Dr. Michael Kraus: Welcome everyone to this episode of Field Notes. I'm Michael Kraus, the associate chief medical officer at Fresenius Kidney Care. Here we interview the experts, researchers, physicians ,and caregivers who bring experience, compassion, and insight into the work we do every day. In 2020, Fresenius Kidney Care launched an initiative to support physician champions for home dialysis. These physician home champions or PHCs are experts who provide mentorship and home dialysis to other physicians and empower physicians to grow home therapies. The goal is to provide more patients home therapy options to improve the quality of life and achieve better outcomes. The physician home champion is a true leader of home therapies in their respective region.

Today, we have two PHCs here with us to discuss the value and success of this program. Dr. Kristin Corapi, a practicing nephrologist with the Reliant Medical Group in Worcester, Massachusetts, and Dr. Arley Diaz, a nephrologist with the kidney care and transplant services of the New England Group in Springfield, Massachusetts. Dr. Corapi, Dr. Diaz, welcome to Field Notes.

Dr. Kristen Corapi: Thanks for having us.

Dr. Arley Diaz: Thank you very much.

Dr. Michael Kraus: Before we dove into details of the physician home champion program, tell us a little bit about why you are such a believer in home therapy. What makes you so passionate about home doctor practical? Dr. Corapi, we’ll start with you.

Dr. Kristen Corapi: I had a fairly unique experience as a medical student. I went to medical school in Ireland, so I was exposed to a lot of home therapies very early in my career, and I was always taught that there is no perfect or ideal candidate for home therapies, but that it really is an option for many folks with end stage kidney disease. So very early on, I saw a variety of patients with different educational levels or physical barriers able to do a home therapy. And I sort of carried that through when I came home to the U.S. to do my residency and fellowship. I've seen such great patient outcomes with home therapies, and I think the literature supports that to some extent, that it's really been a focus of my career to try to grow home therapies and make it available to more patients here in the U.S.

Dr. Michael Kraus: Dr. Diaz.

Dr. Arley Diaz: Thank you, Dr. Kraus. Yes, this is a real passion of mine for years, very eager to help our patients find a way that they would be extremely satisfied with choosing a modality to do dialysis or any form of renal replacement at home. It was very interesting to me to engage the patient and help them get the way to be more comfortable and obtain better outcomes.

Dr. Michael Kraus: Dr. Corapi, how does the Physician Home Champion program work? 

Dr. Kristen Corapi: So, I really see myself as a resource to both the home therapy clinic staff and my physician colleagues in helping people feel more comfortable prescribing home therapies. So I do a lot of education both to the nurses and the PCT and the clinics as well, to our medical directors and physician colleagues about new trends in prescribing home therapies and trying to break down some of the barriers that we sometimes put on who's a candidate for home therapies?

Dr. Michael Kraus: Why did you become a physician home champion? What does it mean to you to be the physician home champion in your market?

Dr. Kristen Corapi: I see it as quite an honor really to be my area's PHC. It's, you know, very I always wanted home therapies to be sort of my niche within nephrology. In my first job Out of Fellowship is working at a big academic center where research was always the focus. And I sort of learned very quickly that it was hard to do a big prospective trial with a population of PD or hemo home hemo patients because it's not a big cohort of them at any given clinic throughout the U.S.. And when I took my next job as a full time clinician, I wanted some sort of education to be still part of my career. And so the PHC program was a great way to blend my passion for home therapies and my goals of having education be part of my career. It's just, rather than educating patients and publishing papers, I'm educating my colleagues and those on the front lines doing home therapies within Fresenius.

Dr. Michael Kraus: Dr. Diaz, tell me why you wanted to upset your busy practice and become a physician home champion.

Dr. Arley Diaz: One of the things that we encountered for years is that in nephrology, changes are a little bit of a challenge as ever since dialysis was started to be incorporated in our patients management, even approved by Medicare in the early 1970s, we were only able to do dialysis in the center in a in a situation where the patient has the capability to be engaged and be empowered to do their own dialysis. I think that's where I became very passionate to help them get through and through my practice, where there is a nephrologist in advance or practitioners who also engage in follow this practice to be, you know, to be leaders basically on on home dialysis therapies.

Dr. Michael Kraus: Dr. Corapi, as PHC, you're part of a team that leads other physicians to be an integrative part of a larger initiative to encourage more patients to choose home. Why is it so important to get other nephrology doctors to advance the way we think about dialysis treatment?

