DaVita Medical Insights

Moderation Versus Elimination for Kidney-Friendly Diets

Receiving the influenza vaccine has always been important for patients with kidney disease, but the COVID-19 pandemic makes influenza vaccinations even more crucial now. Listen to this podcast, in which Mandy Tilton, DNP, MSN, MBA, RN, CNN, chief nursing officer for DaVita Kidney Care interviews Jeffrey Giullian, MD MBA, FASN, chief medical officer for DaVita on why influenza vaccination is so crucial and whom he recommends be vaccinated during the pandemic. Dr. Giullian and Mandy also dispel some myths about the flu vaccine, state which form of the vaccine is most effective, discuss the benefits and safety concerns of getting vaccinated during spikes of COVID-19 prevalence in patients’ communities and provide guidance for clinicians in speaking with patients about influenza vaccination. Podcast Transcript: Mandy Tilton, DNP, MSN, RN (00:44): Hello and welcome to the DaVita Medical Insight Podcast. My name is Mandy Tilton and I have the honor of being the chief nursing officer for DaVita Kidney Care. I'm excited today to be joined on the phone with Dr. Jeffrey Guillian, who is our chief medical officer for DaVita, and today we will discuss the importance of influenza vaccination during the COVID-19 pandemic. Thank you for joining us, Dr. G. Dr. Jeffrey Guillian (01:12): Hey Mandy, I'm glad to be able to speak with you on such an important and timely topic. Mandy Tilton, DNP, MSN, RN (01:18): Timely it is. Receiving the influenza vaccine has always been important, but why does the COVID-19 pandemic make it even more crucial now? Dr. Jeffrey Guillian (01:29): Well, Mandy, as I'm sure you can imagine, the flu season is going to be particularly complicated this year given the similarities in symptoms between influenza virus and COVID. And more than any other year, it's really important that all patients and teammates get vaccinated for the flu. Last season, unfortunately, less than half of all Americans got a flu vaccine and at least 410,000 people were hospitalized. Dr. Jeffrey Guillian (01:54): And remember, that although we don't yet have a vaccine for COVID, we do have a vaccine for the flu. And by getting the flu vaccine, you are also helping to protect the people around you. And this is something known as herd immunity. If the majority of the population is vaccinated against the flu, it then reduces the entire community's risk, particularly for vulnerable patients. And preventing the flu supports good stewardship of resources. Even if your illness doesn't require a hospitalization, it helps avoid visits to the doctor, where you might go if you want to confirm that you actually do have the flu. Mandy Tilton, DNP, MSN, RN (02:31): And knowing all of this, who do you think should be recommended to obtain influenza vaccination during the COVID-19 pandemic? Dr. Jeffrey Guillian (02:41): Well, annual flu vaccine is recommended for everyone six months of age or older, so that's certainly all of us listening, except for rare exception, because it is an effective way to decrease the flu illness, decrease hospitalizations, and certainly to decrease deaths. During the COVID-19 pandemic, reducing the overall burden of respiratory illness is an important way to protect vulnerable populations at risk for severe illnesses, and it protects the health care system, and it protects critical infrastructure. Dr. Jeffrey Guillian (03:12): And I want to highlight one vulnerable population, and that's obviously our patients, those with kidney disease. This group of individuals is at high risk for both severe COVID and severe flu. Clinicians should use every opportunity during the influenza vaccination season to administer influenza vaccines to every eligible person. And time is of the essence. It takes around two weeks after the vaccination to achieve immunity, so don't wait until your friend or your neighbor tells you that they've got the flu. Get vaccinated now. Dr. Jeffrey Guillian (03:45): And that brings up an important point. I have certainly heard some people say they are planning on getting the flu vaccine this year because they're already wearing a mask. Now, Mandy, what is your suggested guidance for clinicians who are approached with this thought, by either their patients or their colleagues? Mandy Tilton, DNP, MSN, RN (04:01): Well, that is an important thing to cover. A mask is great and it is a really important barrier for infections, but it's certainly not perfect for stopping the spread of flu. I would encourage us to think about it this way. When we get into cars, we put on seatbelt. I'm guessing most of us all do that even though our car may have safety features like airbags, but we want to keep ourselves as safe as possible. And while the airbags are great and helpful, combined with the seatbelt, they're even better. The same is really true when we think about fighting the flu. Masks are great. In this case, they're your airbags. The vaccine, however, is your seatbelt. Mandy Tilton, DNP, MSN, RN (04:47): And while we're on the subject of dispelling this, can you help us answer a question that many of us are hearing from patients and others? And that question is, can I get the flu from the flu shot? Dr. Jeffrey Guillian (05:02): No, you cannot. You absolutely cannot get influenza from the flu shot. You can get a sore arm, and trust me, I just got my flu shot and my arm was sore. And you can get some achiness, which is proof that your immune system is waking up and becoming activated, but you cannot get the influenza virus itself. Real influenza is a life-threatening viral infection. Dr. Jeffrey Guillian (05:25): Help me, Mandy, if individuals do want to get the flu vaccine, what is your suggested guidance on receiving the nasal flu preparation in its place? Mandy Tilton, DNP, MSN, RN (05:36): The injectable form of the vaccine has proven to be more effective, but even the nasal option is more effective against influenza than receiving no vaccine at all. It's important to remember though, that the nasal spray is not for everyone, particularly those with a compromised immune system. If you or a patient are interested in the nasal spray vaccine, please do first discuss this with your physician. Mandy Tilton, DNP, MSN, RN (06:06): Dr. G, can you help provide some insight on whether the influenza vaccine will protect individuals against COVID-19? Dr. Jeffrey Guillian (06:16): Well, sure, Mandy. I think it's important to remember that getting an influenza vaccine will not protect against COVID-19 directly; however, influenza vaccination has many other important benefits. Influenza vaccines have been shown to reduce the risk of getting the influenza virus and the illness, and hence hospitalizations and deaths. And getting an influenza vaccine this fall will be more important than ever, not only to reduce your risk from the flu, but also to help conserve potentially scarce healthcare resources as we discussed earlier. Many intensive care units are already full with people with COVID. Dr. Jeffrey Guillian (06:52): Now, Mandy, how would you suggest clinicians respond to patients who wonder if it's safe to get an influenza vaccine if COVID-19 is spreading in their community? Mandy Tilton, DNP, MSN, RN (07:01): Well, as clinicians, we can remind patients to practice everyday preventative actions and follow CDC recommendations for things like running essential errands. We can tell patients to ask their doctors, pharmacists, or health departments whether they are following the CDC's vaccination pandemic guidance. And any vaccination location following CDC's guidance should be a safe place for them to obtain their influenza vaccination. Mandy Tilton, DNP, MSN, RN (07:36): I think we've covered a lot, but do you have any additional guidance for clinicians as they speak with patients about the influenza vaccine? Dr. Jeffrey Guillian (07:45): Absolutely. Please remember, people call lots of bad colds the flu, and this is unfortunate and it's not accurate. The real influenza A and B viruses can be life-threatening and make you feel much, much worse than a bad cold. The flu vaccine doesn't stop you from getting a cold, even a bad one, it does, however significantly reduce the risk that you or your patients or your loved ones will get the actual flu, and that, that might just save a life. Mandy Tilton, DNP, MSN, RN (08:18): Well, Dr. G, thank you for joining me and discussing the importance of influenza vaccination during this ongoing COVID-19 pandemic. Dr. Jeffrey Guillian (08:28): Well, thanks for having me, Mandy. I appreciate you having this opportunity. Mandy Tilton, DNP, MSN, RN (08:32): And listeners, thank you all for tuning in and be sure to check out other DaVita Medical Insights episodes for more kidney care educational podcasts. You can also find additional kidney care thoughts, leadership and industry news by following @DaVitaDoc on Twitter.

