TeleDialysis Care Charles Zachem D O Eugene Springfield

Tele-Dialysis Care Charles Zachem, D. O. Eugene Springfield Nephrology Associates 4/11/13

Eugene-Springfield Nephrology Associates 5 Physician Single-Specialty Nephrology Private practice Serving : Lane, Douglas, Coos and Curry counties. Qualicenters Coos Bay Dialysis: 25 Chairs; 3 shifts 6 days per week (6 AM-6 PM) Provides dialysis/ESRD care to >100 patients. Opened in 1994 Owned by Fresenius (For-Profit National chain) ESNA- Medical Directors and providers to unit.

Coos Bay, Oregon Qualicenters Coos Bay Dialysis: Provides dialysis/ESRD care to >100 patients. 25 Chairs; 3 shifts 6 days per week (6 AM-6 PM) Owned by Fresenius (For-Profit National chain) Opened in 1994 ESNA- Medical Directors and providers to unit. Bay Area Hospital 172 beds Regional Center of Care District hospital

Experience in Tele-Dialysis: Described in Upper Peninsula of Michigan- based out of Marquette General Hospital. Journal of Telemedicine and Telecare 2008; 14: 75 -78 Program quite successful, but shut down due to CMS reaffirming that dialysis unit could not be origination site. Recently, 2 programs described in Indiana and via Geisinger Clinic (Pa. ) Renal Business Today Nov. 2012, Vol. 7 Issue 8, pp 18 -20

Goals of Program Qualicenters Dialysis Improve Quantity presence in unit Improve Quality of presence in unit Bay Area Hospital Initiate inpatient dialysis program Enable chronic stable ESRD patients to stay in their own community for acute care hospitalizations.

Goals of Program cont. Eugene- Springfield Nephrology Associates Improved Dialysis interaction quality for Outpatient ESRD Extend service area to BAH to provide community need. Improved Productivity ESRD service revenue. Decreased inefficiency of care delivery. Increased interaction with Dialysis care team.

Medicare ESRD program Capitated payments for outpatient dialysis care 2004 - CMS changed to a payment bundle based on face to face vists with patients; based on large international study showing correlation between number of F 2 F visits per month and outcomes. (DOPPS) Visit breakdown: 1 visit, 2 -3 visits and 4 visits per month. Comprehensive visit each month by physician F 2 F/inperson.

Our Journey: Began in 2009 with discussions with CMS to see if we could obtain permission for dialysis unit as origination site. Worked with Noridian and subsequently CMS Region X. 2010 BAH first approached us regarding possibility of a nephrology presence within their institution. 2011 BAH broke ground for their new tower for ICU and Cardiac services 7/6/12 - first Tele-dialysis management within BAH 9/12 - Live Tele-dialysis rounding at Qualicenters Coos Bay.

Barriers: Regulatory- CMS did not allow Tele-health origination site in a for-profit free standing dialysis unit. Credentialing/Privileging- BAH did not have credentialing/privileges for Telehealth MD’s to give orders within the institution Hardware/Connectivity- Main issues were regarding the quality/reliability of connection with Qualicenters unit. CULTURAL changes (Nursing, Physician, Patient)

Solutions CMS Region X- John Hammerlund: Regional Administrator gave permission for use in Coos Bay as a Medically Underserved Area (MUA) Credentials for BAH developed and advanced through Medical Staff process GCI Connect MD set up secure encrypted conferencing using Vidyo conferencing with T 1 line form dialysis unit. Stakeholder interviews: Nursing at Dialysis unit, BAH inpatient units, BAH Physician leaders, Nephrologists within ESNA, BAH Administration and Patients at dialysis unit

Cultural Change: Multiple meetings with all stakeholders- Nursing staff at Hospital, Dialysis unit Staff, Medical Staff at BAH, not the least of all my partners. Delineate: needs, wants, desires and fears for the process and the associated changes. Describe/Map all the steps within the new necessary process; create written processes to achieve processes and test and re-design as needed. (PDSA cycles). Educational meetings with Nursing staff Grand Rounds/ MEC attendance at BAH Patient concerns/fears addressed 1: 1

Outpatient Dialysis Unit: Fresenius Qualicenters Coos Bay

ESRD Outpatient process: Dialysis Charge nurse moves Telemed cart around room; 3 -way communication with RN, Patient and MD. MD in office has Fresenius EMR live in side by side screen format, for lab, dialysis treatment and medication review. Family at chair-side can also participate if needed. Quality of interaction is vastly superior- much more private and intimate 1: 1 review with patient of their status and concerns. On the spot review of Dialysis Plan of Care for patient; review MSW and Dietician notes. Rounding on Outpatient shift of 18 -20 patients approximately 90120 minutes. 3 shifts daily, 6 days per week.

Inpatient Dialysis

BAH Process: ESRD patients being admitted to hospital via ER- Nephrologist contacted to confirm appropriateness of patient for Tele-dialysis as inpatient. Nephrologist has Veto authority on appropriateness decision. Coordinate treatment time for team interaction. Tele-Med interaction: Patient, Dialysis RN, Floor RN and Nephrologist; often with Hospitalist- live huddle, briefing and treatment plan. Nephrologist has live side by side screen of BAH EMR Nephrologist dictates interaction note/treatment plan into BAH EMR.

BAH Results to date: Live- 7/6/12 To date: 16 unique patients and 29 inpatient dialysis sessions at BAH. Diagnosis for hospitalization: Cellulitis, Pneumonia, Failure to Thrive, Cholecystectomy, ORIF lower extremity fracture and BKA for PVD.

Future: Florence Dialysis Unit- 9 station unit opening 5/1/13; currently not within a MUA therefore may not be viable origination site. Coos Bay- Delineating a methodology for feasible outpatient interactions/ follow-up. Curry County Medical District- Curry General Hospital: discussions regarding dialysis unit associated with the hospital for outpatient dialysis.

Thank You Questions? ?