Utilizing Physician Extenders to Create a CKD Clinic .

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Using Physician Extenders to Create a CKD Clinic. Theresa Becker, MSN, APNP Midwest Nephrology Assoc. Chronic Kidney Disease Clinic. CKD Clinic. The ideas of: Linking CKD Clinics & Anemia Management Programs Using physician extenders in a multidisciplinary approach Are not new!.
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Utilizing Physician Extenders to Create a CKD Clinic Theresa Becker, MSN, APNP Midwest Nephrology Assoc. Perpetual Kidney Disease Clinic

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CKD Clinic The thoughts of: Linking CKD Clinics & Anemia Management Programs Using doctor extenders in a multidisciplinary approach Are not new!

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CKD Clinic ADEPT Clinic A rizonia D isease E ducation P revention & T reatment Started as a weakness administration facility however soon formed into a CKD Clinic Patients are alluded to the Vascular Access Program when GFRs are 25-30 mL/min. Curtis C, Yee B. The way toward executing a CKD Clinic Nephrology News & Issues . 2005;19:53-54.

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CKD Clinic SHAPE UP Program S taging & S moking Cessation H ypertension, H yperglycemia, H yperlipidemia, H yperphosphatemia, H yperparathyroidism, H yperkalemia, & H ypervolemia A nemia P roteinuria E valuation for KRT U ndo nephrotoxins P reservation of veins & P atient training Gnanasekaran I, Kim S, Dimitrov V, Soni A. Get down to business An administration program for endless kidney ailment Dialysis & Transplantation. 2006;35: 294-302.

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CKD Clinic above and beyond : A study by Curtis et al. proposed that even after fitting & auspicious referral to a nephrologist, there is extra estimation of a multidisciplinary group approach in streamlining both short and long haul tolerant results. Curtis BM, Ravani P, Malberti F, et al. The short and long haul effect of multi-disciplinary centers notwithstanding standard nephrology mind on patient results. Nephrol Dial Transplant. 2005;20:147-154.

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CKD Clinic Midwest Nephrology Associates CKD Clinic Model

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CKD Clinic Components of the CKD Care Plan GFR < 60 ml/min. HTN Anemia Nutritional Status/DM Bone/Mineral Metabolism Neuropathy Functioning & Well-being Delaying Progression of CKD

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CKD Clinic Components of the CKD Care Plan GFR < 30 ml/min. Survey Modality Options Preparation for picked choice Transplant referral GFR < 15 ml/min. Visit Clinic Monitor for ESRD signs & indications

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CKD Clinic CKD Patient Education Topics CKD and outcomes; weakness and bone malady Common pharmaceuticals utilized as a part of CKD Avoidance of nephrotoxic specialists KRT Modalities Arm Preservation for HD get to, Access position & care of site Healthy living

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CKD Clinic Access Teaching Pre AV get to: Evaluation for proper arm, for example, vein mapping and direction on sparing that arm. Post AV get to: Care of the site, practicing the get to, and observing its improvement and direction on its future utilize.

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CKD Clinic Documentation Medication List Clinical Action Plan Health Maintenance Clinic Note Surgical Referral Form Vascular Access Record Chart Label

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CKD Clinic Surgical Referral Form Date: __________________ Surgeon: __________________________ Phone: ______________ Fax: ________________ Patient: _________________________________________________ DOB: _______________ Nephrologist: ________________________ Phone: ______________ Fax: _______________ PCP: ______________________________ Phone: _______________ This patient is being alluded to you for get to arrangement. The wanted get to is an AV Fistula. In the occasion you are not wanting to put an AV Fistula in this patient, please call the nephrologist preceding setting some other get to. Patient\'s non-prevailing are is:  Right  Left Patient has been sparing the accompanying arm:  Right  Left Comments (ie: arm harm/mastectomy/pacemaker/past get to): Vein Mapping done pre-referral:  No  Yes – Date/Location: ______________________ Patient is at present on dialysis: Days: ____________________________________________________________________ Location/Phone: ____________________________________________________________ Patient is not on dialysis as of now: Anticipated hemodialysis begin date: _______________________ months Most late serum creatinine: ________ mg/dL & Creatinine Clearance/GFR: ________ ml/min Patient is on Anti-Coagulant Therapy:  No  Yes ___________________________________ Allergies:  NKDA  Yes _______________________________________________________ The accompanying patient data is likewise encased:  Face Sheet  Vein Mapping Report  H & P  Recent Labwork  Medication List

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CKD Clinic Vascular Access Record Stage 4 (GFR < 30 ml/min): Surgical counsel ought to be for \'AVF Only\'. Educate Patient to Preserve Veins of Non-Dominant or Appropriate Arm Obtain Vein Mapping KDOQI Benchmark: AVF arrangement of > 65% for pervasive patients.