The Importance of Influenza Vaccination during the COVID-19 Pandemic

How the COVID-19 Pandemic Has Affected Kidney Care

“I would just really encourage folks to get upstream and get your patients the information early in their disease state, so that they can be more involved in their care and make good decisions for themselves,” says Josh Lowentritt, MD, a New Orleans nephrologist in private practice. Listen to this podcast, in which Martha Wofford, group vice president of DaVita Kidney Care, interviews Dr. Lowentritt on the importance of patient education, and empowering chronic kidney disease (CKD) patients to make active choices in their care. Dr. Lowentritt discusses his professional background, his passion for CKD education, like Kidney Smart, the patient’s perspective, the need for a CKD educator, the significant conversations related to diet, advice for nephrologists in providing education and the impact of COVID-19 on giving patients support. Podcast Transcript: Martha Wofford (00:40): Hello and welcome to DaVita Medical Insights Podcast. My name is Martha Wofford and I am a group vice president at DaVita Kidney Care, and I am excited to be joined today by Dr. Josh Lowentritt, he's a nephrologist from New Orleans. And just thank you, Dr. Lowentritt or joining us to talk about the importance of education for patients with chronic kidney disease. Dr. Lowentritt (01:03): Well, thanks. Martha Wofford (01:06): Yeah, thanks for being here. Dr. Lowentritt (01:07): Yes. Martha Wofford (01:07): First off, can you start by telling our listeners a little bit about your background and maybe why you're so passionate about CKD education? Dr. Lowentritt (01:15): Sure. So first of all, call me Josh, and I'm delighted to be here today to chat. I did all my nephrology training here in New Orleans at Tulane and finished up 2001. And I've been in private practice since then. So I'm doing hospital work, office work, I go to dialysis clinics. I still see my post-transplant patients after they get released back to me. And also do quite a bit of medical director work and work in population health and value-based care, which helps fill out my day. So, that CKD education, it's strange that it's such a novel idea. I was so lucky when I was in training. We actually had a dialysis CKD PD educator embedded in our clinic when I was a fellow. And so I always included CKD education when my patients would progress further along in their kidney disease, or make referrals to CKD education as appropriate, for patients to get the information they need. I've never imagined nephrology without having a CKD educator. And so I've just really enjoyed that association throughout my career. Martha Wofford (02:45): Oh, that's awesome. Yeah. I think not everybody probably had that advantage and that's a great way to shape your thinking about it. Just being core to what you do with patients. Maybe you can tell us a little bit more about what it's like from the patient's perspective, what their greatest needs are for education? And then when you encounter those needs, when and how you provide CKD education? Dr. Lowentritt (03:11): Sure. Kidney disease, it's intimidating. It's scary for patients. We're talking about real serious stuff, and at the same time, a lot of times patients don't know enough about it to even know what to ask. So my use of the CKD educator and the health materials and the Kidney Smart materials, that really helps round out what I need the patients to know so that they can be empowered to take care of themselves. Because as we know, we're dealing with a chronic disease state and a lot of the care is what people do on their own time, not when they're sitting in front of the doctor. So I think it's really critical that we provide education that is in a relaxed setting, not in front of the doctor. They should be able to feel like they can ask any question. And sometimes they're a bit intimidated to ask questions that might be personal, or they might think they're not really smart questions or something like that. And also because, when I'm talking to patients, there's the time limit. I have to keep moving on my schedule and patients may not remember to come back to ask the question if it slips their mind. So the educational piece is really critical in making sure patients understand what's going on with them. We're asking people to change their diet. We're asking people to manage chronic diseases, check their blood pressures, take care of their diabetes. We're asking them to pay attention to their feet. We're asking them to dramatically change their diet sometimes and they need support for that. So it's really a lot about empowering patients. Being sensitive to their needs. And really creating an educational space for them so that they can get the information and make the good choices for themselves. Martha Wofford (05:19): Yeah, that makes total sense. And I bet the dramatic changes to the diet down in New Orleans must be particularly painful for patients. Dr. Lowentritt (05:27): It's terrible. I have to tell people, "If you like it, you can't have it." Who wants to hear that? And, I'm not a dietitian. I have some thoughts about what you shouldn't eat. But I'm not able to quickly come up with substitutes. A trained renal dietitian, or a kidney educator who has experience in this, they are able to come up with good substitutes. Because obviously, we need people to have good nutrition. But again, I'm not trained for that. And I'm very happy to have folks on the team who are. Martha Wofford (06:04): Yeah. And one of the things that I'm really proud of is, as we overhaul the Kidney Smart curriculum, is we did a lot of work on diet and presenting different options for people so they could swap out something healthier for something that they really like in their diet. So that's a really easy part of the educational material to use for sure. Josh, what piece of advice would you have for other nephrologists who may not be utilizing CKD education or Kidney Smart with their patients today? Dr. Lowentritt (06:36): I would just ask nephrologists, "What is your goal for your patient?" If you want the best care for your patient and you feel like, as a physician you can do it all, by all means, keep doing it all. But, that's not the world that I live in. The world I live in is that kidney disease is a team sport. We need a whole team of people to take care of folks and give them the information they need so that they can make good choices. One of the most wonderful things about kidney care that I've enjoyed as a nephrologist is, I've always been doing care in groups. I'm meeting with my facility administrator and my nurses, my dietitians, social workers. But to be able to bring that upstream, bring that out of the dialysis clinic, why wait till someone has kidney failure to give them that level of care? Why would we not bring that upstream and give our patients the information and empower them to take care of themselves? Why would we wait for that? Let's get upstream. Let's not wait until they go to the dialysis unit so they can get a dietitian or they get dietary advice. Let's take care of that in a relaxed setting. What if we did that and our patients didn't need dialysis for another year or two, or maybe never, because they got the education they needed? Or what if they were able to pick the modality that's most important to them? Or even better, that we send them to transplant. When we get them set up at the transplant center and perhaps have a preemptive transplant if needed. That's what I would tell the nephrology community is if we really want to give the best we can for our patients, we need to include the team earlier and get much farther upstream than the dialysis unit. Martha Wofford (08:30): I love that Josh. I think you and I share, I know, a passion around trying to empower patients and really changing their trajectory, but what if really empowering them and getting them that information so that they don't progress is something that I know we're both spending a lot of energy, trying to make the reality for more and more nephrologists and more and more patients. Maybe if we just talked for a minute about what it's been like with COVID and how it's been to try to support patients and educate them and this period. Dr. Lowentritt (09:09): Sure. And of course, you know how COVID hit New Orleans pretty quickly, and it was really 10 weeks of an ordeal. Currently, we're the one part of the Louisiana where COVID is not flaring so badly after the initial, really it was a terrible 10 weeks. And fortunately, the whole population, especially the vulnerable patients really get it. They really need to say to themselves, they really need to be very careful when they leave their homes. So, I've asked my patients about that. In fact, in the last two days, I've talked to four patients about peritoneal dialysis, people that are new-starts. One patient who's already on hemodialysis. And one of the things I'm telling them now is, you don't have to come into a big group setting. You don't have to come in to the dialysis day clinic. You can do your dialysis at home and maybe reduce your risk of exposure from not having to get on transportation vans and not having to take buses and not relying on neighbors to bring you places. So I think, in the world, in our post-COVID world, we should be mindful of that. That, one of the ways we can help protect our patients is simply to give them their kidney care at home. So if that's education, the Kidney Smart education program currently is doing all telehealth, which is actually giving my patients much more attention than the previous era, when they would come in for meetings and meet in groups. They're actually getting a lot of one-on-one time with the Kidney Smart educator. And for my patients who require dialysis, why wouldn't we want to treat them at home where they can control the environment and get their care in the most comfortable setting possible? So I think post-COVID, it becomes even clearer. Oh, and don't forget, I live in a hurricane zone, and I tell my patients all the time, "If the hurricane comes, you pack up, you pack three days of supplies of peritoneal dialysis and you head out. And you don't have to set up dialysis when you get somewhere. And in our hurricane areas, I think they're also very important. It's pretty scary to rely on dialysis as a modality for life support, especially if you might have to evacuate for a hurricane or natural disaster. Martha Wofford (11:56): Yeah. I think we're such fans of the flexibility that PD offers to patients, and a hurricane's just another example of that flexibility and being able to pick up at a moment's notice. So it's been amazing. We, as I think you know, have about 1,500 educators across the country. And, as you were saying, in New Orleans, we've heard tremendous feedback from many of those educators that the transition to going to telehealth has been just a godsend for patients, where they weren't always able to access all of the health care system. But the ability to connect with an educator and then to follow-up and call them and ask all the questions that they have and get good answers, has been really important to helping them. And for many of them helping them start on PD. So, COVID's been a big push towards telehealth, which has been, in a way, a gift, sort of a silver lining, in the middle of this horrible crisis. So, we've definitely seen some of the advantages and we'll continue to offer Kidney Smart through many different modalities so that we can reach patients however they most want to be connected with. Whether it's in person with a group, or one-on-one over telehealth. So thanks for that. Any other closing thoughts that you would want to offer to our listeners? Dr. Lowentritt (13:25): Well, I would just really encourage folks to get upstream and get your patients the information early in their disease state, so that they can be more involved in their care and make good decisions for themselves. There's nothing better when a patient requires dialysis than a patient who is ready, trained, has an access, whether it's a peritoneal catheter, or a fistula. That they have already made dietary modifications. I like to joke, I have a small group of vegetarians out there among the meat-eating society. But, take advantage of the Kidney Smart program and get your patients involved in their own care. And actually, it allows us as physicians to give advice at a much higher level, and probably a more personal level than we might, if we're having to just really grind it out and have to educate on everything. If we have a patient who's ready for treatment when they need it, is someone who's aware of their transplant options. And someone who is involved in their care, they do a lot better over the long run. And that's my goal for my patients. Martha Wofford (14:46): Yeah. That's so well-said. Love it. All right. Well with that, why don't wrap up? And I just want to thank our listeners for tuning in and be sure to check out other DaVita Medical Insights Podcasts. And you can also find additional kidney care thought leadership in industry news by following @DaVitaDoc on Twitter. So thank you so much Dr. Lowentritt. Really appreciate, it was a pleasure to talk to. Dr. Lowentritt (15:11): Thanks Martha. I've really appreciated it. Thank you.  

