Abstract: SA-OR036

Impact of Transition of Care Visits on Readmission Rates in Dialysis Patients

Session Information

Category: Dialysis

  • 607 Dialysis: Epidemiology, Outcomes, Clinical Trials - Non-Cardiovascular

Authors

  • Ketchersid, Terry L., Fresenius Medical Care North America, Waltham, Massachusetts, United States
  • Alanis, Anna, Fresenius Health Partners, Austin, Texas, United States
  • Maddux, Franklin W., Fresenius Medical Care North America, Waltham, Massachusetts, United States
  • Martin, Michael P., Fresenius Health Partners, Austin, Texas, United States
  • Geary, Daniel E., Fresenius Health Partners, Austin, Texas, United States
  • Garza, Greg S., Fresenius Health Partners, Austin, Texas, United States
  • Radonova, Maria, Fresenius Health Partners, Austin, Texas, United States
  • Reviriego-Mendoza, Marta, Fresenius Medical Care North America, Waltham, Massachusetts, United States
  • Larkin, John W., Fresenius Medical Care North America, Waltham, Massachusetts, United States
  • Usvyat, Len A., Fresenius Medical Care North America, Waltham, Massachusetts, United States
  • Richmond, Chris, Fresenius Health Partners, Austin, Texas, United States
Background

End stage renal disease (ESRD) patients discharged from an acute care facility have 30-day readmission rates that approach 30% (USDS, 2015). In a fee for service environment, the Centers for Medicare & Medicaid Services (CMS) Transitional Care Management Services cannot be submitted by a physician billing for ESRD Monthly Capitation Payment services. Through the Comprehensive ESRD Care (CEC) Model, FMCNA has partnered with CMS to identify, test, and evaluate new ways to improve care for Medicare beneficiaries with ESRD. Utilizing the ESRD Seamless Care Organization (ESCO) care coordination waiver, we hypothesized that nephrology providers could feasibly conduct ESRD specific Transition of Care (TOC) visits that would lower readmission rates. We are obligated to disclose that the statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.

Methods

We established an ESRD specific TOC template. Nephrology providers were paid a care coordination fee for completing the TOC within 14 days of discharge. We analyzed claims data from May-2016 to Dec-2016 using a 3 month claims run out for 6 ESCOs representing 7,248 discharges. We determined the frequency of TOC visits conducted by the nephrology practice within 14 days of discharge. We measured 30-day readmission rates for each ESCO for the patients who had a TOC visit within 14 days of discharge.

Results

Completion of the TOC visits varied among the 6 ESCOs from a low of 11% to a high of 36%; TOC completion rates were inversely correlated with the ESCOs number of discharges (correlation coefficient -0.95). Among 5 ESCOs, 30-day readmission rates were 0.6% to 4.2% lower in patients who received a TOC visit; at one ESCO there was 0.9% increase.

Conclusion

Conducting a formal TOC visit within 14 days of discharge is associated with reductions in 30-day readmission rates. Smaller ESCOs completed TOC visits at a higher rate as compared to larger ESCOs.

Funding

  • Commercial Support