kidney patient job retention:

Kidney Patient Job Retention:Kidney Patient Job Retention:The Next Rehab Frontier

Dori Schatell, MS

Medical Education Institute, Inc

Medical Education InstituteMedical Education Institute MEI Mission:

Help people with chronic disease learn to manage and improve their health

MEI has worked on or developed:• Original DOQI guidelines• Life Options™ • Kidney School™• Core Curriculum for the Dialysis Technician• Fistula First• Medicare Dialysis Facility Compare website• Home Dialysis Central

Sen. Hartke Testimony: 1972Sen. Hartke Testimony: 1972

“60% of those on dialysis can return to work but require retraining, and most of the remaining 40% require no retraining whatsoever. These are people who can be active and productive,

but only if they have the

life-saving treatment

they need so badly.”

Life Options Rehabilitation Program

Life Options Rehabilitation Program

Dedicated to helping people live long and live well with kidney disease

65+48%

20-6450%

0-192%

Age of ESRD PatientsAge of ESRD Patients

52% of incident ESRD patients are <65

Data Source: USRDS 2003 ADR, Table C4, Incident ESRD Patients 1995-2002

N= 607,329

Education of ESRD PatientsEducation of ESRD PatientsN = 1599

11%

14.9%

39.4%

20.5%

9.8%3.8%

Schatell D, Klicko K, Becker BN. Am J Kidney Dis. 48(2):285-91, 2006.

Job Loss is the RulePatients Age 18-55 at 90 Days Post Initiation, May 1995-June

2001


2001

138,821

60,713

78,347

87,149117,877

38,256

7,05915,330

0

50,000

100,000

150,000

200,000

250,000

US Census 6 Mo. Prior At Initiation

Working Not Working Missing Data

in thousands

-22,457 jobs-37%

64%

37% 23%

Data Source: USRDS Special Data Request 2003

Job Loss/Disability Can Impoverish ESRD Families

Job Loss/Disability Can Impoverish ESRD Families

Effect of Job Loss on PatientsEffect of Job Loss on Patients

“Hi my name is X, i’ve been on dialysis for 3 years and im only 36 years old. i got it from high blood pressure.

well now i have no friends and im depressed and my life sucks. im a single person with no job and no life. dialysis sucks and i should just die.”

Actual quote from the dialysis_support listserv, March, 2006

Effect of Job Loss on PatientsEffect of Job Loss on Patients

“I've been on hemo for 11 years now. I lost my job at Central Texas College because keeping up with dialysis and my job was just too much. I lost my wife of 22years and 3 children to another man because I began to have sexual difficulties as a result of renal failure, which

by the way, Cialis, Viagra and Levitra just doesn't help. I've developed carpal tunnel syndrome as a result of calcium deposits in the wrists. And then try to live on an SSI payment of $603.00 a month. It isn't easy let me tell you. Since my divorce 7 years ago I have been bouncing between friends. That's no life.”

Actual quote from the dialysis_support listserv, August, 2006

Benefits of Work for PatientsBenefits of Work for Patients Self-esteem Higher income1

Health insurance2

Built-in social outlet Better physical functioning3

1Insurance Information Institute, www.iii.org 2USRDS Special Data Request, May 20, 20033Blake et al. Physical function, employment, and quality of life in end-stage renal disease. J Nephrol 13(2):142-

149, 2000

Functioning & Well-being: PCS + MCS scores

Functioning & Well-being: PCS + MCS scores

Physical Component Summary: PCS

Mental Component Summary: MCS

Employment and FWB Employment and FWB Employment predicted PCS and MCS in

African American CKD patients

Kusek et al. Cross-sectional study of health-related quality of life in African Americans with chronic renal insufficiency: The African American Study of Kidney Disease and Hypertension Trial. Am J Kidney Dis 39(3):513-524, 2002

FWB Scores Predict Morbidity & MortalityFWB Scores Predict Morbidity & Mortality

1 Point in MCSMortality rate 0.46%Hosp. rate 0.23%

Lowrie EG et al. Medical Outcomes Study Short Form-36: A consistent and powerful predictor of morbidity and mortality in dialysis patients. Am J Kidney Dis 41(6):1286-1292, 2003.

