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Closing the health gap: the case for integrated care services in outpatient dialysis centers

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Closing the health gap: the case for integrated care services in outpatient dialysis centers

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Content Running head: CAPSTONE 1
Closing the Health Gap:
The Case for Integrated Care Services in Outpatient Dialysis Centers
SOWK 722-DSW Cohort 3
Spring 2019—Capstone
University of Southern California
Aaron Levinson
April 3
rd
, 2019
Professor: Dr. Ron Manderscheid
CLOSING THE HEALTH GAP 2
Introduction
The selected Grand Challenge (GC) for this Capstone is closing the health gap regarding
End Stage Renal Disease (ESRD) and how dialysis is delivered to patients. The focus of this GC
will be on determinants of behavioral and physical elements of ESRD patients that lead to
patients missing their dialysis treatments. Moreover, the innovation for the GC will not only
address these identified barriers to dialysis patients missing their treatment but will do so by the
proposed implementation of integrated care services in outpatient dialysis centers. The
innovation for this GC is being called the Intangible Outcomes Program (IOP) and will have two
main elements to act as the essential patient intervention to the problem. The IOP will aim to
improve conditions of patient-daily-lifestyle by enhancing their health literacy and mental health
barriers to increase compliance with dialysis treatments. The IOP will engage in two main
interventions, such as the use of a Licensed Clinical Social Worker (LCSW), and provide pain
management/reduction treatment via an Activator Methods Chiropractor. The LCSW and
Chiropractor are the two services of the IOP that are to be conducted under the umbrella of the
integrated care service model. In this context, the integrated care model is supporting additional
medical providers in a facility that endorses multiple specialties of service for the benefit of
patient healthcare. In doing so, the health gap in the dialysis sector will be filled by providing
additional medical services to address existing ailments that dialysis by itself cannot deter. As
more services are needed for ESRD patients, the expected outcome of the innovation will
advance sustainable health, bring innovation to primary ESRD care, and promote the advantages
of an integrated healthcare system to the overall field of medical practice.
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Executive Summary

Development stage
[Implementation and Testing]

Year founded
[2017]

Number of IOP employees
[2]

Funding Opportunity
[$175,000]

Use of pilot funds
61.2% Program Staffing
19.3% Program Benefits
11.4% Program Renovation
6.5% Operation/Inventory
1.3% Program Surplus

2018 Pilot clinic profit
[$2,151, 966.40]

Projected monthly IOP
profit
[$7,187.50]

Projected annual profit
[$86,250]

Investors
[DaVita]

PROBLEM/OPPORTUNITY
ESRD patients experience difficulties in attending their regular scheduled
dialysis treatments, causing poor outcomes for patients and increased
national healthcare costs from patient hospitalization events. In adding
mental health and Chiropractic services within outpatient dialysis centers
as a part of an integrated care approach, this would decrease patients
missing dialysis, prevent hospitalization, and lower general healthcare
spending. ESRD is the ninth-ranked leading cause of death in America,
with total Medicare spending for ESRD toppling $34 billion annually. This
figure represents seven percent of the overall Medicare budget. United
States (U.S.) healthcare spending exceeds $50 billion in treatment for renal
disease.

THE PURPOSE
The IOP is for ESRD patients to increase adherence to dialysis treatments
within outpatient dialysis centers as an integrated care model in a selected
pilot outpatient dialysis center. The IOP will reduce the incidence of ESRD
patients missing dialysis treatments that lead to hospital admissions. The
IOP will enable patients to receive their dialysis treatment and multiple
services during one visit. As a pilot, the IOP will emerge as a new
approach to ESRD treatment, payment structures for healthcare will be
changed, and utilization of monetary resources will be altered for the
societal benefit. ESRD patients, families, and communities will enhance
health literacy matters that are vital to produce needed health outcomes,
while kidney care providers facilitate the process.

SOLUTION/PRODUCT
IOP will act as an integrated care method to improve conditions of ESRD
patient lifestyles by enhancing their health literacy and reducing
experienced physical pain measures through a non-opioid intervention.
The IOP is an upheaval action on the innovation continuum to create
sustainable patient health, bringing innovation to primary care, and
promoting the advantages of an integrated healthcare system to change the
field of dialysis in policy and procedure. Furthermore, with the capital
gains and healthcare savings the IOP can generate, then other national
Grand Challenges could benefit through the financial savings and provide
them with additional respective resources towards their intractable
problems.

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POTENTIAL RETURN/REVENUE MODEL
The IOP pilot center conducted approximately 16,965 dialysis treatments
in 2018, collecting profit of $126.84 per dialysis treatment provided. In
2018, the pilot center saw 1,209 missed dialysis treatments with 509
missed treatments due to hospital-related reasons from 86 admits. This
equaled a financial loss for the pilot clinic of $153,349.56 and
~$1,272,499.90 in U.S. healthcare spending for 2018. The IOP can reduce
the annual overall missed treatment rate by an estimated 4.1%, which
would create projected revenue of $86,250 for the clinic and save
$635,000 in U.S. healthcare.

EXECUTION PLAN
In the first year of IOP, the program would request full funding from
kidney care provider, DaVita. The IOP would be tested in an alpha-clinic
at DaVita that is already engaged in an integrated care pilot supported by
Medicare. Alpha-clinics at DaVita are testing sites to support and
implement pilot projects. With the existing partnership between DaVita
and Medicare, the IOP is suggesting to use this platform for its
implementation.

