DaVita Medical Insights
With the increased use of technology, such as telehealth and remote patient monitoring, during the COVID-19 pandemic and the overall shift to electronic health records and predictive analytics in health care in recent years, caring for patients from an individual, human perspective, rather than from a numbers or data perspective, is becoming more important. How can patient-centered care have an impact on patients who have chronic conditions like kidney failure? Dr. Francesca Tentori, vice president of DaVita’s Outcomes Research and Patient Empowerment team, discusses this with Ben Brown, senior manager of DaVita Clinical Enterprise team in Denver, CO, in this podcast. While this podcast was recorded before the COVID-19 pandemic was declared a national emergency in the United States, listen now to learn more about how integrated and coordinated care is delivered in DaVita centers.
Ben Brown (00:28): Hello and welcome to DaVita's Medical Insights podcast. My name is Ben Brown. I am a senior manager in DaVita's clinical enterprise team based in Denver, Colorado, and I'm excited to be joined on the phone today by Dr. Francesca Tentori, vice president of DaVita's outcomes research and patient empowerment team. Hi there, Francesca.
Dr. Tentori (00:49): Hi, Ben. It's good to be with you.
Ben Brown (00:51): Well, I'm excited to have you with us today to talk about patient-centered care. Can you talk a little bit about how you define patient-centered care and what that means to you and how do you see it come to life in our dialysis centers?
Dr. Tentori (01:04): Yes, definitely. So to start with, let me give you the definition that the Institute of Medicine has given us on what patient-centered care means. Obviously it's a term that we hear more and more. The official definition is providing care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide our clinical decision.
Dr. Tentori (01:35): And that's the part that is really exciting to me. So to me, patient-centered care means we provide care that aligns with each of our patient's needs, whether they're clinical or whether they are emotional. Obviously we're not always able to address all of their issues, but just awareness around what's important to each individual patient I think is a huge step. Obviously a challenging one, but I am very proud of the progress that is being made in this area, in medicine in general, and in dialysis in particular.
Ben Brown (02:12): Thanks. I think that's great, and how do you see patient-centered care support our patients in a differential way?
Dr. Tentori (02:19): So I think this is really, really important in a condition like kidney failure, and specifically patients on dialysis who are on a life sustaining treatment that they typically undergo three times a week if they're dialyzing in a clinic or every day if they're at home.
Dr. Tentori (02:41): So their disease and their treatment is very much part of everyday life, and if we are honest, traditionally dialysis care has focused on improving clinical outcomes, achieving quality targets, which are absolutely very important, and results in better clinical outcomes. But the patient perspective was not really reflected or was not really always taken into account.
Dr. Tentori (03:15): So in my mind having a structured way to account for the patient's wishes, their desires, to be more mindful that those need to be incorporated in the delivery of care makes a huge impact on the everyday life of our patients, just the fact that they feel valued and respected and listened to. There is a lot of literature and evidence supporting that it has a huge impact on their quality of life as well as potentially in clinical outcomes.
Ben Brown (03:49): Yeah. And I think you make a really important point about DaVita's patient population and what it actually looks like to come to life in one of our centers where the schedules and operations can be very regimented and occasionally appear a bit overwhelming with so many patients being managed at one time.
Ben Brown (04:11): So how do DaVita's care teams effectively deliver patient-centered care? And maybe you could describe what that process actually looks like and what it has meant for them in terms of outcomes.
Dr. Tentori (04:24): Yes, absolutely. So all of us who have been in the clinic know that it's a hectic place. Everybody is running around always trying to do the right thing for patients, but sometimes the communication and integration of the different activities is not ideal.
Dr. Tentori (04:44): One of the basic principles of patient-centered care is the coordination and integration of care. And that is to, across health care providers so the dialysis center communicating with other health care providers as well as within the clinic. We obviously have being able to really work and focus on the communication and integration within our clinic. And we want to make sure that we optimize a communication across the people who interact with patients.
Dr. Tentori (05:22): So, starting with patient care technicians who have the most interaction, nurses, social workers, dieticians, physicians, we want to make sure that they're all aligned and aware what's going on with a given patient in a given time in order to be able to better respond to those needs, whether with changes in the clinical care that's needed or with other types of support.
Dr. Tentori (05:52): The way we have implemented this at the DaVita clinic is starting to having daily meetings of the people who on the floor interact directly with the patients. So you can think typically of patient care technicians, nurses, if it's the week where the social worker are also interacting with that specific patient.
Dr. Tentori (06:19): And that's the place where they communicate whatever is new with the system individual. That is no need obviously to cover every single person who's been treated on the floor that day. But the patients who might present with something new or with a new need.
Dr. Tentori (06:36): And then the next step is to bring those information or the things that cannot be addressed immediately that day to a core team meeting. And that is a meeting for the leads of the care team, including physicians, nurses, etc. And again, the idea is that problems get escalated so that decisions can be made that address the individual needs of the patient who have come, we have become aware of as we interact with them on the floor.
Dr. Tentori (07:15): And obviously one thing that I would like to stress is the importance, not only of communicating what the certain patients specific needs are today, but where we see the real importance is for the clinical team to together make decisions and come away from these meetings with a common understanding of what the care plan or any activity relating to that specific patient is going to be moving forward.
Ben Brown (07:46): I think that's so important, Dr. Tentori, that when the whole team comes together to discuss those, the most important issues that a patient is facing and have the right plan in place that brings the patient's needs and wishes into mind is when we really see success and the right outcomes that we're striving for at DaVita.