Dr. Kristen Corapi: So one thing that I've learned in my first almost 18 months as a PHC is that there's a lot of local barriers in particular clinics that might be a barrier to growing home. So the region that I serve as a PHC is a lot of New England, so I work in both urban settings and more rural settings, big practices, small practices, and there's a lot of different problems at each of those different levels. And so I've driven up to New Hampshire and Vermont and Maine and sort of met with the docs on the ground to see what their issues are. And one of the big takeaways I've had is that there's not a group of nephrologists who are anti home therapies. It's just they need help navigating local issues to be more comfortable getting folks on home or brainstorming ways to attract more patients to home therapies.

Dr. Michael Kraus: Very good. And Dr. Corapi, I'm going to follow up on that. What are some of the challenges you've noticed the program tries to address? Are there challenges with other physicians or patient challenges?

Dr. Kristen Corapi: Sometimes when you've been in practice for a long time, being familiar with some of the nuances of the newer ideas and how to prescribe home therapy might take some getting used to. For example, we've had some physician groups who were very resistant to the idea of a transitional care unit. So trying to share with them some of the outcome data and the benefits of a TCU has helped them be more open to referring their patients to a TCU. We've had some folks who are resistant to solo home hemo or using catheters for home hemo and really just providing some education and sharing what we do locally in our practice and how it might benefit their patients has been a big influence in helping people feel more comfortable with home therapies.

Dr. Michael Kraus: Dr. Diaz, why is it so important to get other nephrology physicians to advance the way we think about dialysis treatment?

Dr. Arley Diaz: Most of our practitioners have the same goal as I do. So by engaging my own practice and engaging the nephrology team I work with and the partners and the surgeons all with the same goal. I think it's been very successful. Clearly there is background information in terms of the research done on home therapies, how it really enhances patient's survival in terms of their outcomes, particularly when it comes to the cardiovascular health. So we engage in two practices that are evidence based and also that we know our patients are going to have better outcomes.

Dr. Michael Kraus: And what are the challenges? A physician home champion program itself tries to address for? For example, are there challenges with other physicians? Patient challenges, the growth of.

Dr. Arley Diaz: Home? It's never going to be an easy, nice, flat road. There's always going to be obstacles. The obstacles mostly are going to be related. In what you mentioned in regards to other physicians. Yes, some folks may not be as firm believers about some therapies and some folks feel that why would I want to put my patient on peritoneal dialysis when I know that maybe they're not going to get the best clearance and they're not going to feel as well as they should by doing in center hemodialysis, for example. So changing that mentality and showing that out that they're able to digest and changing those practice patterns has been a challenge. But I think we're getting there. I think it's like everything else as as we all enroll into this process, I think other physicians also start changing the practice patterns, and I think that's how we get to be successful.

Dr. Michael Kraus: And Dr. Corapi, I'm going to follow up on that. How do you include the other members of your team? But especially let's focus on the nursing and even the cases or kidney care advocates and where they belong.

Dr. Kristen Corapi: So we in my practice in Worcester try to incorporate the kidney care advocates of the cases very early in our patients journey. So we try to refer folks with stage four CKD to the KCA, you know, once their GFR is in the high teens, as she has a chance to meet with them more than once often and sort of educate them about what their options are. I try to tell my patients that as scary as dialysis is, it's important to know that there's a menu of options, and it's our job to match them with the therapy that makes the most sense for them and their family. And the KCA is really important to that piece. But then the nurses and the teams who sort of take over once the patients in training serve a really important role in getting to know the patient's family, their day to day routine, and figuring out how we can make our home therapy fit their routine in a less disruptive manner.

Dr. Michael Kraus: And Dr. Diaz mentioned earlier how growing home dialysis is clearly a team sport and being part of the is being part of a team as a PHC. What is different?

Dr. Arley Diaz: What I think is different is that me as a physician from Champion, my perspective is to engage every member of the team. One of the things we do have a cadence of meetings every week where we have weekly calls and we run a list of our patients that are, for example, in their transitional care unit. And we run through every single aspect that has to do with the patient's ability to perform dialysis. And we engage the kidney care advocate as they are probably one of the most important key pieces of the puzzle, because they really educate our patients tremendously, not only the patient, but also they engage the family members or whoever is their next of kin or whoever is really in there with the patient. Sometimes we have patients that show up in their families and no friends and nobody, and we basically try to get the kidney care advocate also to be sort of like that shoulder to that patient, to feel they're being supported. So engaging every member of our team is really what has made this a clear cut, successful strategy.

Dr. Michael Kraus: And let's let's switch the focus a little bit to the patients. Now, how does the PHC program help patients take ownership of their own health?

