How Renal Care Coordinators Support Value-Based Kidney Care

Dr. William McElhaugh says Interwell Health’s embedded renal care coordinators (RCCs) are key to succeeding in value-based kidney care programs. At his Philadelphia-based practice, which is part of the Kidney Care Specialists (KCS) group, RCC Jane Wardrip has built close relationships with her patients with chronic kidney disease (CKD) and their families to help improve treatment compliance, increase optimal start rates, and decrease hospitalizations.

In this Q&A, Dr. McElhaugh and Jane discuss the role of RCCs in supporting patient care, how value-based kidney care improves patient outcomes, and advice for practices that are just getting started in value-based care models.

Q: Dr. McElhaugh, tell us about your experience at Kidney Care Specialists. How has your practice changed during your time there?

WM: Taking a look back, 20 years ago we were a group of six physicians practicing as Delaware Valley Nephrology. We then combined with three other practices to form KCS and enroll in the government’s kidney care model at the time. Since then, two other groups have signed on.

When I joined, there weren’t many nurse practitioners in the nephrology field. Five or six years ago, our practice hired our first nurse practitioner. We are up to three now, while some of the other practices in KCS have more. We also have an embedded RCC, a dietitian, and a kidney care advocate (KCA).

A lot has changed since I began practicing 21 years ago. We still look at things like blood pressure and creatinine, but now there are a lot of other variables, and it can seem almost impossible to cover everything you need during a 20-minute visit. The biggest changes are the measures for increasing optimal starts and decreasing hospitalizations, and RCCs are essential for supporting both.

Q: When did you decide to embed an RCC in your practice?

WM: We decided to bring in an RCC when we first partnered with Interwell in the current government value-based kidney care program. To be honest, without an RCC I don’t know how this program would work, because the RCCs do so much in terms of increasing optimal starts and engaging family members.

In the past, we might talk to a patient about seeing a surgeon to get an access placed and when we ask if they saw the surgeon in their next appointment — which might be in six weeks or not for another three months, depending on their stage — they’d say they forgot to call. Then six weeks would turn into six months, and nothing would be done. We don’t always have the time to call patients between visits, and the RCCs are very good at staying in close contact and ensuring everything gets done. They are essential for getting family members involved, reminding patients, coordinating with the vascular surgeon’s office, and helping set up appointments.

Being embedded in our office helps Jane build strong relationships with our patients, who often jump into her office to talk after their appointments. We’re much more conscious now of trying to make sure our patients have their access in place, and with an RCC we have seen an improvement in compliance and outcomes.

I work with Jane all the time and she’s fantastic, and from what I hear from the other physicians they’re really happy with all of their RCCs.

Q: Jane, can you give us an idea of how you support the KCS practice?

JW: I was the first RCC for the Delaware Valley practice at KCS. I support 300 to 350 patients, including all our patients in the government value-based care program. I mostly support patients who have CKD stage 4 or 5, and I’m focused heavily on optimal starts and care coordination.

When our patients come in, they often have little to no education on CKD. I reinforce the education provided by our KCA to help them understand the stages and ensure they have the information they need to choose the modality that will work best for them and their lifestyle. I educate on transplant — I have been in nursing for 30 years and have a transplant background — and if patients decide to start home or in-center dialysis I talk to them about what to expect.

I let people talk. I don’t care if they want to talk about something silly to start. Talking creates a bond that helps people open up for what can be difficult conversations about the decisions they need to make for the future. I meet patients where they are and try to use different tools and resources to help them understand their disease and options.

Everybody’s goal is prolonging the life of the kidneys. That’s the patient’s goal, the doctor’s goal, and mine. But as I explain to our patients, even if they might not feel bad now, when they do start to experience symptoms, things can happen quickly, and they might not have time to prepare. If you end up in the ER and you haven’t prepared, your choices are taken away from you.

Q: How would you describe KCS’s transition to a value-based care model, Dr. McElhaugh?

WM: We’ve been partnering with Interwell since the very beginning. It would be difficult to do a value-based care program without a partner like Interwell to determine and then take on some of the risk — I don’t know how even a large private practice would be able to manage that themselves.

We also use Acumen Epic Connect, Interwell’s electronic health record system, which allows us to see patients’ medical histories to ensure that they are risk stratified properly, which you need to do to be successful in a value-based program. If you only have a 20-minute visit with a patient who has advanced kidney disease, there are a lot of other things you want to focus on that center on their kidney disease, and you don’t want to spend ten minutes asking about different conditions. With Acumen, the list of comorbidities is right there to easily document everything that’s needed.  

Q: Jane, how do you see KCS’s value-based kidney care approach helping patients?

JW: One patient who stands out to me is a woman in her seventies who was just a picture of health. She was working, she regularly played pickleball, and she was managing her CKD. Then she got COVID and that turned into pneumonia. She had to start taking her CKD more seriously and finally had her access placed but was hesitant to start dialysis. I spent extra time talking to her about what to expect and she recently started home dialysis and is doing well.

It’s hard to hear you have a chronic disease that you are never going to cure, you are only going to be able to manage, and managing the disease isn’t easy. There can be so much denial. Being in a value-based kidney care model, we talk to patients about everything in their lives, and that makes it easier and possible for them to manage their disease. I recently talked to one of our patients about resources to help him find an apartment. He was optimistic that things would change for the better.

Q: One last question for you, Dr. McElhaugh. For a nephrology practice that is thinking about making the transition to value-based care, where do they get started?

WM: Medicare Advantage plans are all starting to go into value-based programs, and the problem is that many doctors are reluctant to change, and they don’t want to pay to plan for change. My advice is don’t try to do it yourself. Get into a relationship with a partner like Interwell that provides the resources and support you’ll need to be successful in value-based kidney care.