Understanding Care Coordination & Its Value

Most of us have heard of “care coordination” but may not know why it’s needed, why it’s difficult to achieve, or what kind of impact it can have on a patient’s life. Here, we look at an example of how care coordination helped a kidney disease patient live better and stay out of the hospital.

Difficulties facing highly complex patients—like kidney patients

Patients with multiple comorbidities and complex health conditions must often manage an overwhelming amount of “dos” and “don’ts,” medications, appointments, other health conditions, social determinants of health, and more—making it difficult to deal with them all. People with kidney failure fall into this group. With less than 15% kidney function (considered kidney failure or end stage kidney disease (ESKD)), these patients do not have the ability to remove waste and toxins from their blood. Without kidney function, these patients’ lives revolve much around managing their condition with dialysis treatments, medications and strict dietary guidelines critical to avoiding severe complications and hospitalization.

Case study: identification, alignment and intervention

In the case of one ESKD patient, a patient of Revere Health and DaVita Kidney Care, the patient was not adhering to a kidney diet—resulting in dangerous phosphorous and potassium levels in the blood. As a patient of both health care providers, the patient was part of the Shared Patient Care Coordination (SPCC) program which enables the two providers to communicate and collaborate in their care. When the patient’s blood work was evaluated at their DaVita dialysis clinic (part of regular dialysis patient care), the care team identified the concerning phosphorus and potassium levels.

After investigating and learning that the patient’s diet was to blame for the dangerous blood-nutrient levels, the DaVita team escalated the findings to the SPCC program care coordinator. That coordinator communicated with both teams to ensure all providers were aware and aligned on intervention. On the DaVita side, a DaVita dietitian communicated with the patient and patient’s care partner to stress the importance of following a kidney diet, such as avoiding convenience foods (which are high in phosphorus) and using food preparation techniques (such as boiling potatoes) to reduce potassium levels. On the Revere Health side, the team had the patient’s nurse practitioner reach out to the patient, re-engaging the patient with their total care plan and providing additional education on why elevated labs increase the risk for hospitalization.

Care coordination success in a fragmented health care system

Because highly complex patients receive care from multiple providers, and the current health care system lacks broad interoperability (the ability of different information systems to share and integrate data for coordinated use), these providers may or may not be informed of or aligned on each other’s treatment. Under the SPCC program, Revere Health and DaVita received real-time patient updates and coordinated their care across different specialists to help the patient receive holistic care, become adherent with their care plan and avoid hospitalization. Together, Revere Health and DaVita successfully educated the patient on the importance of maintaining normal phosphorous and potassium levels. The patient appreciated the extra support and followed the guidance—now living healthier and with significantly less risk for hospitalization.

This scenario shows how care coordination programs provide a unique level of personalized care, total care team care, as well as the results that can be achieved when patients engage with their care. Ideally, more care coordination programs such as the SPCC will become commonplace in caring for all patients while interoperability capabilities grow across the entire health care system.

For more information on Revere Health’s nephrology services, visit: https://reverehealth.com/specialty/nephrology/

For more information on DaVita’s kidney care services and partnerships, visit: https://www.davita.com/