1 Point in PCSMortality rate 0.43%Hosp. rate 0.43%

Benefits of Work for Providers:

Benefits of Work for Providers:

Renal Community

Medicare~ $130 pertreatment+ meds

EGHPs~ $350 per treatment+ 4x meds

Two Dialysis Revenue Streams

Payer Mix & Dialysis Revenues

Payer Mix & Dialysis Revenues

Payer Mix: Community-wide Dialysis Revenue Sources

Clinic Revenue Per Patient/YearMedicare-only vs. Employer Group Insurance

Clinic Revenue Per Patient/YearMedicare-only vs. Employer Group Insurance

$17,940

$54,600

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

80% Medicare @ $115/Rx If EGHP @ $350/Rx

+$36,660

1-year Impact: Pt. Job Retention vs. Composite Rate

1-year Impact: Pt. Job Retention vs. Composite Rate

Increased revenue to the renal community of a 2.0% composite rate increase for 377,313† patients:

$135 million First-year revenue to the renal community if previously-

working patients kept working*: $183 million

*6,922 patients in 2002 were working 6 months prior & not at initiation†2005 projected population assuming 7% growth/year


2001


2001

138,821

60,713

78,347

87,149117,877

38,256

7,05915,330

0

50,000

100,000

150,000

200,000

250,000

US Census 6 Mo. Prior At Initiation

Working Not Working Missing Data

in thousands

-22,457 jobs-37%

64%

37% 23%

Data Source: USRDS Special Data Request 2003

How Do We Keep Patients Working?

To Keep Patients Working…To Keep Patients Working…

Reach patients early with information Treat predialysis anemia Offer work-friendly treatments Create an expectation that work is possible

Reach Patients Early with Information

Reach Patients Early with Information

% of patients who get predialysis education?

?

How Can Networks Reach Patients Early?

How Can Networks Reach Patients Early?

Partner with:• QIOs• Industry• Media• Centers for Disease Control & Prevention• Nephrologists• Voluntary organizations

Treat Predialysis AnemiaTreat Predialysis Anemia

“Not being able to get up in the morning and be awake— it almost feels like you need another 2 or 3 hours of sleep. And when you get home from work or from a dialysis treatment, you’re not just tired, you’re utterly exhausted. So it’s not like you come home and do something else. You come home and sleep.”


“I finished my garage—I put up some pegboard and some insulation. It took several weekends because I couldn’t do it myself; I had a helper come over. And at 40 [Hct], I could hammer nails. At 36, I couldn’t. I’d take 2 or 3 swats at the nail and then I’d be

winded. That’s kind of incredible, isn’t it?”


“I have pretty good energy and I play 9 holes of golf, but when it [Hct] gets below a certain level, my energy is shot. I’ll walk to the mailbox, which is about 50 feet, and I’ll have to stop and rest a while.”

Offer Work-Friendly Treatments Offer Work-Friendly Treatments

Chi Square 247.711756752216, df = 2, p≤ 0.001Data Source: USRDS Special Data Request 2003

Patients Age 18-55 at 90 Days Post Initiation, May 1995-June 2001

Offer Work-Friendly TreatmentsDialysis “Choices” 2003 N = 324,826

Offer Work-Friendly TreatmentsDialysis “Choices” 2003 N = 324,826

Center HD92%

Home Hemo0.3%

All PD8%

Unknown0%

USRDS 2005 Annual Data Report, Table D.1

Patients Not Told All Options: 1997


Before their first treatment Patients told of in-center hemo: 89.7% In-center patients told of HHD: 24.6% In-center patients told of PD: 25.1%

USRDS 1997 Annual Data Report, USRDS Dialysis Morbidity and Mortality (Wave 2), p. 53.



Among all incident patients in California: Patients not aware of PD: 66% Patients not aware of home hemo: 88% Patients not aware of transplant: 74%

Mehrotra R et al, Kidney Int 2005 Jul;68(1)378-90.

What Makes a Treatment Work-Friendly?

What Makes a Treatment Work-Friendly?

