DaVita Medical Insights

DaVita Medical Insights

Competency Hubs in Nephrology

January 13, 2020

“Competency is a critical factor in every practice as health care in America shifts from what we have understood historically as a volume-based approach to delivery, to now a value-based delivery system,” says Martin Schreiber, MD, chief medical officer of home modalities for DaVita Kidney Care. Listen to this podcast, in which Ashley Henson interviews Dr. Schreiber on what competency hubs are and why they are important within nephrology. Dr. Schreiber also discusses how physicians or care team members can successfully create or improve a competency hub in their practice. Listen and read more DaVita Medical Insights here.

Podcast Transcript:

Ashley Henson: 00:27 Hi, this is Ashley Henson, Senior Manager of Communications for DaVita Kidney Care. I'm joined on the phone today for the DaVita Medical Insights podcast by Dr. Martin Schreiber, Chief Medical Officer of home modalities for DaVita Kidney Care. Welcome, Dr. Schreiber.

Dr. Martin Schreiber: 00:42 Thanks, Ashley. It's great to be here today.

Ashley Henson: 00:45 We have the pleasure of speaking with Dr. Schreiber to learn more about competency hubs and why they're important within nephrology. So Dr. Schreiber, tell me, what is a competency hub?

Dr. Martin Schreiber: 00:56 Ashley, when I talk about competency hub, I specifically am referring to what will be required of providers or physician practices going forward in this new environment of health care delivery.

Dr. Martin Schreiber: 01:10 It's fascinating because competency is a critical factor in every practice as health care in America shifts from what we have understood historically as a volume-based approach to delivery, to now a value-based delivery system. And, I see payers are designing care delivery networks that are focused on reducing costs, increasing the quality of care, and at the same time, optimizing the patient experience.

Dr. Martin Schreiber: 01:48 And, as we undergo this shift in American medicine, practices need to recognize the need to also educate the patient as a priority in providing this care. And, they need to think more about embracing shared decision making, and wherever possible, do this in treatment decisions and create what I see as a true partnership with the payer in achieving this, and understanding what the payer brings to bear and what best practices the payer may have to offer to really help them along their journey.

Dr. Martin Schreiber: 02:25 And, really in order to accomplish this transformational change as I see it, narrow networks of geographically distributed providers will evolve to meet these goals that we just talked about. And it's amazing because the great example is highlighted by the executive order announcement on July the 10th, advancing American kidney health on nephrology practices. This will really force practices to examine their capabilities that lower the progression of kidney disease.

Dr. Martin Schreiber: 03:19 And considering the fact that most Nephrologists were not sufficiently trained in delivering either peritoneal dialysis, or home hemodialysis, not every provider or practice will be considered a competency hub for end-stage kidney disease care and delivery. This gap poses significant challenges to a number of practices today, I believe.

Ashley Henson: 03:44 Got it. So these competency hubs are really locations or areas where a practice has developed expertise. Is that right?

Dr. Martin Schreiber: 03:55 Yes. It is all about expertise as we move forward in home dialysis. And really, it requires a self-examination of the practice, and they're asking themselves multiple questions as to whether they do have the competency to meet these targets.

Ashley Henson: 04:14 Got it. So how can practices and nephrologists assess their capabilities in home modalities?

Dr. Martin Schreiber: 04:19 Yeah. That is an interesting and difficult question. And the whole issue of provider capabilities and competency is really complex since it involves a multidimensional examination of care delivery, which is especially confusing for end-stage kidney disease patients. As I reflect on it though, Atul Gawande, an internationally known surgeon, writer, and lecturer, outlined the impact checklists in medicines can have on patient outcomes in his book, The Checklist Manifesto, How To Get Things Right, that a number of people, I'm sure, have read.

Dr. Martin Schreiber: 04:58 But, it really highlights the fact that checklists help providers or practices ensure easily overlooked patient safety steps are completed. And checklists also identify those minimum explicit steps in completing a complex process successfully.

Dr. Martin Schreiber: 05:17 Again, this is the 50th anniversary of the mission to the moon, and Tom Wolfe also emphasized in that spirit the value of checklists and achieving success in our space program in his book, The Right Stuff. Just think of what was required to put a man on the moon. That same level of teamwork, discipline and consistency is required to be successful in providing the greatest long-term survival for patients that have end-stage kidney disease.

Dr. Martin Schreiber: 05:52 And I believe that the best approach for nephrology providers is to create what I term an end-stage kidney disease patient journey checklist. And this checklist, just like you would want your pilot to go through a checklist to ensure that the airplane is safe before it flies, this end stage kidney disease patient journey checklist is the practice or the physician's approach to identifying what steps need to happen to deliver consistent quality results, proactively avoid complications, and therefore reduce costs. And as I see it, put the patient at the center of their care. And developing a competency in home dialysis will be critical for achieving success with the executive order.

Dr. Martin Schreiber: 06:43 And, people have asked me what are the items that should be on an end-stage kidney disease checklist. And I think that these are some of the questions that practices may want to think about. And they include: Do we have a provider culture that embraces the value of home dialysis? So it's about culture in the practice. Do we have individual physician expertise to care for patients on home dialysis? Do we have the right Team A employee skillset, skill level, as it relates to nurses, dieticians, social workers, care managers in our dialysis program? Do we use evidence-based care in our delivery of home dialysis care? Do we practice what scientists taught us is required, in my mind, to achieve optimal results?

Dr. Martin Schreiber: 07:40 And then thinking about the patients, do we have a multi-pod education program for patients and teammates? And then, what I think is critically important for practices to really just reflect on, is the question about how does our quality outcome in our practice compare to other like-size groups regionally or throughout the United States?

