care team implementing a unified plan specifically for ESRD patients, the iCMP team launched a care management pilot program in 2016. By designating care coordinators to help patients navigate treatment across settings and clinicians—from primary care doctors and hospital staff to specialists such as nephrologists and endocrinologists—the program’s goal is to enhance outcomes by optimizing care and reducing hospital stays.

From her home base at Brigham and Women’s Faulkner Hospital, Nurse Care Manager Diane Goodwin, RN, oversees the approximately 55 patients enrolled in the program. Regular visits to four Boston-area dialysis units lend Goodwin a bird’s-eye view of complications and any troubling symptoms that emerge, such as high blood pressure, volume overload and vascular access complications. Once a month, Goodwin sits face-to-face with each patient, working through medication regimens and overall challenges, from clinical to logistical. To keep patients out of the hospital, Goodwin works with the dialysis units and emergency department (ED) to identify those patients who could alternatively be treated in urgent care centers or primary care offices, and with the inpatient team to tailor treatment to prevent readmissions. 

Diane Goodwin, RN, sits with patient Chantaylor during one of her dialysis appointments. Goodwin oversees around 50 patients enrolled in the Brigham and Women's Hospital ESRD program.

“Diane has really had a major impact and we’ve gotten a lot of positive feedback from primary care providers, nephrologists, and patients about how impactful the program has been,” says Mallika L. Mendu, MD, MBA, a Brigham and Women’s attending physician specializing in nephrology and Assistant Medical Director of Specialty Care at the Center for Population Health. As of October 2017, that impact includes 22 avoided ED visits and 12 avoided admissions, adding up to approximately $894,000 in savings—and enhancements in care for an at-risk patient population. The team also saw that, on average, when patients were admitted to the hospital their length of stay was shorter and their readmission rates were lower.

“The goal was to take these patients who are really complicated, high utilizers of care with traditionally poor health outcomes and try to make the system work better for them,” notes Dr. Mendu. “I think we’re accomplishing that.” Building on this success, the ESRD team now plans to expand the program to eligible patients covered under the Partners Accountable Care Organization, at BWH and beyond. 

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