FINANCIALS
IOP will be seeking initial start-up funding from DaVita for its first full
year of operations. To fully support and fund the IOP program, the amount
expected to be received in year one will be an estimated $175,000. The
selected (pilot) DaVita clinic of the IOP generated a profit of over $2.1
million in 2018.

TIMEFRAME
The IOP intervention will be examined through a course of 12 months,
starting January 1 to December 31, 2020. Beginning with: IOP planning
for 30 days, clinic remodels to support the IOP in the following 60 days,
the next eight-nine months for the IOP intervention to be implemented, and
the final two months of the pilot year allotted for program evaluation
(Appendix B).

SUMMARY
The IOP will provide multiple services to dialysis patients delivered in a
holistic, integrated manner. The IOP intention is to lower overall
healthcare expenditures by increasing ESRD patient health outcomes. The
IOP outcomes have the opportunity to influence legislation to reexamine
current healthcare payment structures and create enhanced policy towards
Medicare spending on ESRD treatment in dialysis.

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While innovative and evidence-based social strategies can improve healthcare and lead to
broad gains in the health of our entire society (Spencer et al., 2018), this Capstone project will
examine the social policy of health contingencies in the field of kidney disease to argue that
social work has a comparative advantage as a practice profession to create a concrete
intervention in addressing the GC of closing the health gap in the U.S. The proposed innovation
of this Capstone has reviewed up-to-date research methodologies, utilized renal profession
experience, engaged leadership roles in interdisciplinary teams, collaborated with government
representatives, and participated in employing strategic approaches within a national pilot
program for dialysis treatment. The Capstone innovation aims to achieve more significant policy
influence over existing intervention methods in outpatient dialysis centers to better serve the
lives of ESRD communities. With aspiration, the IOP outcome should be able to provide a
future pathway to care for medical professionals, to further innovate, disseminate knowledge,
enhance practice, and create policy that will succeed for other vulnerable populations (Spencer et
al., 2018). The IOP will use an interpersonal approach to discovering patient problems and then
providing a solution in a real-time manner. At this time, no alternative options exist in the
dialysis market, such as the IOP.
Methods for project implementation will use a streamlined approach to assess its
obstacles and determine future IOP outcomes. Alternative pathways to implementing the IOP
beyond a pilot project will require the support from its selected stakeholders and kidney care
leadership members to engage in its intended practices for ESRD patients to lower missed
dialysis treatment events. The IOP plans to use the premise of the innovation’s ability to lower
missed treatments to meet Medicare goals, benefit DaVita with profit margins, and will also
address the GC of closing the health gap in reducing national healthcare costs. Reducing missed
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dialysis treatments equivocate to healthier patients, which means less spending in healthcare and
profit gains to DaVita. Methods for assessment of IOP respondents will be Medicare
beneficiaries engaging in a single-group, pre-post test design. For the IOP pilot, the selected
dialysis participants will be current patients already receiving dialysis who have experienced
consistent missed treatment trends. Patients will be given IOP services for approximately eight
to nine months and given pre-post surveys from the SF-36 scale (short form), which is a
benchmark assessment designed to provide a measure of an individual’s general health that
include physical functioning and mental well-being. The pre-post SF-36 administration will aim
to seek clinical meaningfulness of changed scores, thereby allowing more objective assessment
of whether an individual has benefited from the IOP innovation. Further implementation
methods for the IOP to operationalize will use a well-considered plan to confront Federal
obstacles the IOP could be faced with. The IOP communication plan will speak to the holistic
side of the innovation, its need, and how to speak with the needed stakeholders and leadership
members to have a substantial impact on IOP implementation. The Capstone project has
considered ethical concerns and possible negative consequences of the IOP initiation and has
determined it will not need the involvement of the Institutional Review Board (IRB) at this time.
Closing The Health Gap
The current healthcare system and its spending rate with the predominant conventional
model of services provided in the U.S. are becoming unsustainable in the context of monetary
output for quality services in return. Federal funding and Medicare/Medicaid rates for medical
treatments are showing limited returns on its existing investment. The U.S. spends more on
healthcare than any other country in the world (Alonso-Zaldivar, 2016). Predominantly, low-
income countries spend the least on healthcare, with minimal occurrences of international donors
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and people paying out of pocket (Alonso-Zaldivar, 2016). However, the U.S. is not able to
discern this difference because of the overall condition of U.S. society and its payment structure
for services provided. When individuals end up paying out of pocket, low socio-economic
populations will forgo needed treatments, or they will receive treatment and be further into
poverty because of medical costs (Malina et al., 2017; Mangan, 2013). Subsequently, the U.S.
healthcare system is disadvantaged in many areas that stretch across all lifespans. The U.S.
ranked last in infant-mortality rates compared to approximately 20 other industrialized countries
around the world (Malina et al., 2017; Mangan, 2013). Additionally, the U.S. is leading in
obesity and leading in the prevalence of diabetes, heart disease, and chronic lung problems
(Brownstein, 2014). The life expectancy for Americans at birth falls behind 25 other countries
(Brownstein, 2014). Overall, the outcomes of these listed variables lead to America spending
more on healthcare per capita than any other country (Brownstein, 2014). It is increasingly clear
that the U.S. healthcare system is becoming deleterious in several aspects, and its support system
around making citizens equipped with skill sets to identify prevention benchmarks are proving
inadequate (Edwards, Wood, Davies, & Edwards, 2015). An identifiable underpinning
attributing to such norms is an individual’s poor health literacy. For example, international
research has discovered that mortality rates among Americans aged 30 to 74 were 55 percent
higher in the U.S., versus any leading country in health outcomes (Brownstein, 2014). The
connection between health, education, and socioeconomic status are stronger in the U.S. than
anywhere else (Brownstein, 2014). This problem is most common in areas with little financial
resources, though the U.S. stands out among high-income countries having catastrophic medical
expenditures that put people into poverty, vis-à-vis, increasing patient mortality (Mangan, 2013).
America is ranked in the bottom percentile in education and health, which leaves a debilitating
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price to the direction of the country and creates the health gap experienced today in the forms of
medical cost and human lives (Edwards, Wood, Davies, & Edwards, 2015). To circumvent,
integrated care in the outpatient dialysis setting is being proposed as the necessary step for ESRD
population needs, in order to start redirecting preventable problems attributing to the U.S. health
gap. In the dialysis environment, primary care settings are not enough and primary care
providers need more support and resources to treat these individuals with their general healthcare
needs (Krishnan, Franco, McMurray, Petra, & Nissenson, 2014). As research suggests, a
formidable solution to closing this health gap is within integrated care, which is the systematic
coordination of general and behavioral healthcare to produce the best outcomes and is an
effective approach to caring for people with multiple comorbidities (Krishnan et al., 2014).
End Stage Renal Disease
There are several areas of healthcare that require much-needed attention to redirect the
existing problems of our GC in closing the health gap. However, this Capstone will specifically
examine the need in the arena of ESRD and with the innovation of the IOP. In renal disease and
dialysis treatment, there is excellent potential in reducing the U.S. healthcare deficit through
delivering medical services via an integrated care system. The widespread ailment of ESRD
attributes to the exorbitant costs on the Federal system because of the intervention of dialysis.
An ESRD patient will need dialysis for the rest of their life in order to survive. The universal
regiment for dialysis treatment is typically set for three times per week at three to four hours per
session, indefinitely. There is no other intervention as complex and concrete as dialysis in the
medical field (Medicare, 2017). The cost of dialysis in conjunction with the cost of treatments
and disease prevention in outpatient centers is in a unique position to turn financial figures in a
favorable direction while improving the lives of ESRD patients. Due to the significance of
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ESRD and its required life-long intervention of dialysis to sustain life, Congress elected in 1972,
for all ESRD patients to get their dialysis covered by Medicare. Medicare is the federal
insurance program available to all beneficiaries once reaching the age of 65 (Medicare, 2017).
In contrast, ESRD patients are immediately able to obtain Medicare coverage if one was to
acquire the disease, no matter what their age (Medicare, 2017). Unfortunately, in 1972,
Congress never anticipated kidney disease becoming such a moving force in society since that
time. Seventy-five percent of all deaths in this country can be identified by just 10 causes, with
kidney disease ranked ninth overall (USRDS, 2017). ESRD affects people at a rate of over
20,000 per year, making dialysis a staple in the U.S. healthcare system (Medicare Interactive,
2017; USRDS, 2017).
Conceptual Framework
Individuals with ESRD suffer from poor health outcomes and multiple disease
complications. In ESRD, individuals and their families are challenged by the barriers
encountered by coordinating care between multiple providers for their personalized care and
treatment for ESRD. ESRD patients experience high rates of hospital admission-readmission,
and a higher mortality rate than the general Medicare population (Medicare Interactive, 2017).
Moreover, dialysis patients can be faced with more mental health barriers, adverse health
outcomes, physical pain, and increased mortality (Zimmerman, 2017). Currently, the U.S.
healthcare system has not addressed the integrated care advantages needed for individuals with
ESRD. U.S. healthcare is challenged with the lack of policy that does not support preventative
measures such as increasing health literacy and effectively addressing pain management for
ESRD patients. In short, America’s healthcare is faced with fixed and limited options and is
unprepared for the cost of providing the needed services to individuals with ESRD. Recognizing
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the physical and mental health disparities of ESRD patients are vital components of treating their
intangible ailments. This failed recognition has led to the lack of policy measures to support
prevention and treatment modalities for dialysis patients in the outpatient setting. Federal and
state spending for ESRD care is overwhelming, which is why the IOP has been developed as an
integrated care model for people on dialysis in outpatient centers. The IOP is that program to
operate as an integrated care model for kidney care providers in outpatient dialysis centers to
increase the health literacy of dialysis patients and to provide pain management services
(Appendix C).
Statement Of Problem
Predominantly, the Federal insurance program of Medicare covers all forms of dialysis in
the U.S., which has proven to be problematic due to the rate of people diagnosed with ESRD,
annually (CMS, 2017). Currently, there are two million people worldwide with ESRD; 660,000
people in the U.S. with ESRD; and roughly 468,000 of those Americans are on dialysis and
193,000 have received a kidney transplant (National Kidney Foundation, 2018). The cost of an
average Medicare beneficiary on dialysis is $84,000, annually (Medicare, 2017). ESRD
individuals receiving dialysis in America are responsible for seven percent of healthcare
expenditures in the Medicare sector (National Kidney Foundation, 2018). ESRD patients
missing dialysis treatment leads to hospitalization admissions, that create insurmountable
spending and increased mortality rates of patients. These events make a significant need for
preventative and cost-effective interventions for ESRD patients to reduce the prevalence of