Dr. Martin Schreiber: 08:08 And, every practice can formulate their lists of questions on their checklist. But I think practices need to take stock of what they offer, and based on that decide what they need to change and redesign in order to represent what I term a competency hub.

Ashley Henson: 08:27 Okay. That makes sense to me. And I'm also thinking about dialysis providers being a critical component to this. And so, what does that partnership look like with a dialysis provider, and why is that, or how is that, or how could it be an effective component to competency.

Dr. Martin Schreiber: 08:48 Yeah. Trusted partnerships are sometimes difficult, especially if you're talking about medical practices and industry. But we all have to realize that it's going to take partnerships to be successful in this transformative era in medicine.

Dr. Martin Schreiber: 09:06 Most practices may not have all the skills. They may not have the evidence based protocols or processes they need. They may not have the ability to have results tracking programs within their practice to know how they're doing. And they may not have had the opportunity or the financial background to really participate in innovation as it relates to virtual house, remote monitoring in the home. Because this spirit of home dialysis going forward is really taking the care to the patients, and these virtual care platforms are critical to being fully successful and achieving the goal of taking care of the patient and also in meeting the executive order.

Dr. Martin Schreiber: 10:00 And, practices need the assistance from dialysis organizations like DaVita, or other entities to address these deficiencies in their practice. Most practices will need to develop these trusted partnerships, I believe, to really achieve the kind of care model that will provide successful outcomes for patients, and at the same time reduce costs because they're controlling complications as it relates to how the payer sees the individual competency hub.

Ashley Henson: 10:33 Switching gears a little bit, Dr. Schreiber, and looking at this from the patient's perspective, I'm wondering how can patients and even the public assess a practices competency in home modalities if that's what they're looking for as a differentiator for where they want to treat?

Dr. Martin Schreiber: 10:49 That's a great question, Ashley, and patients today demonstrate what I view as three main characteristics as I think about it in judging physician quality.

Dr. Martin Schreiber: 11:03 Patients want and they think that physicians' skills are more important than demographics. If they believe that one practice offers higher competencies than another practice, then they're going to drive to that practice. So, expertise trumps these demographics.

Dr. Martin Schreiber: 11:28 And number two, in my mind, are that patients expect their physicians to be the experts. They want experts and they want competency that's responsible for their care.

Dr. Martin Schreiber: 11:41 And third, patients look for a physician that recognizes the importance of achieving shared decision making where the patient is informed and the patient really is at the center of their care. So, looking at what your practice offers from the patient perspective is also critically important, especially as it relates to home dialysis.

Ashley Henson: 12:09 And from a physician's perspective, I know that they're checking their competency hub and they have their list, and where can they go if they need additional resources to be successful and actually create or improve a competency hub?

Dr. Martin Schreiber: 12:25 There are a number of opportunities where physicians can increase their knowledge. The first thing they need to do is ask the question in the practice, do we have the expertise to provide great care? If the answer to that is no, then absolutely physicians need to acquire knowledge because some of these physicians may not have been trained to be experts in home dialysis during their fellowship.

Dr. Martin Schreiber: 12:53 They can access courses online. They can partner with the International Society of Peritoneal Dialysis. There are a number of meetings, especially what's termed the Home Dialysis University, where there's an intense two to two and a half day course instructing both fellows and practicing Nephrologists on the specific aspects of home hemodialysis as well as peritoneal dialysis. There are other courses which are available. The American Society of Nephrology offers a kidney week before the formal meeting, which I think is really quite important. And then there are a number of regional as well as state meetings that highlight specific aspects of a home dialysis, especially peritoneal dialysis.

Dr. Martin Schreiber: 13:47 So there are a number of opportunities to upscale a Nephrologist's expertise in the area of home dialysis.

Ashley Henson: 13:55 Those are all my questions, Dr. Schreiber. Is there anything else that you would want physicians or care team members who are interested in strengthening or building competency hubs to know before we go?

Dr. Martin Schreiber: 14:07 I think that one final question, Ashley, has to do with how can patients and the public assess a practice's competency in home modalities? Because I think that's critically important for patients to know. And I would encourage providers, nephrology practices, to be aware that publicly-reported data is increasingly making patients as consumers aware of provider practice results. And there are two currently, but I would view there would be more going forward.

Dr. Martin Schreiber: 14:43 The two we have now includes your star ratings, so knowing what your star rating is. And then you have the other metrics, which was really the public-reported risk data, which is also very important. But patients themselves can ask specific questions of their physician when they go in and are evaluated. Or, this physician potentially being the person that's going to care for them on home dialysis.

Dr. Martin Schreiber: 15:25 And some of the questions the patient may ask could entail, did you receive home dialysis training in your fellowship for nephrology training? And have you cared for many patients on home dialysis? Another question is, do you classify yourself as an expert in home modalities? And as one thinks about the practice, how does your practice results compare to other local and regional practices? And specifically asking them, do you employ evidence based protocols?

Dr. Martin Schreiber: 15:53 So, I would encourage a very active discussion on the part of the patient with the practice or the physician on home to make sure that this is the right practice.

Ashley Henson: 16:18 Dr. Schreiber, thank you so much for taking the time to join us on the DaVita Medical Insights podcast. It's been an absolute pleasure speaking with you and learning more about competency hubs, and we hope you'll come back again in the future.

Dr. Martin Schreiber: 16:30 Sure. Thanks, Ashley. I really appreciated sharing these thoughts with you.