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Stephanie Hutchinson is the executive director for the HeathInsight ESRD Alliance. The HealthInsight ESRD Alliance is composed of HealthInsight, the Northwest Renal Network 16 (serving Alaska, Idaho, Montana, Oregon and Washington) and Network 18 (serving Southern California), along with stakeholders in both regions. The alliance serves more than 55,000 patients with ESRD in 569 dialysis facilities.
Stephanie has worked for over 22 years in nonprofit leadership, many of those with the Northwest Renal Network. She previously served as the CEO of the National Kidney Foundation of Florida providing relevant experience in a national organization dedicated to empowering patients impacted by kidney disease. Stephanie earned her Bachelor of Health Education from University of South Florida and a Master of Business Administration from Rollins College.

Radical Resolutions

New Years Resolution

As I reflect on this past year and prepare for new challenges in 2018, I have been inspired by the Institute for Healthcare Improvement (IHI) Leadership Alliance’s 10 guiding principles or simple rules for radical health care redesign. As we move into a new year, it seems appropriate to revisit this simple, yet thought provoking, guidance for quality improvement in health care.

  1. Change the balance of power. Co-produce health and well-being in partnership with patients, families and communities.
  1. Standardize what makes sense. Standardize what is possible to reduce unnecessary variation and increase the time available for individualized care.
  1. Customize to the individual. Contextualize care to an individual’s needs, values and preferences, guided by an understanding of what matters to the person in addition to “What’s the matter?”
  1. Promote well-being. Focus on outcomes that matter the most to people, appreciating that their health and happiness may not require health care.
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Working Upstream

Granddad and granddaughter fishing

Summertime in the Pacific Northwest is a great time to catch a glimpse of salmon making the life and death journey swimming upstream back to the place of their birth.

We often talk about working “upstream” with patients with kidney failure and how critically important, yet difficult, this work can be. One out of seven Americans (30 million!) has chronic kidney disease (CKD), often referred to as the “silent killer,” due to symptoms that are undetectable until it is too late. Not only is CKD a growing public health threat, but the health care costs associated with CKD and end stage renal disease (ESRD) represent more than a quarter of all Centers for Medicare & Medicaid Services (CMS) claims.

Nephrologists who care for kidney patients have increasingly expressed their concern for the lack of care for patients in the early stages of ESRD (stage 1-4) before kidney failure (stage 5). Dr. Louis Cotterell, a nephrologist and member of the ESRD Network board of directors, relayed the importance of working “upstream”, he said:

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More staff please. California staffing ratio bill heats up dialysis industry.

Doctors and Nurses

There is a lot of debate happening these days in California around a proposed staffing ratio bill that has been introduced. It has led to considering the impact this would have on the quality of care for the dialysis patient in California. The Conditions for Coverage that govern dialysis providers nationally give this guidance: "Adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of the patients." Now that is adequately vague.

SB 349, the Dialysis Patient Safety Act, introduced by state senator Ricardo Lara, D-Bell Gardens, proposes a 1:8 nurse to patient ratio, a 1:3 patient care technician to patient ratio, and a 1:75 social worker to patient ratio. When compared to the nine other states that have already passed laws with some kind of staffing ratio language included, California would hold the most stringent ratios.

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Compassion Fatigue

Nurse holding patient hand

The end stage renal disease (ESRD) Networks of HealthInsight play an important role in helping dialysis patients who have concerns about the quality of care they are receiving. The patient services staff, including three Masters level social workers, is required to be available, per the Social Security Act and the Conditions for Coverage, to mediate, coach, listen, instruct and empathize with our dialysis population that exceeds 60,000 patients. What does this all really mean?

If you walk for a minute in the shoes of a dialysis patient, you might understand that their lives have tremendous potential for "issues". Think about it. Dialysis patients receiving their treatments in center must get to the center, check in, wait to be called in, wash their access, interact with the dialysis staff who provide life-saving treatment to them for three to four hours while they are tethered to a chair, socialize with their fellow patients, return home, watch their diet and fluid intake meticulously. Add to that not feeling well and having to return for dialysis two more times each week just to survive.

While most of our patients are heroes - bringing joy and resilience every time they come to dialysis, many struggle through the challenges that living with a chronic illness can bring. Even the most resilient dialysis patients – hit bumps in the road.

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Care Options for the Frail Elderly

Mother and daughter

While at the California Dialysis Conference last week, I attended a thought-provoking session with a panel discussion between three medical directors from the largest dialysis organizations in the U.S. – Davita, Fresenius and U.S. Renal: Dr. Allen Nissenson, Dr. Dinesh Chatoth and Dr. Stan Lindenfeld, respectively. These physicians grappled with many issues affecting dialysis patients nationwide.

As the topic turned towards the Centers for Medicare & Medicaid Services' (CMS) goal to have alternative payment models implemented in 80 percent of the Medicare population by the year 2020, the trio discussed the benefits of the new renal Accountable Care Organization (ESCO), including the unquestionable benefit of providing integrated care for patients with kidney disease. While these doctors agree that cost savings are an ultimate driver, by providing comprehensive services including palliative care, our medical community will be able to provide an alternative to dialysis and have painfully honest conversations about the benefits and challenges of treatment, particularly for the frail elderly. Surprisingly, at least to me, frailty has a medical definition. Frailty is identified when a patient meets three out of five criteria: weight loss (10 or more pounds within the past year), muscle loss, a feeling of fatigue, slow walking speed and low levels of physical activity. With aging frailty comes naturally; patients over 75 represent our largest growing segment with chronic kidney disease – the precursor to kidney failure.

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