Renal Nurse Navigator Vickie (Trang) Luu calls patients every day to help them manage their kidney failure or sign them up for the WellMed renal disease program. This call was different. The woman she was trying to enlist in the program was short of breath and experiencing chest pain. Vickie immediately offered to get her help, but the patient hung up.

Vickie began calling the patient’s sister and asked fellow Renal Nurse Navigator Anjannette Scott to call the patient again. Anjannette called the patient repeatedly until she finally answered. Again, she declined help. “She sounded so weak and breathy, but she wouldn’t allow me to call 911,” Anjannette said. “She said she would get a family member to take her to the hospital.”

Finally, the patient’s sister contacted Anjannette, who explained the situation and stressed the importance of getting her sister to the PCP that day, urgent care or the emergency room.

The patient’s sister called EMS. The patient was admitted to the hospital with acute pulmonary edema, a life-threatening buildup of fluid in the lungs. In this case, the cause was end-stage renal disease.

Kidney failure is serious business

At WellMed, care teams work diligently to ensure the sickest patients are seen at least once a month to receive the acute care they need. Patients with chronic kidney disease fall into this category.

The WellMed renal care program is comprised of a specialized team focused on supporting the holistic needs of patients with disease education, coordination with PCP and nephrologist, alignment to address multiple health conditions and various social needs.

A business need, a patient need

Dr. Lynn Lester, WellMed care and value medical director for the North Texas market, and Tracy Dohogne, SVP of enterprise case management and specialty services, developed the program, starting with 1,620 patients and a small group of specialty trained care management nurses in 2021. The program has expanded to an enterprise-led renal program focusing on more than 14,000 patients (non-concurrent) with end-stage renal disease.

“Before 2021, most Medicare beneficiaries with end-stage renal disease (ESRD) were unable to enroll in private Medicare Advantage (MA) plans,” Dr. Lester said. “However, a new federal law, the 21st Century Cures Act permitted these patients to enroll in MA plans effective January 2021, so it became a need for us to develop a program to help ensure these patients receive the intense care they need.”

The program goals, Dr. Lester says, are to ensure all of the patient’s needs are met and care is not fragmented. “This is our One Team model in action,” she said. “We want to close quality gaps and improve the patient experience.”

What do we mean by ESRD?

ESRD is the final, permanent stage of chronic kidney disease, where the kidneys can no longer function on their own. While end stage may sound daunting, patients on dialysis can live a quality life with appropriate and regular care.

How does the program work?

“Helping patients get the care they need so they can have a quality life is what we’re all about,” said Karyn Scott, director of care management, who oversees the renal program.

The team uses claims information to identify qualifying patients. A nurse navigator will study the patient’s file and call to offer help. Once a patient agrees to enroll in the program, the nurses make arrangements to ensure the patient has everything he or she needs.

Patient advocates at no cost

The program is offered at no cost to patients. “We are here to help patients and be their advocate,” Karyn said. “We let them know they can turn to the nurse for help with anything including connection to a social worker, medication help, transportation, palliative home health, transplant support, hospice needs, and communications with the PCP, nephrologist and dialysis center.”

Success: getting patients to the doctor, navigating care

Since its inception just a few short years ago, the program has helped thousands of patients receive the care they need – care they may have not known they needed.

“One of the great results of this program is we have been able to get these patients in to see a primary care physician (PCP) and make sure they build relationships with WellMed,” Dr. Lester said. “It’s also important they see a nephrologist, but a doctor who is focused on treating kidney disease may not be looking at all of the issues a PCP will treat. It’s a huge success that we’ve been able to get so many of them back to the PCP.”

Dr. Jason Nichols, care and value medical director in Houston, co-leads the renal program. His market includes the highest-need patients in the WellMed enterprise. “We see so many patients who have co-morbidities like diabetes or high blood pressure, which are the two most common causes of kidney disease,” he said. “It can be very confusing and frustrating for these patients to navigate all they need to do to take care of themselves. We’re here to help them do that.”

The renal specialty care program has made great strides in helping patients stick with their program of regular care. “We help get obstacles out of their way by helping them navigate a complex situation,” Dr. Nichols said. “These patients not only have multiple medical needs, many have sometimes daunting social needs such as food and transportation. Our program helps them with all of that, so overall we have coordinated care that leads to better health outcomes.”

To read more WellMed articles, visit agehealthynow.com. To see WellMed patient success stories, see agehealthystoriescom.