Dr. Kristen Corapi: I think one of the main benefits is seeing the growth of home therapies. I really think the PHC program is really having an impact. And you know, as a PHC we get information about the growth of home therapies in regions with the PHC and without it, and it's really refreshing and inspiring to see the impact that we're having throughout the country. If at the end of the day, being a PHC means more folks are in a home therapy and more folks are in charge of their care and active participants. I think that's a huge win. You know, when I was a fellow, everyone did in Center Hemo because that's what everyone, everyone's aunt and uncle and neighbor up the street did. And as home therapies become more prevalent throughout our community and more folks are exposed to them, it's not as foreign an idea, and I think patients will definitely be more comfortable talking to their nephrologist about it if their doctor hasn't brought it up already.

Dr. Michael Kraus: And Dr. Diaz, how does the PHC program help patients take ownership of their health and how are patients benefiting from this.

Dr. Arley Diaz: By seeing the progress and as they have the education piece in as as they see that there are ways to be more proactive in empowering them to do their own treatments. They become part of the team. And that's how in the beginning I kind of alluded to that because I feel like the education and the nurturing not only of our own peers in terms of our team, but also the education and nurturing of our own patients, makes a home conversion, probably one of the most challenging processes, but also very successful at having patients make the right choice.

Dr. Michael Kraus: When we talk about education, home therapies, do you think the patients are becoming more empowered to ask their doctors about these home therapy options?

Dr. Arley Diaz: Clearly, yes. And I think that's become probably the norm. And I don't know if it's because, you know, we live in a world where now patients have Internet access and they can really have a lot of information being supplied by different sources. And I think they become very savvy. I, I think it is not the patient is the family members that really want to be involved and they want to be part of the, of the treatments. And by helping them, giving them that resource and that empowerment. We have an amazing team of nurses who are really, really involved with each patient and each family member to make sure they're really fulfilling their their own treatment dream which is be successful at home.

Dr. Michael Kraus: It good and with the success of your program the success locally and hopefully nationally as more patients are choosing home, obviously more patients need to be trained. How are doctors working around the patient's schedules to make their treatments happen?

Dr. Arley Diaz: Well, that's been or more of a coordination, right. So because as you know, and as I mentioned before, again, doctors are really busy and we are running in different dialysis centers, different units. So by me being the physician home champion, in a way, we have become very much a team of transparency, which means we share information and we are all transparent on how we are prioritizing the care of the patient. So by giving me that trust as being the physician home champion, we've been able to engage every member, including the physicians that are very busy doing their own rounds, but then also delegating and sharing and being transparent about how we share the patient's information.

Dr. Michael Kraus: How our patients benefiting from this Dr. Corapi.

Dr. Kristen Corapi: I know at least locally here with our home therapy clinic, I'm amazed at the flexibility of the staff. Every industry right now is sort of hampered by staffing shortages, but the home therapy community is so passionate and really want to see their patients succeed that I've seen nurses or PCTs willing to train folks after their 9 to 5 job. So they come to the clinic in the evening. I've had folks have transportation issues, so the home therapy program go to their home for the bulk of the training sessions and getting creative and thinking outside the box like that is how we're going to be successful. Getting more folks on home.

Dr. Michael Kraus: And Dr. Diaz, what do you say to other physicians who may not have heard about the physician home champion program yet?

Dr. Arley Diaz: Usually I, I, I am very cautious because a lot of folks really, again, they have their own way to practice. But I do really have just a little pieces of information that makes them very curious to become, you know, how does this work? How do I actually make my patient be more interested in home? How do we so I throw information that really is just very brief. I don't really kind of inundate with data or anything like that, but I try to really just have a conversation very informal. And then if, if the doc is really engaged, then we, we sit down and we talk in more detail. And I think that's that's also very informative and very useful because at the end of the day, it's all about communication.

Dr. Kristen Corapi: You know, I am your partner and your colleague. I was chosen for this role because I'm in the same area of the country as you are. I was chosen for this role because I'm really passionate about home therapies and it's something I love to talk about. So I'm not at all bothered by questions or patient cases that you need help with because I love navigating that with other physicians and helping things go smoothly so more focus can end up on home because it's really such an important decision and has such an impact on their overall health care trajectory.

Dr. Michael Kraus: Dr. Corapi. Dr. Diaz It's been a fantastic conversation. It's great to hear about the success of the PHC program. Thank you for joining us today.

Dr. Arley Diaz: Thank you. Dr. Kraus. It's been a pleasure. Appreciate it. Thank you.

Dr. Kristen Corapi: Thank you so much for having us.

Dr. Michael Kraus: And to our audience, thank you for joining us. If you're new to the Field Notes podcast, you can download past episodes on the Apple Store, Google Play or right here at FMCNA.com. And while you're there, please subscribe to receive the very latest updates as they happen. Until next time, I'm Michael Kraus and you've been listening to Field Notes by Fresenius Medical Care North America. Take care, everyone.