Chronic kidney disease can develop so slowly that the earliest signs of it may show up in routine lab results after it becomes more serious.
To improve disease diagnosis and slow progression, Health Care Service Corporation has paired innovative predictive modeling with its clinically trained care coordinators.
A team of HCSC data scientists developed a model identifying nearly half a million members who could be in the early stages of CKD and mapping their expected disease progression. The model indicates whether a member is likely to progress to a higher CKD stage within a year.
Care coordinators reach out to those members, as well as their providers, to offer education and help improve care and outcomes.
“Many members don’t know they have CKD and identifying them early is crucial,” says Toni Johnson Wright, an HCSC clinical operations executive director. “This allows us to educate them on how CKD impacts their overall health and help them be proactive in managing their well-being.”
CKD occurs after the kidneys have become damaged at least three months, according to the National Kidney Foundation. It also increases risk of conditions, including heart disease and stroke. The disease is divided into five stages to help guide treatment decisions.
The Centers for Disease Control and Prevention estimates more than 35 million people have CKD. Disease risk factors include diabetes, high blood pressure and being overweight. Treatments for late-stage CKD, or kidney failure, are dialysis and kidney transplant.
“You do not want to wait until your condition advances to a more costly complex stage,” Wright says. “We want to help members start to get treatment as early as possible and help them manage their conditions.”
The CKD prediction model is among the ways HCSC uses technology to try to identify members who may need care coordination to address their health conditions, find providers or access resources to improve their health.
Lab results, diagnoses, medications and other claims data help identify members in the earliest CKD stages to try to slow disease progression. Care coordinators assess a member’s knowledge of their condition and provide health education, guidance and specialists to help them get the care they need.
Resources such as digital health tools and videos can help members better understand their conditions and manage their care. Care coordinators also can facilitate referrals to nephrologists and endocrinologists.
They may also collaborate with other teams to coordinate non-medical services such as transportation and food access, as well as medication compliance.
“We don’t want to alarm members,” Wright says. “But we do want them to be aware that there are some relevant health factors they should discuss with their providers.”
Donna Clark, an HCSC wellbeing health advisor, reaches out to members identified with stage 1 CKD because of a hypertension or diabetes diagnosis. She tries to ensure they routinely schedule provider appointments and get lab work done to monitor their conditions.
“Sometimes they don’t know they have CKD,” she says. “Or they’re just seeing a primary care provider and not doing so well at controlling their conditions. There are so many adversities members can face. It can be a lot.”
Clark arranges for blood pressure devices and diabetes equipment to be sent to members who need them. She also offers to help them get referrals to specialists and ensures they get their medications.
The key is to ask questions and encourage engagement in their care before it gets more complicated to manage. She always tries to leave each member with a piece of education to try to build trust.
“I want to make them aware we care and we’re willing to help,” Clark says.