Walking the walk or just talking the talk: how do we make progress? Richard Fluck Date: 16th March 2016

The strategic challenge Numbers requiring RRT are growing Population is older with more comorbidities Home therapies are in decline – especially PD Economic downturn has implications for healthcare expenditure 19/04/2018 Home Therapies Richard Fluck

UK Renal Registry 16th Annual Report Figure 2.2. Growth in prevalent patients by treatment modality at the end of each year 1997–2012 UK Renal Registry 16th Annual Report 19/04/2018 Home Therapies Richard Fluck

Falling PD UK Renal Registry 16th Annual Report Figure 2.9. Modality changes in prevalent RRT patients from 1997–2012 UK Renal Registry 16th Annual Report 19/04/2018 Home Therapies Richard Fluck

Home Therapies Richard Fluck Rise in home HD Figure 2.10. Detailed dialysis modality changes in prevalent RRT patients from 1997–2012 * Scottish centres excluded as information on satellite HD was not available UK Renal Registry 16th Annual Report 19/04/2018 Home Therapies Richard Fluck

Variation UK Renal Registry 16th Annual Report Figure 2.8. Percentage of prevalent haemodialysis patients treated with satellite or home haemodialysis by centre on 31/12/2012 ∗Scottish centres excluded as information on satellite HD was not available. No centres in Northern Ireland have satellite dialysis units UK Renal Registry 16th Annual Report 19/04/2018 Home Therapies Richard Fluck

Home Therapies Richard Fluck 19/04/2018 Home Therapies Richard Fluck

Home Therapies Richard Fluck Ambitions 3. Self-management: All people with kidney disease are offered as much information as they would like in order to understand and manage their condition. 4. Person-centred care: Care is centred on the person, taking into account individual needs and preferences, quality of life, symptom burden and the presence of co-existing medical conditions. 19/04/2018 Home Therapies Richard Fluck

Home Therapies Richard Fluck 6. Preparation and Choice: All people approaching end-stage renal disease, or moving from one type of treatment for end-stage renal disease to another, understand and are given sufficient time and support to prepare for a treatment that is suitable for them, chosen from the full range of options. 19/04/2018 Home Therapies Richard Fluck

Home Therapies Richard Fluck The House of Care 19/04/2018 Home Therapies Richard Fluck

Commissioning of RRT The base

Home Therapies Richard Fluck Key principles Ensure patient pathway integrity Enable CCGs to better allocate their resources efficiently Move to accountability linked to population outcomes Improve financial incentives for commissioners and providers Offer value across the system and to individuals 19/04/2018 Home Therapies Richard Fluck

But at all times our guiding principle will be: walk in the shoes of the people we serve. Think like a patient, act like a taxpayer Simon Stevens, April 2014, Newcastle

Home Therapies Richard Fluck Reimbursement Short term Mitigate short term issues Long term Process of internal and external consultation Review of pricing engine Challenge re reference costs Renal specific – strategic review of reimbursement structure Incentives? 19/04/2018 Home Therapies Richard Fluck

Service specifications Modality specific Clear pointers to shared care CQUIN re shared care Better metrics 19/04/2018 Home Therapies Richard Fluck

Home Therapies Richard Fluck Specialised status Advantages High costs and complexity Disadvantages Reimbursement structure One aspect of patient pathway Collaborative solution Reintegrate patient pathway Plan A, B and C Reestablish provider networks driven by peer review 19/04/2018 Home Therapies Richard Fluck

Patient participation The left hand wall

Home Therapies Richard Fluck Engaging the patient on multiple levels Carmen, Health Affairs Feb 2013 32:232 19/04/2018 Home Therapies Richard Fluck

Integration Care delivery Location Dependent Independent Home AAPD ?AHHD PD HHD (>4x week) In-centre HD (3x week) Self care HD (3-7x week)

Skills, knowledge and confidence matrix Education, self-awareness, changing beliefs about patient‘s role, self-management support, skills development Skills, knowledge and confidence matrix Interventions High (Clinician support for patient activation) CSPAM scores Changing beliefs about clinician’s role, leadership, skills training e.g. MI, communication, coaching Low Low High PAM scores (patient activation) 19/04/2018 Home Therapies Richard Fluck

Measurement and improvement: the ceiling

Home Therapies Richard Fluck Data Numbers Organisational process Outcomes Clinical Patient centred Value 19/04/2018 Home Therapies Richard Fluck

Survival by Dialysis Modality—Who Cares? All-cause patient mortality rates, overall and by modality, US Renal Data System ESRD Database, 2011. Adjusted for age, sex, race, and primary diagnosis. HD, hemodialysis; PD, peritoneal dialysis. 19/04/2018 Home Therapies Richard Fluck CJASN 2016 ePub Martin B. Lee* and Joanne M. Bargman†

Home Therapies Richard Fluck Value The Renal Alliance: UKRR, PHE, CVIN, RightCare and Commissioning for value 19/04/2018 Home Therapies Richard Fluck

Home Therapies Richard Fluck Recovery time after HD Lindsay Clin J Am Soc Nephrol. 2006 Sep;1(5):952-9. 19/04/2018 Home Therapies Richard Fluck

Home therapies: Patient Quality Markers - Restless legs and depression Jaber Clin J Am Soc Nephrol 6: 1049–1056, 2011 (FREEDOM study group) 19/04/2018 Home Therapies Richard Fluck

The right hand wall: professionals

What do the professional stakeholders need to offer? Leadership: vision, courage and commitment Individual Organisational Expertise Drive improvement – e.g. quality improvement 19/04/2018 Home Therapies Richard Fluck

Home Therapies Richard Fluck Home therapies QI KQuiP Stakeholder led RA, BRS, BKPA, NKF, KRUK, BTS NHS England and home nations Strategic alliance to foster QI 19/04/2018 Home Therapies Richard Fluck

Home Therapies Richard Fluck Improving the pathway Establish an MDT to assess new starters Consider legibility Shared decision making – ?Physician led PD insertion Training Late presentation Perit Dial Int. 2013 May-Jun; 33(3): 233–241. Dialysis Measurement, Analysis and Reporting (DMAR: Oliver Medical Management, Toronto, ON, Canada) 19/04/2018 Home Therapies Richard Fluck

Home Therapies Richard Fluck Home haemodialysis 19/04/2018 Home Therapies Richard Fluck

Home Therapies Richard Fluck Summary 19/04/2018 Home Therapies Richard Fluck

Home Therapies Richard Fluck 19/04/2018 Home Therapies Richard Fluck