The Importance of Patient Education

“If self-care was important before the pandemic, it has become almost essential in everybody's life today,” says Usha Peri, MD, who is a DaVita medical council member and a SKY breath meditation instructor for the Art of Living Foundation. Listen to this podcast, in which Ryan Weir interviews Dr. Peri on self-care, with a focus on self-care for clinicians and during the pandemic. Dr. Peri discusses what burnout is and how to counteract it, what self-care means to her, how she became interested in the SKY breath meditation technique and why she became an instructor, and what tools she uses to help with her own self-care. During the podcast, she also demonstrates a couple breathing exercises that one can do in less than 5 minutes during a break in the day to unwind and reset before going back to work. Podcast Transcript: Ryan (00:40): Hello and welcome to the DaVita Medical Insights podcast. I'm your host Ryan. We're joined on the phone today by Dr. Usha Peri. Dr. Peri is on the medical council of DaVita and is a SKY breath meditation instructor for the Art of Living Foundation. Dr. Peri, how are you doing today? Dr. Usha Peri (00:57): Great. Thanks, Ryan. Ryan (00:59): All right. Dr. Peri, we're talking about self-care today and as we all know, there's a pandemic going on. So can you talk about the timing of this topic and why self-care for clinicians is so relevant right now? Dr. Usha Peri (01:11): Absolutely. Even before the pandemic physicians' burnout rates and health care professionals' burnout rates have been on the rise. Even though this word was coined back in the '70s, it has started becoming much more relevant recently with the rise of regulatory burden, as well as electronic health documentation burden that's being placed on the physician. Now, with the pandemic hitting, all of this has just gone exponentially high. Things are changing quite rapidly and they're asked to keep up with all the changes. As you know, regulations are changing, by the day, sometimes, and our telehealth visits, all of us had to transition to telehealth almost overnight. And the documentation rules around that keep changing as well. At the same time, our patients are also in this uncertain, anxious time. And so their demands on the health care professionals are higher and our ability to deal with the death and the grieving process, all of this is taking a huge toll on the health care professionals. If self-care was important before the pandemic, it has become almost essential in everybody's life today. Ryan (02:42): Yeah. And especially going months into this pandemic too. Dr. Usha Peri (02:47): Yes. And not knowing when it's going to end either, Ryan. Ryan (02:50): Right. Right. So self-care can mean a lot of different things to different people. What does self-care mean to you? Dr. Usha Peri (02:58): Right. That's a good question. Well, you're right. Anybody, who's human and living actually health care professional or not, is doing self-care in some form and fashion whether they call it that or not, right? All of us that are humans have to eat good food, hopefully, good, nutritious food, drink plenty of water, get a good night's sleep, and if things go well and we have a little extra time on hand, exercise perhaps, or spend some time with nature, walking, listening to music, et cetera. All of that would fall under self-care to me. I mean, that all sounds simple, right? And why do we even need to talk about it? Why podcast? Well, the challenge there is that the increasing demands that we talked about, we as human beings start cutting corners and start cutting into our eating time. What used to be an hour long lunchtime at one point in my own work day has now pretty much disappeared and exists in my car while I'm driving. Dr. Usha Peri (04:09): What used to be exercise time can go away if you have to catch up with your notes or do other important things for the family. What used to be sleep time can easily disappear, once again, when you're juggling multiple different tasks. And more importantly, if there's stress of negative outcomes, then it takes away your sleep. Even if you're in bed, you're running around not getting good quality sleep. So all of this starts taking a toll on your physical energy levels as well as mental energy levels. And then you slowly start feeling burnt out; emotional exhaustion, depersonalization and compassion fatigue, which is the three components of burnout. So now when we're in this stage, when we moved away from doing our usual things in a happy natural way, on to this vicious downward cycle of burnout, we have to do something extra to get ourselves back up at least to the baseline. Dr. Usha Peri (05:19): And that extra obviously is something that can recharge and rejuvenate us. And again, in our current society, it would be great if I can get this in the form of a pill. And if not in the form of a pill, something quick, that is not very time consuming, right? So while I was going through this journey in my own life, I stumbled upon this great breathing and meditation technique called the SKY breath medication. This is almost 15 years ago. And initially I used to do it as a hobby that made me feel great. And lately it has become a very essential part of my day. I spend about 20, 25 minutes of my time doing this and it recharges and rejuvenates me very naturally and very automatically. Ryan (06:10): So you mentioned that self-care isn't something new. It's gotten a lot of news lately but it's been around for a bit and you've been dealing with this subject for a while. So how did you originally get interested in this subject? Dr. Usha Peri (06:22): Sure. So, like I mentioned, these things happen very naturally but then I am a mother of two kids who are now young adults, 24 and 20. I have held many leadership roles in my company, including the immediate past presidency. And I've seen this company grow from a five employee to a 70 employee company. I'm a medical director on the medical council, married for 28 years. So I've obviously worn many hats. And in the process, just like I mentioned earlier, I've realized that I was cutting into things that are necessary to maintain a healthy body and a healthy mind. So during this time I stumbled upon this breathing technique. And now I come from a tradition of yoga. Growing up and going through medical school in India, I've taken great interest in doing some yoga postures and breath work. And I came here and all of that got lost in the business of daily life. Dr. Usha Peri (07:25): But then I rediscovered it about 15 years ago. Initially I was doing it for fun but later on, as life caught out and I was juggling all these different things, I realized that this is a great source of energy for me. It's a great source of winding down without having to have a drink of alcohol, which I've never been a big drinker at all but even social alcohol or just to wind down, which I used to do many years ago, at the doctors and parties, I've completely given up. And I realized that yoga, breath work and meditation are just much more powerful in helping relieve, let go of the daily stresses and to recharge and rejuvenate me. And not only am I now combating burnout but I've actually got an extra perk by practicing this which is peak performance. I realized that my mind can dive into the creative, intuitive sites of myself and come up with very beautiful problem solving. Dr. Usha Peri (08:29): For any problem solving we do need the creative and intuitive sites of our minds and brains active. And I noticed that doing this practice on a regular basis helps me do just that. So I'm actually a very sought after person in whatever field I choose to enter, right? Whether it's as a parent, spouse, at work, wherever I am, I'm considered a cheerful person who brings value. My patients love me because I bring that extra human element to the equation. And I have people who drive many miles across town to come visit with me as well, yeah? And then I realized that this is too beautiful of a tool to keep to myself. That I would love to share it with the world. So that's how I became an instructor five years ago. And now I teach this to youth as well as adults and health care professionals. Ryan (09:29): Yeah. Can you talk more about the tools that you use to help with your own self-care? Dr. Usha Peri (09:33): Sure, Ryan. So when I started out I took this workshop, a 10 hour workshop, called the happiness program or living well for health care professionals, which teacher the 20, 25 minutes take home breathing technique called the SKY breath or Sudarshan Kriya. The term that comes from yoga. And what it is it's a very deep involved breath work that allows us to clear up the day to day stresses. And allows us to get into a very meditative mode of mindset that allows me to just then slip into meditation. And meditation to me is effortless. It's not concentration, it's not focused. It's actually the ability to disconnect from our day to day activities. Dr. Usha Peri (10:24): We use our senses from the time they're up to we go to sleep, especially in this information overload, connected gadgets heavy world today. So that 30 minutes allows me to disconnect from all of that while I'm still awake, not when I'm sleeping and gives me a tool that's physiologically actually allowed for relaxation and disconnection and deep meditation, which is automatically recharging or rejuvenating. So yes, my tools are I do about five minutes of yoga stretches. The postures that are very well known. 