missed dialysis treatments that will naturally reduce poor health outcomes that lead to
hospitalizations (DaVita Kidney Care, 2017). For the dialysis patient, life is changed and altered
in unimaginable ways—lifestyles and daily routines of ESRD patients are not easily balanced,
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and the newly required adjustments take a significant mental and physical toll on the body
(Rivera, 2017). Patients in outpatient dialysis centers need more medical attention than just
receiving conventional dialysis.
Review Of Problem And Innovation
For this Capstone proposal, mental health will be defined as a state of a person’s well-
being in which every individual has a quality of life to maintain for their own identified success
(Brkovic, Burilovic, & Puljak, 2016). Furthermore, in this context, sufficient mental health
acknowledges how a person can cope with the normal stressors of life, how they can survive
productively and fruitfully, and how they can give contribution on a personal and community-
based level (Brkovic, Burilovic, & Puljak, 2016). Additionally, mental health issues are
synonymous with physical pain experiences (Healio, 2019). Therefore, if the person is
experiencing both mental and physical health barriers, their quality of life is going to be
compromised. Physical health is a driver for almost any achieved success that is experienced,
and the ability for someone to successfully engage in his or her regular physical abilities can
instill mental gratification (Healio, 2019). This pathway suggests that both mental and physical
health are prominent keys to overall quality of life (Healio, 2019). Each year in the U.S.,
approximately 25% of the population struggles with their mental and emotional well-being
(Brkovic, Burilovic, & Puljak, 2016), and no country aside from the U.S. spend more currency
on treating physical pain (Healio, 2019). Maintaining aspects of mental and physical health can
be a challenge for anyone, but it is even more difficult for ESRD patients on dialysis
(Zimmerman, 2017). The treatment of dialysis by itself can create a source of ongoing painful
events, such as abdominal distension, muscle cramping, and needle sticks, all of which can
poorly affect the alignment of the body to cause reoccurring pain (Activator Methods, 2017).
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Consequently, approximately one out of two dialysis patients end up missing a weekly
prescribed dialysis treatment (dialysis prescription is three times per week), 45% of ESRD
patients have a behavioral health issue, and 81% of ESRD patients report experiencing physical
pain (Dialysis Patients Citizens Education Center, 2017; Healio, 2019). It is well-known that
physical pain and mental health issues are commonly experienced by ESRD patients who receive
dialysis (Healio, 2019). The continuing presence of mental and physical health deterrents are
thought to be primary factors contributing to reductions in quality of life for ESRD patients and
the primary antecedents of the ESRD population missing their dialysis treatment(s) (DaVita Inc.,
2016). Research has shown that death rates from illnesses such as heart disease and diabetes are
two to three times higher for individuals living with a mental health condition, making the
statistic significant in showing that chronic conditions can impact mental wellness and worsen
symptoms of illness (Brkovic, Burilovic, & Puljak, 2016; Zimmerman, 2017). The health of an
ESRD patient on dialysis surpasses the metrics of their machines or medical lab printouts. The
IOP is an integrated care innovation for outpatient dialysis centers that will investigate the
intangibles a person experiences. In using mental and physical health-based interventions, the
IOP will reduce the number of patients missing dialysis treatments and enhance the quality of
life of ESRD patients.
Environmental Context
U.S. healthcare representation (insurance, medical practice, policy) is aware of the
financial crisis and dissipating health of their clients and has made attempts over the years to do
something to the change the current direction of the system. For instance, one notable approach
to redirect the GC of closing the health gap in the U.S. came in the form of the Affordable Care
Act (ACA) in 2010 (Croft & Parish, 2013). The ACA made affordable health insurance
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available to more people in the name of supporting innovative medical delivery methods, such as
integrated care that was designed to lower the costs of healthcare (Croft & Parish, 2013). Similar
to the IOP intentions, the ACA took a fragmented system of care that contributes to poor patient
health outcomes and wanted to enhance levels of unmet treatment needs (Croft & Parish, 2013).
Unmet patient needs in the U.S. healthcare system are not unknown factors amongst policy and
medical practices providing services. Like the ACA, the underlying creation of the IOP
innovation is from the environmental context of the GC, specifically to increase access to
medical services cost-effectively, restructure finances and reimbursement mechanisms, and
enhance the infrastructure of ESRD care in dialysis.
Logic Model
The logic model for the IOP and its connection to ESRD patients missing dialysis
treatment will review an explanation of the importance of a patient-centered medical model of
integrated care solutions. The logic model is designed to display a minor blueprint of methods
used to evaluate and refine this integrated care approach that is going to support the use of
external medical specialists to provide services in the outpatient dialysis center setting. The IOP
is an integrated care method that aims to improve the quality of dialysis services to ESRD
patients, lower U.S. healthcare costs, and improve ESRD patient and provider experiences. As
the problem being ESRD patients missing regularly scheduled hemodialysis treatment, the
solution suggests patient-centered, comprehensive, coordinated, accessible integrated care in
outpatient dialysis centers. The resulting logic model shows links in a chain leading toward the
desired outcomes of the IOP. The logic and sought after changes of the IOP occur in the context
of the selected measurable indicators to be used in its implementation and impact analyses. The
intervention will provide individualized mental health and physical pain resources to deliver the
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expected services to attain the outcomes of interest to this GC. The logic model should visualize
the relationships among the inputs to create and deliver the intervention, the activities the
intervention offers, and the outputs leading to the expected results of the program (Appendix D).
Theory of change. Describing the IOP logic model to the IOP funder (DaVita) will
illustrate the important features of stakeholders, such as the patients, its collaborating agencies,
and policy (legislators). The IOP logic model outcomes are focused on the activities that will
facilitate program development. If IOP resources, such as staff, equipment, and funding are
available, then the program will provide the certain services to ESRD patients. If the IOP
participants receive LCSW and Activator Method Chiropractor services, then they will
experience changes in their mental health, health literacy, and reduced physical pain. If IOP
patients enhance their mental health, health literacy, and reduce physical pain measures, then
they will change their lifestyle and approach to attending dialysis treatments. If enough IOP
patients change their lifestyle and approach to attending dialysis treatments, then the innovation
may have a broader impact on the patients’ families, community, and healthcare system.
Problem of Practice and Solution
The IOP innovation will alter the general outlook of renal healthcare (dialysis) by
changing the paradigm to an integrated care approach that will begin making changes in the way
medical service is provided. Organically, the IOP will focus on administration in kidney care,
professionals involved in direct and indirect patient care, its patients, families, and their
community. With many challenges at the crossroads of kidney care, redirecting these issues
requires a multi-faceted approach that supports patient-centered interventions. The long-term
expectation of the IOP is to prove the concept of integrated care being useful in the outpatient
dialysis setting that leads to the increase of ESRD patient adherence to dialysis treatments.
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ESRD patients miss their treatments because there is a perceived lack of understanding as to why
the need for dialysis exists and what it will take from the individual to increase their life
expectancy. The lack of patient understanding correlates to the underutilization of patient coping
skills that would help them make sense of their health situation, as well as adverse physical
effects including hospitalization admission (Edwards, Wood, Davies, & Edwards, 2015).
Limited health literacy and experienced physical pain measures from ESRD patients is a
common phenomenon, which is associated with substantial outcomes including reduced health
knowledge, self-awareness, low-adherence to treatments, increased hospitalization rates, and
increased mortality (Dageforde & Cavanaugh, 2013). At this juncture, the IOP positions itself as
an innovation to bring problem-solving services such as the LCSW and Activator Methods
Chiropractor to the outpatient dialysis setting, in order to produce needed results for patient
health and U.S. healthcare spending. The IOP is an innovation intended to be multifaceted in its
implementation for:
• Addressing unresolved ESRD patient problems.
• Integrated care; bringing services to the ESRD patient at their dialysis center.
• Creating healthier patients by providing more services outside of dialysis.
• Lowering U.S. healthcare costs by creating healthier ESRD patients.
• Challenging status quo of Federal policy structures toward the current healthcare
approach of patient care.
According to the United States Renal Data System Annual Report (2017), over the last 10 years,
less than 10% of individuals were aware of having early stages of kidney disease and the number
of individuals who became aware of having kidney disease increased to 40% by the time those
patients reached ESRD status (Rivera, 2017). This specific increase in knowledge for the patient
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has likely been related to the presence of symptoms and more frequent visits to a nephrologist
where education around their condition is provided more thoroughly (USRDS, 2017). Therefore,
specific education tailored to ESRD patients is being suggested as an active component to
increase efficacy towards stable compliance with dialysis treatments (Dageforde & Cavanaugh,
2013). It is speculated that once a patient has been diagnosed with ESRD, the same format of the
patient processing their illness or delegating tasks for themselves while in their early stages of
kidney disease follows similar thinking patterns that supported their lack of awareness for their
illness (Cavanaugh et al., 2010; Rivera, 2017). Various elements of ESRD patient-conditions are
unbeknownst to them in the same manner during the early stages of kidney disease as it is in
post-ESRD diagnosis (Rivera, 2017). Therefore, IOP efforts will seek to address these broad and
overlapping sets of issues that ESRD patients experience on a mental and physical health
platform.
The IOP is requesting to operate as a pilot program with a world leader in kidney care—
DaVita. The pilot center would be a DaVita outpatient dialysis unit in Phoenix, Arizona. The
selected clinic for the IOP is already engaged in an integrated care pilot for Medicare, which
makes the conditions ideal for the IOP innovation to co-exist with what is already being
implemented at this time. Medicare’s End Stage Renal Disease (ESRD) Seamless Care
Organization (ESCO) is the current integrated care pilot that constitutes a nursing case
management team that provides medical follow-up for ESRD patients. An ESCO follow
up/action consists of referring patients to medical specialists that reside outside the dialysis
center. However, with the IOP integrated care format, IOP professionals will practice within the
dialysis unit, thus implementing the integrated care model in the dialysis treatment center. Using
integrated care in this manner is going to be innovative because it simply has not been done in
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this capacity. The selected pilot clinic has a patient census of 135 and would operate under the
auspices of the board of Directors and the Divisional Vice President (DVP) in its respective
region.
Proposed Innovation
The IOP will consist of two professionals providing services to patients. For mental
health intervention, there will be mental health consultation services performed by an LCSW.
For physical health intervention, a Chiropractor that specializes in Activator Methods adjustment
techniques will be used to address physical pain experiences of ESRD patients. The LCSW will
troubleshoot patient health literacy matters to cover tasks such as, but not limited to, patient
emotional identification, effective decision-making, quality information-seeking, problem-
solving, and critical thinking directed at their condition.

