Proactively Catching the Declining Patient

The greatest innovations often rest in radical common sense — made after stepping back to identify real problems and deliberately applying viable, sometimes simple, solutions. In light of national and state incentives to improve health care value, health systems have numerous opportunities to implement common-sense care to meet patient needs and these aims. To accomplish this, health system leaders must ask themselves: Why do we currently have processes blind to common-sense problems, why do we lack proactive guidance of patients into appropriate care, and is there more we can do?

For example, it is possible to know when patients with late-stage kidney disease miss dialysis. However, health systems without strategies to capture and act on this information may be allowing these patients to clinically decline until they reappear in the hospital with electrolyte abnormalities or breathing problems. Similarly, it is possible to know when patients on life-saving medications do not pick up prescriptions; yet, often these patients are out of sight until they enter emergency departments in distress.

UCLA Health, motivated by these clinical stories and a need to reduce unnecessary expenditures, aimed to use this common sense in redesigning care for patients with chronic kidney disease. CKD is a leading cause of expenditures nationally with Medicare expenses for CKD beneficiaries (12.5% of total) exceeding $79 billion in 2016, with an additional $35 billion for end-stage renal disease. The UCLA Office of Population Health and Accountable Care leadership realized that there was an opportunity for improvement, as the average expense for kidney injury admissions requiring dialysis topped $42,000 while care centered out of clinic or home was significantly less expensive.

Here, we describe their development of an ambulatory Population Health Value infrastructure to proactively prevent and capture clinical decline among the high-cost population of CKD patients to reduce unnecessary utilization and expenses. Because of the diversity of needs and range of costs associated with different types of kidney care, the organization used a population-based approach that tailored interventions to the needs of subpopulations.


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