20 minutes of the breath work called the SKY breath and followed by a 20 minute meditation. So total about 45 minutes to 50 minutes. That's all. That's how my day starts. And then the rest of the day, I feel like I can face anything that comes my way. Ryan (11:23): So these breathing techniques that you do is this something, I mean, while we're on the podcast and while people are listening, is this something that we can demonstrate now briefly? Dr. Usha Peri (11:34): Absolutely. So I won't be able to demonstrate the SKY breathing. For that you have to come to one of my workshops that I teach and learn. However, there are several breathing techniques that we can learn that can be done throughout the day intermittently, which I also do just to kind of like the reset button on the computer, right? You can pause. Actually we say "take a deep breath," right? It's similar to that. Except when done in a more scientific way, the way yoga has taught it to us over the year, then it has a much more physiologic effect on our body and allows us to reset that brain that's going a hundred miles an hour to give it that needed pause and bring it back to the center, right? So I'm more than happy to demonstrate a couple that everybody actually who's on the podcast can learn and use it throughout the day. Especially when you're feeling a little anxious or things seem chaotic around . Are you're ready for the demonstration, Ryan? Ryan (12:36): Yes I am. And for any listeners listening to this, is this something they can do while sitting, while standing? Dr. Usha Peri (12:42): Yeah, ideally it would be best to sit in a quiet corner with your spine erect. So when we start talking about yoga, we're talking about energy. We are energy bodies and we are gathering our energy up and when you're out and about doing our things, our energies are getting scattered and used. So when we are taking a deep breath, we're gathering our energy and we are balancing it. So to do that, just sitting in a quiet corner, closing our eyes, which takes away one of the outward focus, turning it inwards and taking a regular breath in and out, which let's do now. Let's take a regular breath in and out. And the first breath I'll demonstrate is called the straw breath. It's very simple like its name suggest. Take a deep breath through your nostrils and exhale through your mouth. It's like your mouth is now a straw. You're puckering your lips like a straw. Dr. Usha Peri (13:54): And you're blowing bubbles into the invisible water at the end of the straw like kids do. And now observe how you feel when you're doing it. Just take a couple of minutes to do this on our own and observe what happens in the body and mind. (Silence) Dr. Usha Peri (14:23): Taking long, deep breath. (Silence) Dr. Usha Peri (15:32): Observing any sensation that you may have in your body, any prospect maybe going through your mind. So put in your full attention on the breath. Breathing out through the closed lip like a straw. (Silence) Dr. Usha Peri (15:59): And then we get going with that last breath, relax your breath and continue to sit with your eyes closed (Silence) Dr. Usha Peri (16:19): Just observing how your body and mind feel and then when you feel complete, you may open your eyes. And if you're ready, I have one more breath to demonstrate. Ryan, are you ready? Ryan (16:41): Yeah, let's try the next one. Dr. Usha Peri (16:43): So this one is called the alternate nostril breath and as the name sounds, it's pretty intuitive. Actually the breath starts with a exhalation. With the breathing out through the left nostril and then automatically we breathe in through the left nostril and the left nostril is closed. We breathe out to the right nostril, breathe in through the right nostril. Close the right and release the left nostril. Then breathe out through the left and breathe in through the left. It's pretty intuitive. Whatever side you exhale, you breathe in, close that side of nostril, release the other and breathe out. And as we do this, once again, no rush, take your time, elongate the breath a little at a time and just watch how your body and mind feels. Okay. So let's get started with the thumb on the right nostril. The left nostril is open. Breathing out through the left, breathing in through the left. Dr. Usha Peri (18:14): Close the left nostril. Breathe out through the right. Breathe in. Close the right nostril, breathe out, breathe in. Close the left, breathe out through the right, breathe in, now out. (Silence) Dr. Usha Peri (18:53): Elongating the breath a little each time. (Silence) Dr. Usha Peri (19:16): Feeling the inhaling through your body and the relaxation that you feel. (Silence) Dr. Usha Peri (20:02): And then now you're done with that last breath. You may relax your breath and your hands. (Silence) Dr. Usha Peri (20:14): And hopefully you're feeling a little bit more relaxed in your body and your mind as well. And you may open your eyes. Ryan (20:34): Well, I think the analogy you used earlier about a computer restart button, I think that's pretty spot on after those breathing exercises. Dr. Usha Peri (20:43): Yeah. How long did you breathe, Ryan? Maybe four, five minutes at the most? Ryan (20:48): Yeah. I'd say so. Dr. Usha Peri (20:50): Yeah. And so four, five minutes in the middle of the day is not at all hard to find. And I do this in the lunch hour as well. Definitely use a few different breathing techniques from my two toolkit to unwind, reset, eat quickly, and then get back to work. Ryan (21:10): And can you talk about some of the science behind these breathing techniques? Dr. Usha Peri (21:15): Sure. Yeah. Yoga is a very ancient science. It's 6,000 years old. And the postures that we talked about, the breath work as well as meditation all have their roots and origins in yoga. And if you notice, Ryan, when we are angry, do you notice any change in your breath? Ryan (21:36): It gets quicker, right? Dr. Usha Peri (21:38): Yeah, it gets quicker, faster, and it actually ... If you're really aware, you'll notice it gets hotter because our body temperature goes up. Anger is associated with heat, isn't it? Ryan (21:50): Yeah. Dr. Usha Peri (21:50): We talk about a heated argument, right? So yeah. Physiologically the temperature of the breath actually goes up. Now, when you feel sad, how does the breath change? Have you ever noticed it or thought about it? Ryan (22:06): I think it slows down. Dr. Usha Peri (22:08): It does. It gets kind of long, slow. And we talk about sighing. So every emotion in our body is associated with a type of breathing. And emotions are what drain our energy as well. If you notice beyond the physical work that's involved, it's the emotional drain that is huge, especially in these days of pandemic. So in order to manage your emotion, have you ever tried telling your mind, "don't get sad, don't get angry"? Have you tried that, Ryan? Ryan (22:45): I have. And I've gotten mixed results. Dr. Usha Peri (22:48): Absolutely. For the most part it really doesn't work because it's like, we cannot run and manage our mind with our own mind but we can manage our mind using the breath. That's what the ancient users of yoga, the yogis, have found. And that's why they have actually come up with a repertoire of these breathing techniques, each one with a slightly different effect on our physiology. Now this context, we do not have the time to go into the details but very briefly with a very big overview of the science of breath work is that, normally, when we're in a stress state, which on a day to day basis, we are in a stress state, because there are many deliverables, our sympathetic system is in the overdrive: the fight, flight or fright, which is a new addition of adrenaline and cortisol overdrive, is something that's well known to us as clinicians and we are operating in that mode for the most part. Dr. Usha Peri (23:55): The breath work puts a break to all of that and activates the vagus nerve in the parasympathetic nervous system and creates better relaxation like we're on the beach right there for us, right? Wherever we're sitting, wherever we're standing, we can bring the beach to us by breathing a few different times in the prescribed format and so that's the science behind the breath and why it actually works for me. Ryan (24:25): Dr. Peri, where can some of our listeners find more information about this? Dr. Usha Peri (24:29): Sure. You can go to the artofliving.org which is the main web page for this foundation; artofliving.org. The main webpage. We are in the process of creating a separate page for the health care professionals but there's a lot of information on the breathing techniques and our basic program, the SKY breathe medication program on there. I'm a volunteer faculty for the foundation. This is the largest nonprofit organization that's totally volunteer driven, based off of volunteers like me who found the value in their lives and who give back in the spirit of volunteerism. Ryan (25:12): That's great. And thank you so much for joining us today on the DaVita Medical Insights podcast to talk about self-care, especially for clinicians and especially during a time like this where there's a pandemic and there's plenty of stressors everywhere. So thank you again for stopping by. That was much appreciated. Dr. Usha Peri (25:29): Thank you, Ryan, for giving me this opportunity. And hopefully many of you in the audience can take advantage of these techniques that are out there. Ryan (25:37): Thank you again. And we hope that you'll join us next time on the DaVita Medical Insights Podcast.