The Chiropractor within the IOP will be
a licensed professional who is trained in Activator Methods techniques, which is the most
widely-researched adjustment method and only adjusting approach with clinical trials to support
its efficacy for redirecting pain (Activator Methods, 2017). Activator Method Chiropractic care
uses a hand-held device that applies slight impulse forces to the targeted area of pain. This
process has shown the ability to improve neurophysiological responses, improve neck/low back
pain, blood pressure, reduce anxiety, correct irregular heart function, and stimulate nervous
system damage (Activator Methods, 2017). The IOP's onsite LCSW will troubleshoot ESRD
patient lifestyle choices, mental health, and overall health literacy components, and the IOP's in-
center Chiropractic service will counteract the reported physical pain from patients. These IOP
services are intended to be comprehensive and patient-centered to provide prevention-aimed
interventions to deter patients from missing dialysis treatments. If this pilot is successful, the
integrated care model of the IOP intervention can potentially be disseminated to other outpatient
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dialysis centers across America. Despite the potential challenges of engaging full integrated care
(allowing any medical professional to practice in outpatient centers) due to Centers of Medicare
and Medicaid Services (CMS) licensing restrictions, the deployment and testing of the IOP
intervention should be a Federal priority. The IOP is a response to the limited interventions
existing for dialysis patients to reduce their missed treatment and hospitalization rate.
Comparative assessment. The IOP will stay within the current DaVita structure of the
integrated care pilot. The focus arena for the IOP is on integrated care as opposed to the
traditional model of care of just providing dialysis to ESRD patients. However, as DaVita is one
of the largest kidney care providers in the world, so is its competitor at Fresenius Medical Center
(FMC). FMC is another large kidney care provider serving dialysis to the national community
and is also currently engaged in integrated care efforts. FMC has recently adopted the integrated
care process in bringing on ESCO services from Medicare, such as DaVita has (Personal
communication, March 22
nd
, 2019). However, FMC has taken the integrated care process a step
farther than DaVita has by contracting with primary care physician (PCP) services that come into
their clinics without violating Stark Laws, Anti-Kickback Laws, and bypassing any collusion or
financial conflict of interests. Stark Laws prohibit physician self-referral, specifically a referral
by a physician of a Medicare or Medicaid patient to an entity providing designated health
services if the physician has a financial relationship with that entity (Stark Law, 2013).
Similarly, Anti-Kickback Law prohibits a person or entity from paying another to induce that
entity to refer services, which may be reimbursed by a Federal healthcare program (Anti-
Kickback Statute, 2019). FMC has been able to contract with a service that is PCP based and is
offered nationwide to several medical settings, making it a service that is free of CMS restriction
by being a provider for the general public to use (Personal communication, March 22
nd
, 2019).
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In contrast to the IOP, the PCP services (medical specialist) FMC have contracted with
are still ‘outside provider-based’ and not housed in the dialysis unit. Furthermore, the PCP
service practices general healthcare, meaning if there is a significant issue identified, the ESCO
service will continue to refer the ESRD patient outside the unit to seek services (Personal
communication, March 22
nd
, 2019). Essentially, this service of FMC can be replicated,
considering the general dialysis patient has access to a PCP and currently possess the ability to
receive PCP services by making an appointment with their provider. Even with outside PCP
services visiting dialysis patients, PCP prescriptions will still be written that most nephrology
services address in the clinic already (Personal communication, March 22
nd
, 2019). The IOP will
be different in this regard, in that it will have in-center services available to the patient in real-
time, with the mindset of troubleshooting problems before they occur to stay ahead of missed
dialysis treatment events. The IOP is acting as an integrated care service that is patient-focused,
individualized, and hands-on without the use of psychotropics, opioids, and other prescriptions to
address problems that could potentially be resolved through mental and physical health
interventions.
Key Stakeholders
The IOP’s key stakeholders that have an awareness of the Capstone GC would be
Southwest Kidney Institute (already a contracted partner with several kidney care providers in
the Arizona region), Medicare/CMS, and ESRD Networks of America. However, the most
important of stakeholders could be considered the ESRD patient, their families, and the general
community at large. As the patient, families, and communities take on a new responsibility for
their outcomes through the IOP, the financial and physical stressors that exist in the current
system will begin to dissipate. With the other stakeholders listed, these partners meet the IOP’s
CLOSING THE HEALTH GAP

