Excellence Is Iterative: Leveraging Data Analytics, Community Partnerships to Improve Kidney Health Outcomes

Seth Southwick, MHA, of Intermountain Health, overviews the Intermountain Health Kidney Services model amid Intermountain's quest to improve patient outcomes. The model involves a variety of techniques, particularly by leveraging community organizations and leaning into advanced analytics and machine learning to optimize care delivery. Here, Southwick discusses the Intermountain Health Kidney Services model at length to demonstrate how the initiatives can be adopted by other health care systems seeking to explore the benefits of community partnerships.

These topics and more were discussed at the Institute for Value-Based Medicine event, “Optimizing Kidney Health: Advances in Proactive Care Models,” held in Park City, Utah, this past September.

This transcript has been lightly edited.

Transcript

What innovations in kidney care or population health management were highlighted during this year’s event, and how do these align with the goals of the Intermountain Kidney Services model?

We have a partnership and a collaboration with MDClone, which is an analytics company. In 2019-ish we worked with MDClone to create an algorithm and some machine learning. Through that process, we were able to pull out of our EMR [electronic medical record] all of the patients that we designated as high risk. And it was really the first time that we had insight into those patients. And before, we relied heavily on primary care and others to manage it and look at it. And what we found, historically, really nationally, was that patients were crashing into the hospital finding out they’re on dialysis. It was too late, like our opportunity to intervene was too late. This partnership with MDClone and the algorithm, the innovation of that was that it, again, pulled those patients in a really succinct, stratified way to the forefront of our work, so that we could proactively reach out to the primary care partner and collaborate and get patients the care that they needed sooner rather than later. So that will be something that has been highlighted for the session this year.

What elements of the Intermountain Kidney Services model have been most successful for improving patient outcomes and how can these be best adapted by other health care systems?

Over the last few years, our COO at Intermountain Health, she has a phrase that says: “Excellence is iterative.” And we've learned a lot over the last several years. In particular, we were really neck deep in this work when COVID-19 hit, and so we had to transition quickly into virtual-based care and not completely remove access.

I think one of the parts that has been really successful, and honestly, there's still a lot of opportunity, but [it's] the collaboration with primary care. Primary care is very overwhelmed. And I attend a lot of different service line presentations and meetings, and more often than not, they always say, “Oh, we'll have primary care do this.” And nephrology is no different when looking at kidney health. So, we tried early on to really partner closely with primary care, and do it in a way that leverages our EMR as well as the data through that EMR. That's something that really can be applied to many, maybe not all, just depending upon infrastructure and structure of organizations, but from a clinically integrated network that is something that could be applied very broadly: closer, deeper collaboration with primary care.

How does the Intermountain Kidney Services model integrate value-based care into its approach and what key metrics are used to measure its success in kidney health management?

It's changed over the last few years, and we've really started to shift as more research and literature has come out specifically about key transition points in patients' journeys. There's a lot of opportunity specifically for our kidney services program to intervene, to manage those patients, through transitions. And really, the key one is around chronic kidney disease stage V transitioning into end-stage renal disease, or kidney disease when the patient is preparing for dialysis. Huge opportunity, both within our system and enterprise, as well as internationally and across the nation and across the world.

Optimal starts is a really key one that we've leaned into heavily over the last probably 3 years, and the literature shows that as patients have a very smooth landing into a dialysis modality, that their overall cost of care and total cost of care is significantly less. And one thing that we've done is dug a little deeper in some of those measures, in the optimal starts, and even started to look at suboptimal starts, where we've made some effort and some change in that patient's glide path, but it's probably not the best glide path. So we continue to focus in and drill down on some of those key measures, you know, from the perspective of the integrated delivery system or network to really help drive some of that value.

What role do partnerships with community organizations and local health care providers play in the effectiveness of the Intermountain Kidney Services model, and how are these collaborations fostered?

There's probably a couple of different areas. So, we work closely with the state of Utah. The state has a number of different kidney disease or kidney health initiatives and efforts that really get into community health and public health clinics. We've collaborated with them off and on over the last probably 5 years, looking at sharing resources, providing some of the education literature to the state so that the state can disseminate that out to the community health clinics. We also lean heavily into some of our population health—not measures, but entities within Intermountain Health. Castell is our population health company. And through those entities, we do leverage their networks as well to get more into community-based practices. Internally, we obviously have a pretty direct connection with our own employed primary care medical group, and through Castell we're able to touch more patients as we share that information and share part of the model with them. And so, those are a couple of different ways that we've gotten more involved more directly within the community.