Self-Care for Clinicians

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. Podcast Transcript: 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.  

Patient-Centered Care

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. Podcast Transcript: 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. 

Kidney Care Transformation: A Global Perspective

Jeffrey Giullian, MD, is passionate about his new—as of Jan. 1, 2020—role as chief medical officer (CMO) for DaVita Kidney Care. Listen to this podcast, in which Halie Peddle interviews Dr. Giullian on his priorities and vision as CMO for DaVita. He gives us some personal background on why he pursued a career as a physician, specifically in the field of nephrology, and what originally brought him to DaVita. Dr. Giullian also discusses his views on kidney care-related innovation and how kidney care is leading all of health care in the shift from volume- to value-based care. Listen and read more DaVita Medical Insights here. Podcast Transcript: Halie Peddle: 00:33 Hello, everyone. This is Halie Peddle with the DaVita Medical Insights Podcast. Today we're joined by Dr. Jeff Giullian, newly announced chief medical officer for DaVita Kidney Care. Dr. G., Thank you so much for joining us. This is our first opportunity to sit down with you since you started your new role. I'm excited for our listeners to get to know you even better and hear your thoughts on innovation in the field of nephrology. Dr. Giullian: 00:57 Well, thanks Halie. I'm really excited to be here and share some of my passion for taking care of patients with kidney disease. Halie Peddle: 01:03 Great. Well, let's dive right in. Lots to talk about today. I want to start off just a little bit more personal. Would love to hear what made you decide to pursue a career as a physician? Dr. Giullian: 01:16 That's a good question. Believe it or not. Growing up I was going to be a lawyer. Don't tell any of our lawyer colleagues. They won't believe it. Freshman year in high school, I got a chance to shadow some lawyers. And I have to tell you, I realized that day, the law was not for me. I didn't really understand what they were doing, and it really didn't appeal to me. Dr. Giullian: 01:36 And right after that I had some biology classes where we were actually doing anatomy and physiology, and somehow it just clicked. The timing was right. And finally I found something that I could really sort of sink my teeth into from a passion standpoint. And that was the human body, the physiology of the human body. And from that point on I was dedicated to becoming a physician. Halie Peddle: 01:56 And of all the fields you could have chosen, what made you choose nephrology? Dr. Giullian: 02:00 Yeah, that's another, I think, funny story, or one at least I like to tell. When I was a medical student, nephrology was the last possible thing that I enjoyed doing. It wasn't something that I particularly understood very well. It wasn't something that really captured my heart or my interest. And turns out that the very first month of internship, I was given a chance to spend about five weeks with a couple of nephrologists. And by given a chance, I went kicking and screaming. It was the elective that was given to me, not the elective that I asked for. It turns out I absolutely fell in love with the physicians I was working with, the patients that they were taking care of, the pathology and the physiology that goes along with kidney disease. And I was hooked from that point forward. Halie Peddle: 02:46 And then tell me what brought you to DaVita? Dr. Giullian: 02:48 So I was in clinical practice here in Denver. My wife and I, we're both from Colorado. We're both natives. I met her while I was in school in Nashville. She and I were, I was in training at Vanderbilt, and she was on faculty at Vanderbilt. And we had every intention of staying at Vanderbilt and staying on faculty. In fact, I was going to practice transplant nephrology and general nephrology there. Dr. Giullian: 03:12 And then fortunately we had a little gift that arrived, my daughter, and we realized very quickly that if we didn't want to spend every vacation flying home from Nashville back to Denver to see all the grandparents, if we actually wanted to take trips on vacation, we'd be better served coming home and being in Denver. And so I came home, and I went into practice here in Denver. Practiced nephrology, general nephrology and transplant nephrology, just about 15 minutes south of downtown. Loved it. Loved every minute of it. Loved my patients. And during that time became more involved with DaVita, doing some work as the group medical director where I helped other medical directors in the center part of the country with clinical outcomes. Dr. Giullian: 03:59 And as I got more and more involved with DaVita and started spending more time at DaVita and a little bit less time with my practice, it became evident that I needed to choose one or the other. And so when I had the opportunity to come to DaVita full time, just about four years ago, I jumped at it. Halie Peddle: 04:14 And now as chief medical officer, what aspect of the role are you most excited about? Dr. Giullian: 04:19 Gosh, there are so many aspects. I'm really pinching myself every day that I get to wake up and really serve our physician partners, serve our village, and most importantly serve our patients as chief medical officer. Dr. Giullian: 04:33 And really, I have three big priorities. The first one is holistic care for our patients. And what that means is providing kidney care wherever patients are on the entire spectrum, whether they have early CKD, more advanced CKD, whether they're considering dialysis because they've advanced to the point that their kidneys are not working any longer, or they're on dialysis, or they're waiting for a transplant, or have gotten a transplant. That's really my number one goal is to provide holistic care to that entire group of people. Dr. Giullian: 05:01 The second is to really double down on the foundation that my predecessor Allen Nissenson put into place, which is a focus on patient safety, clinical quality and patient experience. Dr. Giullian: 05:12 And then the third is forging a future of innovation so that we can in time truly reduce the global burden of kidney disease. Halie Peddle: 05:19 There's tremendous innovation in our field right now and as we look to the future. So I'd love to ask the next couple of questions on that topic. So how would you say DaVita defines innovation? Dr. Giullian: 05:31 Well, for DaVita, continuous improvement is in our DNA, and innovation, I think, takes continuous improvement, really to the next dimension. DaVita pushes for what health care can be, not necessarily what it is right now. And that's especially true around transforming the care that we provide to improve quality of life for our current patients and certainly for our future patients as well. So in that context, I think innovation takes forms. And we are driving innovation by improving care delivery, by developing cutting edge technology, and by advancing new models of care. Dr. Giullian: 06:06 We've also really focused heavily on the science of implementation. So this is a discipline of science that focuses on applying research findings and evidence based interventions to routine clinical practice. And this is really part of how we innovate. And the bottom line is we are committed to helping patients manage their kidney disease, really at all stages from, from early on as I mentioned, so that we can delay the progression of their disease, and to those that are later on so that we can ultimately, if they do need dialysis, we can help them in that transition. We can provide them the greatest possible health during all of that. And importantly, we can help them seek a kidney transplant. Dr. Giullian: 06:46 So really regardless of where somebody is on that continuum, I think that at DaVita, and certainly within the office of the chief medical officer, we really embrace our patient's unique lifestyle needs. And