20
aim in titrating the costs of dialysis, via reducing missed dialysis treatments. There are currently
contracted performance objectives to be carried out by ESRD Network contractors for
Medicare/CMS, but achieving overall national quality improvement goals are not being met.
The IOP innovation has a positive relationship with the stakeholder interests through the
foundational problem of ESRD patients missing dialysis treatments. ESRD Network contractors
serve as partners in quality improvement with beneficiaries, practitioners, healthcare providers,
and other healthcare organizations to disseminate best practices (National Institutes of Health,
2017). Implementing the IOP as a standard service will require new policy and procedures to be
acted upon, which makes the support of the selected stakeholders vital. The IOP’s
implementation will appeal to the stakeholders because of their contributions and desire for
patient-centered care to increase the health of our ESRD community and reducing costs of ESRD
services (National Institutes of Health, 2017). With the primary goal of keeping the patient
coming to dialysis treatment consistently, the IOP coincides with the political environment for
ESRD treatment.
Opportunities For IOP
The problem that the IOP is set to address is one that has been identified for current
policy changes and been introduced to the House of Representatives. The missing treatment
problem has influenced the policy and political stream for closing the health gap in ESRD, in
order to change the course of the continued economic restraints on corporate, state, and federal
budgets in dialysis treatment (Schmidt, 2016). More specifically, the Dialysis Patients
Demonstration Act (DPDA) is the proposed bill that entered legislation within the last two years
and is currently waiting to be passed. If passed, the DPDA would allow integrated care within
outpatient dialysis clinics around the country, meaning CMS changing its policies around what is
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21
allowed to be medically practiced within a dialysis center (Schmidt, 2016). Politically, CMS, the
Medicare bundle, and DPDA are within the IOP framework to justify its needed services. The
IOP problem of ESRD patients missing their dialysis treatments has had a significant influence
on the national mood and interest groups of resolving the GC (Appendix B). While IOP barriers
exist on an implementation level, its pilot program is a reality and so are its practices to help
close the health gap. If the IOP operates as a pilot to prove its concept, it would be protected by
various elements of immunity to CMS regulations to create a pathway to its success. If the IOP
proves to be successful, then it can dictate future policy streams to enhance the knowledge of our
policymakers for the needed changes to become a permanent action in dialysis—with or without
the legislation of the DPDA.
Innovation Link To Other Grand Challenges
If successful, the IOP approach shows the ability to potentially assist in other Grand
Challenges from the money it will be able to save through reducing missed dialysis treatments
(keeping patients out of the hospital). The less money the U.S. healthcare system is spending on
dialysis hospitalizations, the more monetary resources begin to accumulate for more purposeful
actions. If monetary resources can accumulate as the IOP suggests it will, Grand Challenges in
the areas of advancing long and productive lives, ending homelessness, creating social responses
to a changing environment, harnessing technology for social good, reducing extreme inequality,
and building financial capability for all would benefit in their respective intervention initiatives.
More capital gains create more opportunities for innovations to come forward for vulnerable
events in America. Any monetary gain that can be achieved through the IOP is additional
funding for the rest of the country to redirect disparities. Alternatively, innovation leads the way
for methods to change the course of existing functions into a higher level of business acumen and
CLOSING THE HEALTH GAP

