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  1. Home
  2. Defragmentation Of Care In Complex Patients With Eskd Improves Clinical Outcomes.
  1. Home
  2. Defragmentation Of Care In Complex Patients With Eskd Improves Clinical Outcomes.

Related Experiment Video

Digital Home-Monitoring of Patients after Kidney Transplantation: The MACCS Platform
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Defragmentation of care in complex patients with ESKD improves clinical outcomes.

Nathan Moore, David Roer1

  • 1DaVita Inc, 2000 16th St, Denver, CO 80202.

The American Journal of Managed Care
|May 15, 2024

View abstract on PubMed

Summary
This summary is machine-generated.

Coordinated care for end-stage kidney disease (ESKD) patients reduced hospital admissions by 15%. The Shared Patient Care Coordination (SPCC) program improved clinical indicators and patient outcomes.

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Area of Science:

  • Nephrology
  • Healthcare Management
  • Public Health

Background:

  • Fragmented care for end-stage kidney disease (ESKD) patients presents significant challenges.
  • A kidney care organization and an integrated health system collaborated to improve care coordination.
  • The program aimed to enhance patient experience, clinical outcomes, and reduce healthcare costs (the Triple Aim).

Purpose of the Study:

  • To evaluate the effectiveness of the Shared Patient Care Coordination (SPCC) program in its first year.
  • To assess the impact of coordinated care on hospitalizations, emergency department visits, and key clinical indicators for ESKD patients.

Main Methods:

  • Retrospective examination of the first year of the SPCC program.
  • Comparison of hospitalization and emergency department visit rates between SPCC participants and non-participants.
  • Benchmarking of clinical indicators (central venous catheter use, home dialysis, advance care planning, missed dialysis treatments) against normative data.
  • Main Results:

    • SPCC program participants showed a 15% lower rate of hospital admissions compared to non-participants (P = .02).
    • By the second year, SPCC patients demonstrated favorable rates (above the 95th percentile) for central venous catheter use, dialysis treatment adherence, and advance care plan completion.

    Conclusions:

    • Structured communication between dialysis providers and care teams is crucial for coordinated, patient-centered care.
    • The SPCC program demonstrates a successful model for improving outcomes in end-stage kidney disease patients.