we've developed a patient centric care model. And this is all, I believe, due to the innovation that has been put in place. And we believe in offering the right treatment for the right patient at the right time. Halie Peddle: 07:08 And for a patient with kidney disease today, how do you see innovation showing up for them? Dr. Giullian: 07:13 Yeah, so that's a good question. As I think about sort of my own patients, patients that I've cared for in my career, I think it really comes down to giving each individual the best possible experience and the best chance for improving their health. And so I think patients want to know that they are cared about as well as being cared for. And that's really something that I've tried to incorporate into my clinical practice back when I was in practice. Dr. Giullian: 07:38 So for anybody helping care for patients that have a chronic disease, whether that's kidney disease or anything, it means providing holistic care, care for really the whole being. And that's greater than just kidney care for us. It also means helping them with the healthy lifestyle, helping them stay out of the hospital, fewer days in the hospital. At least the way I think about it means more moments at home with their family and with their loved ones. Dr. Giullian: 08:04 And so, we live in an era now where we can personalize care. We no longer are confined to sort of a one size fits all treatment options. We can really help optimize care for any individual. And so I think that's what innovation looks like to our patients. Halie Peddle: 08:20 Yeah. And now if we want to look just a little bit broader at the nephrology community as a whole, what do you think the focus is right now in terms of innovation? Dr. Giullian: 08:30 The kidney community as a whole has focused on improving safety, decreasing hospital admissions, reducing mortality rates through implementation science, which I mentioned earlier, and specifically by leveraging data from the entire population. Research has demonstrated ways that we can implement quality improvement activities really at scale. And I think this is what the community has been focused on as a whole, and we are all to transform the patient experience, provide broader access to care, improve outcomes, and ultimately reduce costs. That's how we provide value. Dr. Giullian: 09:04 The constraining factor has really been reimbursement, which has been stagnant for more than a half a decade. And the dialysis industry, as an example, provides onsite social work. It provides insurance counseling, care coordination, gosh, you name it, nutritional counseling and a lot more to help provide holistic care of patients. But the ability to innovate, at least in the past, has been constrained by regulations, and to some extent, reimbursement has not kept up with the increasing needs of our patients. Dr. Giullian: 09:34 Fortunately, I would say that the kidney community has achieved very high levels of health equity. And this is really due to a tremendous amount of work by members of industry and the community as a whole. And that's health equity and access to safe, effective treatments and continuing, I think the entire community is looking towards new models of care to do even more for kidney patients. Dr. Giullian: 09:58 DaVita believes strongly, and I certainly believe strongly, in equitable access to care from early CKD identification all the way to nephrology care and ultimately to access to kidney transplants. Halie Peddle: 10:10 So it seems like innovation at an industry level, and even as we look at it from a DaVita standpoint today, it's focused not only on that full continuum of care but also how that shows up day to day. But when we look to the future, 20 years from now, what big innovations do you think could change the way that care looks like? Dr. Giullian: 10:30 Boy, it's so exciting to think about 20 years from now because I think the landscape for kidney patients will look very different than it looks today. And I was recently remembering that I saw my very first kidney patient as a medical student just a little over 20 years ago. I will probably retire, God willing, sometime in approximately 20 years. So I'm in the middle of my career, and what I can say is that I think things will look very different in the year 2040 than they look in the year 2020. That will include things between now and then like wearable dialysis devices, implantable devices that can go inside the body and work like a kidney, but that are not necessarily biologic. They're technology based. And there will certainly be new options for kidney transplants as well. So I think over the next 15 to 20 years or 25 years, we will see a complete revolution in the way that patients with kidney disease are cared for. And I'm hoping that we will even begin to see the beginnings of regenerative medicine, the ability to actually go in and do things to repair kidney damage for those patients that have chronic kidney disease so that they don't progress on to needing dialysis. Halie Peddle: 11:41 Very exciting. And I want to switch gears just a little bit, and I'd love your thoughts on this, Dr. G. Many people within the health care community are talking about kidney care because it's thought to be the tip of the spear when it comes to value-based care. Why do you think kidney care is leading this conversation? Dr. Giullian: 11:59 Well, first off I think it's worth mentioning first and foremost that it's really an exciting time to be part of the kidney care community. There's a lot of attention on us now that we didn't necessarily have in the past. In fact, I would say never in my career have I seen so much emphasis on finding new ways to care for really what I think of as one of the most vulnerable patient populations in our country. So I'm excited. Kidney care in general is leading all of health care in the shift from volume to value-based care and reducing care fragmentation by compensating providers for really improved clinical access, clinical outcomes, quality of life, patient related outcomes rather than just the number of services that are rendered or the number of treatments that are given. Dr. Giullian: 12:44 Kidney care providers continue to prove that the drive towards integrated care inspires innovation and the delivery of better outcomes compared to what's called the traditional fee-for-service models. So for health systems, for payers, for providers, this means moving to the value-based reimbursement models and managing risk. And it's really about managing what we call outlier populations. Patients that don't necessarily fit in the "norm" from a clinical standpoint. And those can be small in number, but they tend to be very high in acuity, and they tend to be high in cost. And patients with kidney disease often fall into these categories. Dr. Giullian: 13:27 And so what we're focused on, and what the entire community is focused on right now, is managing the total cost of care for these patients. And I would say this is where DaVita and our partner nephrologists are really in the best position to manage the total cost of care for patients and improve their clinical outcomes. And this is true for patients with advanced stage chronic kidney disease. It's also true for those patients with end stage kidney disease. I think value-based care enables the delivery of holistic care across the entire continuum. And this results in patients staying healthy longer and avoiding hospitalizations. And for me as a clinician first, first and foremost, this is really what we want to achieve on behalf of our patients. Halie Peddle: 14:08 Dr. G., thanks for joining us again today and sharing more on your clinical vision for DaVita. Dr. Giullian: 14:13 Thank you for having me. I appreciate it. Halie Peddle: 14:15 Listeners, thank you for tuning in and be sure to check out other DaVita Medical Insights episodes for more kidney care educational podcasts. You can also find additional kidney care thought leadership and industry news by following @DaVitaDoc on Twitter.