22
approach to problems. Healthcare funds from private, Federal, and public sectors should not be
dissipating at their current rate while producing the current outcomes that are being exhibited at
this time. The IOP should enhance healthcare spending in the arena of ESRD, with its ripple
effects being spread to its patients and ultimately for the country. Arguably, if the
implementation of the IOP model were able to contribute to the reduction of poor health
outcomes and multiple disease complications of individuals with ESRD, then there would be
cost-savings.
Innovation Links And Change Theory
To clarify how the proposed innovation/solution aligns with its logic model and theory of
change presented in the conceptual framework, the IOP-aim is to lower rates of ESRD patients
experiencing mental health issues, health literacy disparities, and physical pain related to their
disease. Therefore, integrated care resources are needed in the dialysis sector that will reduce
healthcare expenses and enhance the health of the patient. The IOP model will be implemented
within the existing pilot program of integrated care in outpatient dialysis centers by adding
mental health consultation and Chiropractic services within the dialysis facility. The IOP model
is an added dimension to the current pilot program of integrated care for dialysis centers by
introducing a social work/mental health component and Chiropractic treatment. It is anticipated
that these additional components will reduce health complications of ESRD patients on dialysis.
Current context for proposed innovation. Individuals with ESRD suffer from poor
health outcomes and multiple disease complications and co-morbidities. ESRD patients usually
experience high rates of hospital admission, readmission, and a high mortality rate (Medicare
Interactive, 2017). ESRD-Medicare beneficiaries are less than one percent of the Medicare
population but account for approximately seven percent of total Medicare spending. This is an
CLOSING THE HEALTH GAP