Dr. Tentori (08:09): Absolutely.
Ben Brown (08:10): Thanks, Dr. Tentori. I think that insight is incredibly helpful for our listeners. What type of results have you seen tangibly come from this patient-centered care approach that you just mentioned?
Dr. Tentori (08:22): Yeah, actually we have been able to measure this. We conducted this initiative in 400 DaVita clinics and we were able to really see an impact on measurable outcomes. If you think of hospitalization, for example, as one of the things that are most important, definitely to patients. I have never met a patient who wants to spend time in the hospital as well as from a dialysis organization perspective, obviously the logistics of a patient not showing up for dialysis and then having to make up for treatment or the treatment that's received at the hospital, not being ideal.
Dr. Tentori (09:01): That's definitely something that we have put a lot of energy into and when we looked at hospitalization, at the center that participated in this initiative, there was significant and meaningful reduction among patients treated with three times a week in center hemodialysis, as well as in PD patients.
Dr. Tentori (09:24): So we were able to see a full impact on daily tangible clinical outcome that's important to patients. To me even more importantly is that this type of initiative, so implementation of patient-centered care in a structured manner was really well received. Patients found that they were being listened to.
Dr. Tentori (09:49): One concern obviously was that clinical staff would feel overwhelmed and that it was too time consuming and we have not received that pushback at all. And physicians as well thought that they were receiving better information and more coordinated information. So I think that overall it was really a win-win both for patients and the clinical staff.
Ben Brown (10:13): That's awesome to hear and I know it's great not just for our clinics, but to share what impact it's really had on our patients.
Dr. Tentori (10:21): Absolutely.
Ben Brown (10:21): And for our patients, one of the most important and most difficult decisions they have to make is where they will receive their dialysis treatment. That may be in a dialysis center or within their own home. However, when as you mentioned, a patient goes to the hospital, which no one wants, their risk of being able to maintain treatment on their preferred modality increases significantly, especially for our patients who treat at home. Can you talk about how patient-centered care affects those patients treating at home and their quality of life?
Dr. Tentori (10:53): Yeah, absolutely. I think that, well you brought up I think two separate issues. One is how disruptive hospitalizations are and the risk that might result in a switch in modality specifically for patients who are being treated at home to them go to in-center hemodialysis. The benefits of a patient-centered care approach is that we are all aware of what's happening individualized. We are also more aware of what the barriers might be and we are better equipment to address them.
Dr. Tentori (11:32): So for example, if a patient goes to a hospital and they're not able to receive PD while they're in the hospital, we are more aware that that was the case. It might very well be that the patient needs a few sessions of in-center hemodialysis, but we are better prepared to facilitate the transition back home.
Dr. Tentori (11:55): The other topic I think that you brought up is the perception and experience of care for those patients to dialyze at home and while there's so many positive aspects, the flexibility, the fact that they can maintain their lifestyle, they can remain employed, et cetera, et cetera. For some patients, dialyzing at home can also be an isolating experience just because they don't have the social interactions with our other patients and clinical staff three times a week as it happens with in-center hemodialysis patients.
Dr. Tentori (12:33): So I think that more intentionality, and being more willing and really invested in understanding what's important for a person who is dialyzing at home, as well as what are the obstacles. Has something happened at home that we would not have otherwise being aware of that is making it harder for that person to dialyze at home and can we support them in any way?
Dr. Tentori (13:01): I think that's really what's valuable for this process is not only looking at the clinical parameters, which obviously are very important, but in the case of an older person doing peritoneal dialysis at home. It might be very important for us to know that that spouse is now in the hospital for other problems and so suddenly the responsibility and the burden of the treatment is all on our patient. Those are the kinds of things that can help us, as clinicians, better support that patient and I think really, really have an impact on the experience of care, as well as the overall quality of life for patients dialyzing at home.
Ben Brown (13:49): Thanks, Dr. Tentori. I think it's so important what you just said about how patient-centered care can help patients receive dialysis on their modality of choice, whether that's in home or at the dialysis center. For our podcast listeners who are clinicians, what are one or two takeaways about patient-centered care you would like them to leave with and do you have any recommendations for how they can implement this approach into their own practice?
Dr. Tentori (14:17): Yes. Thank you, Ben, for that question. This is obviously a topic that I have a lot of passion about. I also think that the term patient-centered care is a little bit scary and sometimes we don't really understand what it means.
Dr. Tentori (14:33): Really to me the most important message is something that each of us interacting with patients can implement every day. The big first piece is do we know what the needs and the preferences for our patient, that specific individual patient is today, and are we intentional, are we mindful in making sure that's the case? So, do we ask that question?
Dr. Tentori (15:04): And then the other piece is do we share whatever we have learned about that specific individual? Do we share that with our colleagues, with other members of the clinical team so that we're all on the same page and then we can come up with a plan that will address that need?
Dr. Tentori (15:25): And I want to stress that for many of our patients who have multiple comorbidities, we are not going to be able to address all of their needs or solve all of their clinical issues, but just the awareness that this specific problem—the fact that Ms. Jones has been, was admitted to the hospital yesterday is important. And just having that awareness, I think can really make a huge difference in the type of care that we as a dialysis community deliver to our patients.
Ben Brown (16:00): Dr. Tentori, I think that is a great message for all listeners, clinical or non-clinical, to be able to take away and think about how patients not just receive their treatment, but how they feel cared for. And so I am really happy that you are able to join us today and for our listeners, if you're interested in learning more, please check out the DaVita Medical Insights podcasts that are available online today.