Defragmentation of care in complex patients with ESKD improves clinical outcomes.

Objectives: Given the problematic fragmentation of care for patients with end-stage kidney disease (ESKD), a kidney care organization and an integrated health system within a large accountable care organization partnered to best utilize their individual capabilities to collaborate around their shared patients in a coordinated care approach. Ultimately, the goal of the program is to allow care teams to achieve the triple aim of improving the patient experience, improving clinical outcomes, and reducing the total cost of health care.

Study design: This is a retrospective examination of the first year of the Shared Patient Care Coordination (SPCC) program.

Methods: The analysis consisted of 2 parts. First, rates of hospitalizations and emergency department visits were compared between the SPCC patients and other patients of the integrated health system who had ESKD but did not participate in SPCC. Second, rates of clinical indicators-central venous catheter (CVC) use, home dialysis, advance care planning, and missed dialysis treatments-were benchmarked vs normative data taken by bootstrap sampling of the kidney care organization's patient population.

Results: Overall, dialysis patients participating in the SPCC program had a 15% lower rate of hospital admissions than those not participating ( P  = .02). Additionally, the bootstrap analysis showed that by the second year, dialysis patients in the program had favorable rates (above the 95th percentile) of CVC use, dialysis treatment absenteeism, and completion of advance care plans.

Conclusions: Enhanced and structured communication between dialysis providers and patient care teams provides a unique opportunity to coordinate patient-centered care and improve patient outcomes.