23
amount of over $34 billion in U.S. Federal spending; overall healthcare spending on ESRD going
over $50 billion between Federal and private expenses (National Kidney Foundation, 2018).
ESRD-Medicare beneficiaries often require several visits to multiple providers for their
personalized care in ESRD, and usually, attention is not coordinated with other medical
specialists to address the multiple co-morbidities to their condition (Krishnan et al., 2014). The
piloted integrated care model in outpatient dialysis centers and DPDA are all in the wake of
ESRD patient hospital admissions and re-admission events (DaVita Kidney Care, 2017). On
average, ESRD patients are admitted to the hospital nearly twice a year, and approximately 30%
have an unplanned re-hospitalization within the first 30 days following their discharge (USRDS,
2017). These hospitalizations represent a significant societal and financial burden, considering
the cost is approximately $15,000 for a five to six-day hospital admission for an ESRD patient
(Personal communication, January 29
th
, 2019). The IOP focus is on determinants of health
elements that ESRD patients possess and lead to those patients missing their dialysis treatments.
With such factors in place, integrated care in outpatient dialysis centers will reduce the amount
of missed dialysis treatments and eliminate the prevalence of patient hospitalizations.
Based on projections, the IOP will be the first intervention of its kind to have significant
effects on the mental health of an ESRD patient influencing continued adherence to dialysis
treatment, increasing a patient's health literacy, and reducing experienced physical pain. In time,
the IOP can transcend to billable services with government funding as a part of patient care in
these areas of treatment. Although Medicare billing exists for mental health services, both the
reimbursement rates for mental health and Chiropractic services are minimal for the tasks
required in serving a dialysis patient as the IOP intends. As much as integrated care is needed in
healthcare, dialysis treatment will be the first medical intervention to pioneer the long-term
CLOSING THE HEALTH GAP