Nine Questions with Dr. Jeffrey Giullian, Chief Medical Officer for DaVita

Predictive Analytics

According to Mandy Hale, vice president of nursing for DaVita, “It's really important for us as dialysis organizations to be very innovative and very laser focused on retaining our nurses, engaging them and attracting more nurses to the field of dialysis and nephrology.” Listen to this podcast, in which Christy Diehl, senior director in People Services for DaVita, interviews Mandy on why it is important to retain nephrology nurses. They also discuss how to retain these nurses and attract new ones through different types of support and training specific to nephrology. Listen and read more DaVita Medical Insights here. Podcast Transcript: Christy Diehl: 00:30 Hi, this is Christy Diehl and I am a senior director in People Services. Thanks for joining us today. I have the privilege of being joined by Mandy Hale, our VP of nursing, and I will pass it to her to share a little bit more about herself. Mandy Hale: 00:45 Well, thank you, Christy. Hi, I am Mandy Hale and as Christy said, I'm really privileged to serve in the role as vice president of nursing here at DaVita. I have actually had an exciting career both in health care and nephrology and at DaVita over the past about 19 years to be real specific. I actually joined DaVita as a patient care technician many years ago while I was in nursing school. And since that time, I have worked as a nurse and charge nurse, a clinical coordinator where I managed patient outcomes for my dialysis facility. And I've had the opportunity to work in several different operational roles as well. During this time, I've also been able to not only work in our in-center hemodialysis facilities, but also work in the hospital setting where we provide dialysis treatments as well. So that's a little bit about me and my background. Christy Diehl: 01:44 Thanks, Mandy. So today we're going to talk a little bit more about how to retain new nephrology nurses, and as someone who's been a nephrology nurse for almost 20 years, we'll start with just what's your perspective on why this matters? Mandy Hale: 02:02 Well, Christy, I'll let you know we're kind of in a perfect storm really of what could turn out to be a pretty significant nursing shortage. And that's because there's a high percentage of upcoming nurse retirement as the baby boomer generation starts to see more and more retirement. Simultaneously, we also have an increasing volume of Americans who will need and utilize health care services. And during this time, health care organizations here in the U.S. are experiencing poor retention of the nurses who they employ. So all of these things together are going to present some challenges for us in the health care system and actually already are in many places. And it's important to note that for us, the dialysis setting is not going to be immune to this nursing shortage and the talent as presented. So it's really important for us as dialysis organizations to be very innovative and very laser focused on retaining our nurses, engaging them and attracting more nurses to the field of dialysis and nephrology. Mandy Hale: 03:15 I think more importantly or as importantly at least is this importance of patient care and the continuity in that care that occurs when nurses remain with their employers and for us in dialysis for a long period of time. There's just a whole bunch of nursing knowledge and ability to provide really high quality care that comes along with nurse retention and so for our patients being cared for by an experienced nurse is really important. Christy Diehl: 03:56 Yeah. You know, thanks, Mandy. One thing you mentioned really was just the broad challenge facing the health care industry with the increasing nursing shortage and that the dialysis setting won't be immune. So digging in a little bit more, what is the breadth of this issue specifically for those in the dialysis setting? Mandy Hale: 04:19 Sure. Well it is pretty significant. There's almost half a million individuals in the U.S. who have end stage renal disease and received life sustaining care such as dialysis treatment. Mandy Hale: 04:33 There's actually over 6,000 dialysis facilities in the United States and this population of Americans who have end stage renal disease and do require dialysis, it's projected to continually increase. So the patients that are impacted, these patients who are receiving dialysis treatment, really require the care of trained and competent nurses. Christy Diehl: 04:58 So do nephrology nurses require additional training compared to those in other specialties or industries? Mandy Hale: 05:06 The answer to that is yes. So the Centers for Medicare and Medicaid Services, which we often just abbreviate as CMS, require that nurses must have at least one year of registered nursing experience before they can staff in dialysis facilities without another nurse present. So we call that staffing independently. Once the nurse has obtained this one year of nursing experience, the nurse can work in a dialysis facility without the need for a more experienced nurse to be present alongside him or her. And during this one year period, a lot of training and things like that occur and the nurses can provide care. But again, in order to have that ability to practice independently, that does take an extra year. Christy Diehl: 05:53 Great. You've obviously touched on the importance of retaining these nurses and that they take an extra training, right, especially within nephrology. And so for nurses who are new to nephrology, what are they searching for and how do we support them? Mandy Hale: 06:12 Well, nurses new to nephrology have clearly established wants and needs, I believe. They desire things like additional support as they transition from learning and training about how to give dialysis care as they make that transition into practice. They also seek healthy and supportive professional environments. And additionally, they benefit from good preceptors who provide opportunities for clinical experience for them and they really rely on these preceptors or for trainers who are providing them with the education to perform their skills and deliver care. Mandy Hale: 06:50 I personally believe that good preceptors are critical to help not only teach skills but really instill faith and hope in our new nurses here in the world of nephrology. Just in general, nurses will remain in positions where they experience rewards and recognition for their work. So I really feel that is a critical piece of support as well. And then it's important to allow nurses, once they start to gain experience, allow them to practice with a lot of autonomy and provide all sorts of opportunities for career mobility and those sorts of things. However, everything starts with that nurturing care and training as our nurses kind of move from new or not as a dialysis nurses