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CKD Clinic Surgeon ___________________ Date _______________

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CKD Clinic

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CKD Clinic Chart Label

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CKD Clinic AVF Statistics Patients Initiating HD 1/1/06 to 10/31/06

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CKD Clinic Vaccination Statistics 7/1/06 to 12/31/06

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CKD Insurance Issues CPT Office Visit Billing Codes Low many-sided quality visit ( ~ 15 min.) – 99213 Moderate multifaceted nature visit ( ~ 25 min.) – 99214 High unpredictability visit ( ~ 40 min.) – 99215

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CKD Insurance Issues ICD 9 Office Visit Billing Codes CKD Stage 1 (GFR > 90) – 585.1 CKD Stage 2 (GFR 60-89) – 585.2 CKD Stage 3 (GFR 30-59) – 585.3 CKD Stage 4 (GFR 15-29) – 585.4 CKD Stage 5 (GFR<15) – 585.5

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CKD Insurance Issues Office Visit Reimbursement Commercial Insurances repay NPs at 100% of MD charges Medicare just repays NPs at 80% of MD charges Medicare and an optional protection repays NPs at 100% of MD charges

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Anemia Management Program Erythropoietin Stimulating Agents (ESA) Available for Stage 1 – 5 CKD Patients McClellan, Schoolwerth A., Gehr, T. Clinical Management of Chronic Kidney Disease. Cadido, OK: Professional Communications, Inc.; 2006:185-208.

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ESA Agents Aranesp Package Insert Amgen ®

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ESA Agents Side Effect Profile HTN and Headaches Myalgias Diarrhea Contraindications Uncontrolled HTN Known touchiness to the dynamic substance or any of the excipients

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ESA Agents FDA Black Box Warning Issued 3/9/07 Use the most reduced measurements of ESA that will bit by bit increment the Hgb focus to the least level adequate to maintain a strategic distance from the requirement for RBC transfusion. ESAs increment the hazard for death and genuine CV occasions when directed to focus on a Hgb > 12 gm/dL.

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RPA Renal Physicians Association Risks and advantages must be on individual patient premise Evidence based Hgb targets are useful and ought to be reintroduced May prompt unsuitably low Hgb levels AAKP American Association of Kidney Patients Warning might befuddle to patients & suppliers Supports focusing on Hgbs somewhere around 11 and 12 Lower Hgb prompt concerns in regards to QOL ESA Agents

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ESA Agents Epoetin alfa (Procrit) Single-Dose Preservative Free Vials 2,000 units, 3,000 units, 4,000 units, 10,000 units, 40,000 units/1 mL Multi-Dose Preserved Vials 20,000 units/1 mL 20,000 units/2 mL

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ESA Agents Darbepoetin alfa (Aranesp) Single-Dose Preservative Free Vials 25 mcg, 40 mcg, 60 mcg, 100 mcg, 200 mcg, 300 mcg, 500 mcg/1 mL 150 mcg/0.75 mL

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ESA Agents Darbepoetin alfa (Aranesp) Single-Dose Prefilled Syringes 25 mcg/0.42 mL 40 mcg/0.4 mL 60 mcg/0.3 mL 100 mcg/0.5 mL 150 mcg/0.3 mL 200 mcg/0.4 mL SingleJect Syringe SureClick Syringe

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ESA Utilization Guidelines Hgb Level of < 11.0 gm/dL inside 30 days T. Sat. and additionally Ferritin inside 30 to 90 days Serum creatinine inside 30 days Patient\'s weight in kilograms ESA Dose per kilogram Erythropoietin level is NOT prescribed

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ESA Utilization Guidelines Target Hgb at or above 11.0 gm/dL Caution when purposefully keeping up Hgb > 13.0 gm/dL Monitor Hgb least of at regular intervals Target Ferritin > 100 ng/mL and T. Immersion > 20% Monitor Iron Indices Quarterly

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ESA Utilization Guidelines Dose Adjustments If Hgb increments by > 2 gm/dL per 4 weeks or potentially Hgb level > 12 gm/dL, diminish measurement by 20 to 25% If Hgb level is expanding < 1 gm/dL per 4 weeks, increment dosage by 20 to 25%

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ESA Utilization Guidelines Dose Adjustments 20 to 25% measurements conformities might be accomplished by: Altering the ESA measurement Altering the time interim between infusions

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ESA Utilization Guidelines Dose Adjustments Increases in measurements ought not be made more oftentimes than once every month. Abstain from holding measurements to maintain a strategic distance from checked drop in ESA touchy RBC forerunners and the "teeter-totter" impact of Hgb poor reaction design.

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ESA Utilization Guidelines Dose Adjustments More successive Hgb &/or press records observing might be fundamental when: Recent draining or surgery Post hospitalization Post IV press course Periods of ESA hypo-reaction

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ESA Utilization Guidelines ESA Resistance Infection/Inflammation Blood Loss, Guiac Positive Stools Hyperparathyroidism B12, Folate Deficiencies Sickle cell, Thalacemias Multiple Myeloma/Malignancy ACE Inhibitor Use

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ESA Utilization Guidelines Dose Adjustments Recent information demonstrates Hgb levels can be kept up with at regular intervals epoetin alfa dosing and month to month darbepoetin alfa dosing. Benefits incorporate expanded staff profitability and patient fulfillment/consistence. Moore T., Chookie S. Expanded dosing od darbepoetin alfa in patients with ceaseless kidney ailment not on dialysis: An audit of late information. Diary of ANNA 2005;32:399-407.

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ESA Utilization Guidelines Medicare considers measurements surpassing 90,000 units for each week for epoetin alfa or 200 mcg for each week for darbepoetin alfa to be once in a while sensible and vital. Medicinal legitimization for dosages surpassing these sums ought to be archived in the patient\'s record.

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