Innovations in Kidney Care within the Veterans Health Administration

/kidneynews/6_2/7/graphic/7f1.jpg

The Veterans Health Administration (VHA) is the branch of the Department of Veterans Affairs (VA) charged with the responsibility to “care for him who shall have borne the battle,” in all its facets, including the management of kidney disease. With over 150 medical centers, and more than 1200 non-hospital venues at which veterans receive care, the VA is the largest integrated health care system in the nation. In addition, with over 8 million enrollees and an estimated prevalence of stage 3 and 4 CKD in nearly 11 percent of patients using VHA health services, the VHA can also be viewed as the largest provider of chronic kidney care in the United States. With an increasing number of veterans turning to the VA for some, if not all, of their ESRD care, and with a continuing growth in the veteran population of obesity and diabetes, the VHA is facing similar challenges to the containment of kidney disease as are being witnessed globally.

The VHA Kidney Program operates 69 VA hospital–based and four freestanding hemodialysis units. With 837 dialysis stations, the current treatment capacity is approximately 3500 hemodialysis patients. In addition, over half of the dialysis programs offer home dialysis options. In terms of number of patients, the size of the VHA Dialysis Program ranks among the top 10 dialysis organizations in the United States. Despite this in-house capacity, many veterans are not able to utilize VA-based units due to geographic constraints; therefore, the VHA pays for approximately 13,000 patients to receive in-center hemodialysis or home dialysis in the community. Kidney transplantation is also offered within the VA at five sites across the nation (Portland, OR, Nashville, TN, Birmingham, AL, Iowa City, IA, and Pittsburg, PA) with plans to expand to seven kidney transplant centers.

The VHA Kidney Program is part of the Office of Specialty Care within the Office of Patient Care Services. It is supported by a field advisory committee consisting of nephrology experts. As a collective effort, the VHA recently developed a strategic plan to address advanced kidney disease and guarantee access for Veterans to dialysis care. Consisting of the expansion of cost-effective VA dialysis services, the development of a streamlined national dialysis contract service, and a reinvigoration of the pursuit of innovative health service delivery options, the ultimate goal of the strategic plan is to promote CKD prevention and delay the onset of ESRD.

The VHA transformed itself over the past 2 decades from a hospital-based care-delivery system to that of a patient-centered, home-based care model. Implementing a patient-aligned care team and using the revolutionary power of health information technology—including arguably the world’s best electronic health record system and an extensive array of teletechnologies—the VHA seeks to consistently “provide the right care, at right time and at right place.” To provide a structured way to identify, fund, and test further new health care system proposals, the VA established the VA Center for Innovation (VACI). In 2010, the VACI held the second of its new annual innovation initiative (VAi2) competitions, this time highlighting kidney disease as one of the six preidentified priority areas. Issuing a broad agency announcement, the VA solicited submissions from industry and academia for new models of kidney disease treatment that would leverage VA strengths to improve the quality and cost effectiveness of, and access to, kidney disease care for veterans. Four VAi2 proposals pertaining to kidney disease were selected for piloting, each of which targeted at least one of the facets of the VHA dialysis strategic plan:

VA e-Kidney Clinic—The Medical Education Institute (MEI, Inc.) was selected to assist in the development a virtual kidney clinic with the goal of creating an easily accessible, standardized, veteran-customized kidney disease education portfolio.

Renal Video Teletechnology—Investigators from VA Minneapolis submitted a proposal to test the feasibility of providing advanced care management of veterans with CKD using clinical home-based video technology provided by American Telecare (ATI, Inc.). Outcomes of this novel application of existing VA teletechnology will include measures of care coordination including hospitalization rates and urgent start dialysis.

VA CKD VA Renal Information System—The University of Michigan Kidney Evaluation Center (KECC), will develop a national comprehensive VA kidney database, thereby permitting the evaluation of the epidemiology of acute kidney injury, CKD, ESRD, and renal transplantation in a large national integrated health care system.

Automated Wearable Artificial Kidney (AWAK)—AWAK, Inc. will be piloting the use of a novel wearable “home” peritoneal dialysis device, the automated wearable artificial kidney.

The results of these pilot awards will be the topic of future articles in ASN Kidney News. For further information about kidney health and disease prevention resources, as well as CKD and ESRD treatment options and other federal benefits available to veterans, readers are encouraged to visit the VHA Kidney Program website at http://www.medicalsurgical.va.gov/kidney.program.asp.

Notes

[1] Susan T. Crowley, MD, FASN, is the VHA National Program Director for Kidney Disease, Chief of the Renal Section at the VA Connecticut Healthcare System, and Associate Professor of Medicine at the Yale University School of Medicine in New Haven, CT. Rudolph Rodriguez, MD, is the VHA Renal Field Advisory Chairperson, Chief of Nephrology at the VA Puget Sound Healthcare System, and Professor of Medicine at the University of Washington, Seattle, WA.

February 2014 (Vol. 6, Number 2)