Chronic kidney disease (CKD) is growing in prevalence, impacting more than 37 million Americans. More than 100,000 of these patients begin dialysis each year and 20% of those diagnosed die from the disease or its complications. At an annual cost of $114 billion annually, CKD is one of the most expensive chronic illnesses.
Because chronic kidney disease progresses through stages, Nephrologists provide ongoing monitoring, care coordination, and symptom management throughout a patient’s CKD journey. Much of that non-clinical time has traditionally been unpaid.
About 15% of Medicare recipients live with CKD. Through Medicare programs such as Principal (PCM), Chronic Care Management (CCM) and Remote Patient Monitoring (RPM), nephrologists can implement a team-based approach to care coordination that achieves six objectives:
- Improves population health management and clinical outcome measures
- Streamlines care to maximize efficiency at scale
- Provides reimbursement for previously-unbillable time
- Simplifies managing rising-risk and complex patients
- Enhances coordination and communication with other clinicians
- Improves patient experience, satisfaction, and quality of life
When combined, CCM and RPM provide physicians and their care teams with timely data, evidence-based assessments, and a care coordination structure yielding clinical, operational, and financial benefits.
CKD treatment powerhouse: Chronic Care Management plus Remote Patient Monitoring
As Figure 1 shows, chronic kidney disease is a five-stage illness.
Figure 1: Five stages of CKD progression from early to late stage disease.
The nephrologist’s goal is four-fold:
- Improve kidney function and manage current symptoms
- Prevent exacerbations and disease progression
- Maintain current kidney function as long as possible, particularly in stages 3a/3b
- Support patient self-management and quality of life
As a proactive, evidence-based approach, CCM and RPM go beyond the traditional model that relies on fee-for-service, singular clinician oversight, in-clinic, and face-to-face interactions.
Early detection and diagnosis: Helps to ensure that patients at risk of CKD are identified early through regular screenings and assessments, especially for those with risk factors such as diabetes, hypertension, and family history of kidney disease. Early detection allows for timely interventions to slow disease progression and prevent complications.
Optimal management of CKD progression: Regularly monitoring patients' kidney function, blood pressure, proteinuria, and other relevant parameters. By facilitating communication and collaboration among healthcare providers, care coordination ensures that CKD patients receive guideline-directed management, including blood pressure control, medication optimization, lifestyle modifications, and specialist referrals as needed.
Prevention of complications: Coordinated care ensures that CKD patients receive preventive interventions to reduce the risk of complications, such as cardiovascular disease, anemia, bone mineral disorders, and electrolyte imbalances. This may include vaccinations, nutritional counseling, smoking cessation support, and management of comorbid conditions.
Medication management and adherence: Includes reconciling medications, identifying potential drug interactions, and ensuring that CKD patients understand their medication regimens. By promoting medication adherence and addressing medication-related issues, care coordination helps improve CKD quality measures related to medication management and patient safety.
Patient education and self-management support: Provide CKD patients with education about their condition, treatment options, self-management strategies, and the importance of adhering to medical recommendations. Empowering patients to actively participate in their care and make informed decisions can lead to better outcomes and patient satisfaction.
Transitions of care: Enables smooth transitions between healthcare settings, from hospital to home or primary care to specialty care. Effective communication and care planning during transitions help prevent gaps in care, medication errors, and avoidable readmissions, ultimately improving CKD quality measures related to care transitions and hospital utilization.
Reduced hospitalizations and emergency room visits: Continuous monitoring of CKD patients remotely can help prevent acute exacerbations of their condition, reducing the need for hospitalizations or emergency room visits. This improves the patient's quality of life and reduces healthcare costs.
Patient quality of life, convenience, and satisfaction: Regular touchpoints help patients manage symptoms better. Remote monitoring allows CKD patients to receive care from the comfort of their homes, reducing the need for frequent clinic visits. This can be particularly beneficial for patients who live in rural or underserved areas or those with mobility issues.
Quality reporting and performance measurement: Facilitates collection and documentation of relevant data needed for quality reporting and performance measurement in CKD care. This includes tracking key indicators such as estimated glomerular filtration rate (eGFR), albuminuria, blood pressure control, and achievement of treatment targets, which are essential for evaluating the effectiveness of care delivery and identifying areas for improvement.
ThoroughCare enhances the management of chronic kidney disease
ThoroughCare’s care coordination platform simplifies launching, managing, and scaling a Chronic Care Management program that can be seamlessly combined with a Remote Patient Monitoring program.
It provides one place to manage all patients enrolled in care management or RPM programs. While ThoroughCare can integrate with EHRs, it can stand alone as a comprehensive, team-based care coordination, education, and analytics platform.
Our software tool empowers the nephrology specialist and their care team to confidently manage more patients while reaping reimbursement for previously unbilled services. ThoroughCare provides everything needed to start with a small patient cohort and easily expand and bill as the program grows.
Principal and chronic care coordination capabilities
Evidence-based care guidelines: ThoroughCare's CCM services are guided by evidence-based care guidelines and best practices in nephrology, supporting comprehensive disease and medication management.
Proactive monitoring, intervention, and analytics: Proactively monitor patients' health status, track symptoms, and intervene early to prevent disease progression and complications. When combined with RPM, care teams can receive automatic alerts when readings are out of range.
Multidisciplinary team collaboration: Facilitate harmonious communication and task management among internal and external care teams.
Lifestyle modification and goal-oriented care: Leverage integrated, evidence-based education to keep staff up-to-date and empower patients to self-manage, make informed decisions, and adopt healthy behaviors like dietary changes, stress management techniques, and exercise recommendations.
Quality and billing reporting made easy: ThoroughCare automates quality, time logging, and billing reporting for reimbursement, quality performance, and regulatory compliance.
The power of ThoroughCare comes from the straightforward way that care teams can launch new care management programs by simply enrolling existing patients or entering/uploading new patients into a new program. When combined, CCM and RPM create a powerhouse for comprehensive coordination and personalized patient care.
Learn more about Medicare’s CCM program, requirements, and billing rates.
Remote Patient Monitoring capabilities
Real-time health monitoring & early detection: Remotely monitor patients' vital signs, symptoms, and disease progression in real time. Detect potential complications and intervene to prevent adverse health events.
Enhanced patient engagement: Use data to engage patients in their care, empowering them to manage their health and adhere to treatment plans actively.
Customizable monitoring parameters: Tailor monitoring parameters based on individual needs and conditions, ensuring data is relevant and actionable.
Data-driven decisions: Have reliable and timely data that inform clinical decision-making, treatment adjustments, and personalized care plans.
Learn more about Medicare’s RPM programs, requirements, and billing rates.
Maximize impact by combining RPM and CCM
Nephrologists manage more complex patients who live with chronic kidney disease and are at risk for other chronic diseases and complications. ThoroughCare is a platform that equips specialists and care teams with evidence-based care coordination capabilities. The software provides comprehensive clinical, operational, and financial capabilities when used through a Medicare care management or RPM program.