Flexible or patient-centered schedule Fewer symptoms & hospitalizations Less restricted diet & fluids

Communicate the Relative Burdens of Dialysis

Communicate the Relative Burdens of Dialysis

No schedule control Strict diet/fluid limits “Dialysis hangover” Other patient deaths Travel to/from clinic Time off work/school No choice of stick-er Travel planning…

Putting in needles Dialysis emergencies Order/store supplies Space for equipment Wiring/plumbing Doing treatments Alarms at night Troubleshooting

In-Center Home

No normal range of ECV, K, Bicarb, P, Ca, pH

Physiology of 3x/week Hemodialysis

1 2 3 4 5 6 7

Normal range of ECV, K, Bicarb, P, Ca, pH

Physiology of Daily Dialysis

1 2 3 4 5 6 7

Work-friendly Treatments: CAPD

Work-friendly Treatments: CAPD

Training takes 1 week Patient sets schedule Preserves residual renal

function longer Transplant is more likely 1,549 US clinics

Work-Friendly Treatments: CCPD

Work-Friendly Treatments: CCPD

Abdominal catheter needed Cycler does exchanges Possible manual exchange/day Training: 1-2 weeks 1,524 US clinics

Fresenius NewtonIQ Cycler

Fresenius Freedom Cycler

Baxter HomeChoice Pro

Baxter HomeChoice

z

What Patients Say About PDWhat Patients Say About PD

"PD and work go well together. I feel fine after doing my exchange. PD is closer to what I

want out of life.”

“I thought about doing hemodialysis at the dialysis center, but the people looked so wiped

out after their dialysis. Plus, I didn't have the time to go in there 3 times a week. I've got

work to do!”

"I am so afraid of needles. I was only a little kid when I had my first needles and problems with

my fistula. If you have to do dialysis, this is the way to go!"

Connie

Mary Ann

Tish Sandoval

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Work-Friendly Treatments: Daily Home Hemo

Work-Friendly Treatments: Daily Home Hemo

2-2.5 hrs, 5-7 times/week Training 2-8 weeks Trained partner needed 132 US clinics

Aksys PHD NxStageSystem One

RenalSolutionsAllient Sorbent

What Patients Say About Daily Home Hemo

What Patients Say About Daily Home Hemo

"I feel so much better. I dialyze seven times a week."

“I feel great now! I have no up-and-down days and I feel very similar to

when I had no kidney failure.”

"People shouldn't live to dialyze but to have a life and do the things they were

meant to do."

Dadi Ding

Jake Casey

Bill Peckham

Work-Friendly Treatments:Nocturnal Home Hemo

Work-Friendly Treatments:Nocturnal Home Hemo

Done 7-8 hours, 3-6 nights/week Training takes 4-8 weeks Trained partner is needed 127 US clinics

What Patients Say About Nocturnal Home Hemo

What Patients Say About Nocturnal Home Hemo

"Now, I am able to work full time and fit my treatments into my life!”

“On in-center dialysis, I felt like I was in

prison. I couldn't eat a tomato, eat cheese, or drink milk. Now, you have control. You have

your life back.”

“People who don't know that I'm on dialysis can hardly even tell that I'm sick."

Melissa Bensouda

Sarah Taxman

Wanda Wilson



How Can Networks Offer Work-Friendly Treatments?

How Can Networks Offer Work-Friendly Treatments?

Include information in patient & professional newsletters & meetings

Track & report availability by Network Gather thought leaders & practitioners





US: NHHD US: DHHD

Create An Expectation ThatEmployment is Possible

Create An Expectation ThatEmployment is Possible

Share success stories in newsletters or bulletin board displays

Track & report employment data Include job retention as a topic in meetings

& QI initiatives Offer Life Options Patient Interest

Checklists (www.lifeoptions.org)

Conclusions Conclusions

Job loss is the rule—but job retention benefits patients, clinics, & the government

Half of all ESRD patients are working-age ESRD Networks can help by:

• Reaching patients early with information• Encouraging treatment of predialysis anemia• Offering work-friendly treatments• Creating an expectation that work is possible

kidney patient job retention:

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