into independent practitioners. Christy Diehl: 07:43 Thanks, Mandy. You highlighted a lot of key transitions and steps that are important and as someone who has personally probably gone through a lot of those in your professional nursing career, how can all of those wants and needs be combined into a program to support new nurses? Mandy Hale: 08:05 Yeah, that's a great question and as I've identified the transition from being a new nurse and not even new to nursing practice, but being new to nephrology, even, can be challenging. However, an effective foundation can be built to help our nurses in the world of dialysis and nephrology continually be able to advance their professional practice. And to me, pulling us all together with like very effective nurse development programs that are based on nursing framework and has historically demonstrated the ability to pull all of these critical elements together. Mandy Hale: 09:00 I believe the position of nephrology care is continually increasing in complexity, so initial education and ongoing education for our nurses is really imperative to provide optimal patient care. So not only having an initial training program but also a clearly laid out plan for ongoing education as well. Christy Diehl: 09:23 Great. What specific elements of nursing are imperative for nurses who are new to nephrology to be extensively trained on? Mandy Hale: 09:33 Well, Christy, I'm glad you asked that question and the answer is not a brief one. There are quite a few just absolute imperative pieces of knowledge and expertise for nurses to obtain through training. So really nurses have to learn a lot of skills that are particular to nephrology and dialysis. These include things like really understanding the dialysis vascular accesses or the peritoneal dialysis access for home modalities. And we refer to these as a patient's lifeline. So having this a very detailed understanding and be able to carefully provide care for our patients access is critical. Nurses has to be very well trained on patient safety and quality and also assessments and critical thinking skills so they can pull all the pieces of a puzzle together for a patient and really put together just a high quality plan of care. Mandy Hale: 10:34 Also in nephrology, nurses have to be trained on and very skilled in interprofessional collaboration including physician relationships, dialysis facilities teams are just that they find their team. So nurses will work alongside of other nurses, patient care technicians, social workers, besides physicians assistants, et cetera. And each of those roles is very critical to the overall care delivery for patients. And so that type of collaboration and team building capabilities is really important. Mandy Hale: 11:05 Also, our nurses are really the leader of the dialysis team and the floor that they're running. So they have to be skilled in leading teams in conflict resolution and all of the things that go along with that. Additionally, I would say that our nurses really have to kind of understand the overall field of nephrology, not just the particular piece of dialysis that they're working in because patient's are going to really kind of move around to different and kind of the different pieces of care. For instance, for patients and for the dialysis facility, they've been under the care of a nephrologist most likely for chronic kidney disease. They may have been in a home modality or have had a transplant or be headed to one of those places. So our nurses really have to be well rounded in overall nephrology knowledge. Christy Diehl: 11:58 Wow. You know that's quite a list. I'm sure we could go and spend a lot more time on each of those and even build it out further. I'm curious, in addition to clinical training and what you kind of talked through, what else is critical in supporting new nephrology nurses? Mandy Hale: 12:17 Well in DaVita, I think we kind of summed that up with one sentence and to me it is, be the kind of nurse you want to work with. So it's really important that not only do we provide our nurses with the clinical knowledge and expertise when they're new to us to be able to provide care to patients. But also, it's important to me that we teach and support our nurses in caring for one another, also. There's a lot of research that shows that nurses who are more satisfied and happier and work more collaboratively with other nurses provide better care. And so for me, I really consider that a twofer. If our nurses are kind to one another and care for one another and their entire care team, not even just limiting that to nursing, then we provide better care for our patients and everybody wins. Christy Diehl: 13:07 Wow. Well, Mandy, I want to thank you for all of your insights on this very important topic. DaVita is lucky to have you leading the charge and supporting all of their new nephrology nurses as well as nurses in other care side staff moving forward. So thank you for all of the insights and your time today. Mandy Hale: 13:35 Thank you as well! It was a pleasure to speak with you, Christy.

Retaining Nephrology Nurses

 “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. 

Competency Hubs in Nephrology

“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.  

Preemptive transplant is the best option for the vast majority of patients with ESKD; however, innovation is needed to keep up with the demand for kidneys. Listen to this podcast, in which Allen Nissenson, MD, chief medical officer of DaVita and emeritus professor of Medicine at UCLA along with Gabriel Danovitch, MD, medical director of the Kidney Transplant Program and professor of medicine at UCLA discuss the current state of kidney transplantation and how that state can be improved through innovation. Drs. Nissenson and Danovitch also describe how nephrologists and providers can help patients be transplant ready through education and waitlist support. Finally, they discuss current developments in transplantation that may help the transplanted kidneys function better in the future, as well as the need for innovations in kidney disease prevention.

Innovations in Kidney Transplantation

“We are very far from parity and equality in terms of access to kidney transplant,” says Samira Farouk, MD. Listen to this podcast, in which Dr. Farouk and Sam Kant, MD, discuss the history of kidney transplants, the current barriers and some of the groups that are affected by the disparities in the system. They also talk about potential solutions for the future with the advent of new options and technologies.

Innovations and Reducing Barriers to Kidney Transplants

DaVita Medical Insights is place for conversation among physicians regarding kidney care, dialysis treatment, and delivering excellent-quality healthcare in a dignified and compassionate manner. This podcast is brought to you by DaVita Inc.

hubhopper

DaVita Medical Insights

hubhopper