Walking the walk or
just talking the talk:
how do we make
progress?
Richard Fluck
Date: 16th March 2016
The strategic challenge
• Numbers requiring RRT are growing
• Population is older with more comorbidities
• Home therapies are in decline – especially PD
• Economic downturn has implications for healthcare
expenditure
19/04/2016
Home Therapies Richard Fluck
2
Figure 2.2. Growth in prevalent patients by treatment modality
at the end of each year 1997–2012
19/04/2016
UK Renal Registry 16th Annual Report
Home Therapies Richard Fluck
3
Falling PD
Figure 2.9. Modality changes in prevalent RRT patients from 1997–2012
19/04/2016
UK Renal Registry 16th Annual Report
Home Therapies Richard Fluck
4
Rise in home HD
Figure 2.10. Detailed dialysis modality changes in prevalent RRT patients from 1997–2012
* Scottish centres excluded as information on satellite HD was not available
19/04/2016
UK Renal Registry 16th Annual Report
Home Therapies Richard Fluck
5
Variation
Figure 2.8. Percentage of prevalent haemodialysis patients treated with satellite
or home haemodialysis by centre on 31/12/2012
∗Scottish centres excluded as information on satellite HD was not available.
No centres in Northern Ireland have satellite dialysis units
19/04/2016
UK Renal Registry 16th Annual Report
Home Therapies Richard Fluck
6
19/04/2016
Home Therapies Richard Fluck
7
Ambitions
• 3. Self-management: All people with kidney disease are offered as
much information as they would like in order to understand and
manage their condition.
• 4. Person-centred care: Care is centred on the person, taking into
account individual needs and preferences, quality of life, symptom
burden and the presence of co-existing medical conditions.
19/04/2016
Home Therapies Richard Fluck
9
• 6. Preparation and Choice: All people approaching end-stage renal
disease, or moving from one type of treatment for end-stage renal
disease to another, understand and are given sufficient time and
support to prepare for a treatment that is suitable for them, chosen
from the full range of options.
19/04/2016
Home Therapies Richard Fluck
10
The House of Care
19/04/2016
Home Therapies Richard Fluck
11
Commissioning of
RRT
The base
Key principles
•
•
•
•
•
Ensure patient pathway integrity
Enable CCGs to better allocate their resources efficiently
Move to accountability linked to population outcomes
Improve financial incentives for commissioners and providers
Offer value across the system and to individuals
19/04/2016
Home Therapies Richard Fluck
13
But at all times our guiding principle will
be: walk in the shoes of the people we
serve. Think like a patient, act like a
taxpayer
Simon Stevens, April 2014, Newcastle
Reimbursement
• Short term
• Mitigate short term issues
• Long term
•
•
•
•
•
Process of internal and external consultation
Review of pricing engine
Challenge re reference costs
Renal specific – strategic review of reimbursement structure
Incentives?
19/04/2016
Home Therapies Richard Fluck
15
Service specifications
• Modality specific
• Clear pointers to shared care
• CQUIN re shared care
• Better metrics
19/04/2016
Home Therapies Richard Fluck
16
Specialised status
• Advantages
• High costs and complexity
• Disadvantages
• Reimbursement structure
• One aspect of patient pathway
• Collaborative solution
• Reintegrate patient pathway
• Plan A, B and C
• Reestablish provider networks driven by peer review
19/04/2016
Home Therapies Richard Fluck
17
Patient
participation
The left hand
wall
Engaging the patient on multiple levels
Carmen, Health Affairs Feb 2013 Home
32:232
19/04/2016
Therapies Richard Fluck
19
Integration
Care delivery
Location
Dependent
Independent
Home
AAPD
?AHHD
PD
HHD (>4x week)
In-centre
HD (3x week)
Self care HD (3-7x
week)
Education, self-awareness, changing beliefs
about patient‘s role, self-management
support, skills development
Skills, knowledge and
confidence matrix
CSPAM scores
(Clinician support
for patient
activation)
High
Low
Low
High
Changing beliefs about clinician’s role,
leadership, skills training e.g. MI,
communication, coaching
Interventions
PAM scores (patient activation)
19/04/2016
Home Therapies Richard Fluck
23
Measurement
and
improvement:
the ceiling
Data
• Numbers
• Organisational process
• Outcomes
•
Clinical
•
Patient centred
•
Value
19/04/2016
Home Therapies Richard Fluck
25
Survival by Dialysis Modality—Who Cares?
All-cause patient mortality rates, overall and by modality,
US Renal Data System ESRD Database, 2011. Adjusted for age, sex,
race, and primary diagnosis. HD, hemodialysis; PD, peritoneal dialysis.
19/04/2016
Home Therapies Richard Fluck
CJASN 2016 ePub Martin B. Lee* and Joanne M. Bargman†
26
Value
The Renal Alliance: UKRR, PHE, CVIN, RightCare and Commissioning for
value
19/04/2016
Home Therapies Richard Fluck
27
Recovery time after HD
19/04/2016
Lindsay Clin J Am Soc Nephrol.
2006
Home Therapies Richard
FluckSep;1(5):952-9.
28
Home therapies: Patient Quality
Markers - Restless legs and depression
19/04/2016
Jaber Clin J Am Soc Nephrol 6: 1049–1056, 2011
(FREEDOM study group)
Home Therapies Richard Fluck
29
The right hand
wall:
professionals
What do the professional stakeholders
need to offer?
• Leadership: vision, courage and commitment
•
Individual
•
Organisational
• Expertise
• Drive improvement – e.g. quality improvement
19/04/2016
Home Therapies Richard Fluck
31
Home therapies QI
• KQuiP
•
Stakeholder led
•
RA, BRS, BKPA, NKF, KRUK,
BTS
•
NHS England and home
nations
•
Strategic alliance to foster
QI
19/04/2016
Home Therapies Richard Fluck
32
Improving the pathway
•
•
•
•
•
•
•
Establish an MDT to assess
new starters
Consider legibility
Shared decision making –
?Physician led PD insertion
Training
Late presentation
Perit Dial Int. 2013 May-Jun; 33(3): 233–241.
19/04/2016
Dialysis Measurement, Analysis and Reporting (DMAR: Oliver
Medical Management, Toronto, ON, Canada)
Home Therapies Richard Fluck
33
Home haemodialysis
19/04/2016
Home Therapies Richard Fluck
34
Summary
19/04/2016
Home Therapies Richard Fluck
35
19/04/2016
Home Therapies Richard Fluck
36