Our approach to care coordination for renal patients
As a long-time leader in the development and successful application of value-based models of care for chronic needs populations, Fresenius Health Partners focuses on quality to help drive improved health outcomes while reducing the total cost of care.
We place patients at the center of an integrated care team. As part of one of the nation’s largest providers of dialysis services, we are uniquely positioned to leverage our advanced analytics — using both clinical data and in-person interactions — to identify health risks and create informed individualized care plans.
Care models uniquely designed for high-need, high-cost populations
Fresenius Health Partners coordinates care for renal patients through a unique value-based care model. Unlike most traditional care management programs, our distinct model of care is tailored to suit the needs of the populations we serve through:
- Nephrologist-led care teams
We put the experts at the head of our care team to lead health decisions resulting in better health outcomes.
- Real-time monitoring and predictive risk modeling
We monitor clinical data from our dialysis centers in real time while applying predictive risk models to our patient care database to identify early signals of impending hospitalization allowing for timely interventions to reduce the incidence of avoidable inpatient admissions.
- 24/7 Care Navigation support
Our Care Navigation Unit (CNU), a dedicated team of nurses and care coordinators, provides both remote telephonic and in-market face-to-face interactions with patients, families and caregivers to address the medical, psycho-social and logistical challenges faced by the CKD/ESRD patients enrolled in our value-based care programs. Working as part of the integrated care team, the CNU helps remove barriers to patient care by providing patients with support around transportation, referrals and appointments, palliative care and behavioral health. Patients also have 24/7 access to the CNU to answer their questions and get the help they need.
- Targeted interventions
Preemptive and time-of-need interventions are dual-focused to provide solutions for immediate needs while addressing underlying, long-term issues that can impact health outcomes. We are constantly measuring and fine-tuning our interventions based upon well-established metrics to optimize their impact on our patients and their contribution to our program objectives.
- Focus on care transitions — both at time of admission and at discharge
With technology-enabled early identification of patients presenting to the ER, the CNU is able to engage hospital staff and the patient care team to coordinate outpatient treatment options, reducing avoidable hospital admissions. Our programs engage with our patient’s nephrologists to assist with transition of care plans upon discharge to reduce readmission rates, which are much higher with the ESRD population than the general population.
Innovation starts here
With a 100-plus-year history as care innovators, we’re never satisfied with the status quo when it comes to patient care. Using our Clinical Innovations Lab we can vet, pilot and optimize interventions for our high-risk patient population. Using a robust data platform, we determine which interventions are most likely to create value where value = quality/cost. These interventions are then piloted and, if successful, scaled for our patient populations.
Partners at every step: CKD/ESRD Transition Management Program
The transition from late stage CKD to ESRD is often marked by fragmented care leaving patients vulnerable and resulting in a total cost of care during the first 90 days of dialysis that is 45 percent higher than that of the prevalent dialysis population. To address this critical period of care, Fresenius Health Partners offers a comprehensive Transition Management Program. Through the analysis of claims and lab data, we identify later stage CKD patients (Stages 3b, 4 and 5) most likely to progress to ESRD and then:
- Connect the patient with a nephrologist to improve the patient’s renal care
- Provide the patient with access to renal care coordinators, relevant educational resources, and continued monitoring of kidney disease progression through the facilitation of regular physician appointments and renal lab tests
- At the earliest clinically appropriate time, we provide the patient with education about ESRD treatment modalities, including kidney transplants and home dialysis, through our KidneyCare:365 program.
- For patients choosing dialysis as their treatment modality, facilitating their timely completion of the procedures required to ensure an optimal start of dialysis, including arranging for vascular access through a fistula or graft (rather than a catheter).
Improving quality of life extends beyond dialysis, so we have built an integrated network of people, technology and resources focused on delivering the right care to patients.
— Bill Valle, CEO, FMCNA