24
outcomes it is capable of producing, and the IOP has the opportunity to make great changes in
the healthcare system by addressing patient lifestyle events that have gone unaddressed. No
other medical intervention is as patient-centered as the IOP, regarding its ability to counteract
patient mental health literacy issues that affect the decision making of the patient that lead to
poor health outcomes. The IOP will be expected to reduce approximately four percent of the
annual total missed treatment rate for the selected pilot clinic. If an annual four percent
reduction of the missed treatment rate were achieved in the pilot clinic of the IOP, then the
monetary gain of internal revenue for the respective outpatient unit would be nearly six figures
and over one million dollars in savings for the U.S. healthcare system. With this success of the
IOP, the last stage of its implementation will be the request of the IOP becoming a part of the
Medicare bundle for the ESRD patient as a Medicare beneficiary. This bundle goal is not yet a
reality, but a top priority for the IOP to achieve over time with its expected results. If IOP
services were to be a part of the ESRD-Medicare bundle, it would forever change the landscape
of dialysis and Federal funding for healthcare delivery.
Comparative Projects
In the context of in-center hemodialysis treatments, the comparative analysis in the
business of dialysis is limited in the context of the types of dialysis providers that exist within the
market, and how they operate in similar capacities. Integrated care in ESRD is the new action
step in the dialysis arena that encourages changes for future analyses. Currently in dialysis care,
analysis in integrated care interventions is missing critical data for outcomes leading to the
intended goals of reducing financial costs by improving patient health. In the current climate of
treatment for ESRD, different factors such as political events, economic changes, or industry
changes will influence these needed analytical trends. Capturing “why” our ESRD patients are
CLOSING THE HEALTH GAP

25
missing dialysis treatments should be the leading infrastructure and premise for future
interventions. The existing state of dialysis needs innovation for useful comparative analysis to
be present to show such suggested data for ESRD patients missing dialysis treatment. The more
data obtained through a comparative analysis for integrated care implementation in dialysis
centers will create more room for innovation in the future, as these analytics will propose
continued changes for a dialysis field that has not seen any changes in over 30 years (Robinson
et al., 2016).
Market Analysis
Analysis of the current market for the IOP innovation relative to alternative options
shows correlations with existing integrated care efforts that are circulating the dialysis arena at
this time. In review, most notably since 2015, nephrology practice groups have joined together
to participate in the Medicare (ESCO) pilot, which is Medicare’s integrated care effort for
outpatient dialysis centers. The ESCO service takes place in dialysis facilities that collaborate
with nephrologists, interdisciplinary renal team providers (dietician, social worker, clinical
coordinator), and other healthcare providers to coordinate care being provided to ESRD patients
within their respective outpatient clinics (Wish, Johnson, & Wish, 2014). The goal of ESCO is
for dialysis facilities to work together for high-quality care to be delivered that meets the
individual needs of patients and their medical situations (Wish, Johnson, & Wish, 2014). An
ESCO team is intended to provide highly coordinated care for Medicare "fee-for-service”
beneficiaries with ESRD to leverage care coordination services and real-time interventions as a
prevention measure for ESRD patient co-morbidities (Wish, Johnson, & Wish, 2014). The
ESCO is the most prominent, current, and relative intervention in the field of dialysis.
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26
The IOP would respectfully compete with the ESCO not in the manner of making
attempts to eliminate the ESCO service or making it obsolete, but to enhance the project and to
work in unison. According to DaVita ESCO team members, since the ESCO inception to the
dialysis market in 2015, progress at times has been slow moving and more resources will be
needed to resolve the missed treatment problem (Personal communication, January 29
th
, 2019).
Even with ESCO staff in place such as registered nurses, care coordinators, and regional
operation management oversight, ESRD patients are still being admitted to the hospital at a rate
that needs to be lowered (Personal communication, January 29
th
, 2019). ESRD patients in three
DaVita dialysis markets across the U.S., in Arizona, Pennsylvania, and Florida have benefited
from ESCO efforts of identifying ESRD patient medical needs, but the “fight is still being lost to
a degree” (Personal communication, January 29
th
, 2019). It is being encouraged that ESCO
services be given more time to provide additional care services, and for integrated care efforts to
expand their abilities for the necessary changes Medicare is searching for (Personal
communication, January 29
th
, 2019). However, hospitalization rates from these three DaVita
ESCO markets have shown improvements over the last three years in reducing admission rates,
indicating integrated care can and will work (Personal communication, January 29
th
, 2019). At
this time, more needs to be done to stabilize our ESRD population to avoid hospitalization rates
that have created the financial instability that has been identified over the years (Personal
communication, January 29
th
, 2019).
Innovation Landscape
The IOP project design will be innovative in comparison to the ESCO intervention
because it is an innovation that is the first of its kind regarding treating the patient holistically,
with the onus of making the service solely patient-centered around the integrated care model of
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27
having in-center providers treating patients in alignment with dialysis. Integrated care is a
concept that is authoritatively not utilized in the field of medicine and does not exist in the
official landscape of kidney disease. Although ESCO is a current pilot to integrated care efforts,
it is only a team of staff members who refer patients outside their dialysis centers to external
medical specialists. With that approach, there is no guarantee of patient follow up, consistency,
and/or accountability on the patient. In many instances, the ESCO is an impersonal approach to
integrated care that involves the patient on a low level. The IOP innovation would be the first
ever to focus services on the mental and physical health of dialysis patients, while the patient is
coming to their dialysis center; nothing like this exists in ESRD treatment, nationwide. In short,
IOP integrated care benefits, have the opportunity to truly honor Medicare’s goals of the ESCO
program to lower healthcare costs by increasing the health of the patient.
Project Methods For Project Implementation
The proposed framework and implementation of the IOP innovation will utilize a
Multiple Streams Framework (MSF) approach to construct an analysis of the facilitators and
barriers involved in the implementation of the IOP. The MSF constitutes a pathway for
understanding policy processes and agenda-setting through three separate streams of
dissemination of research, which correlate with the IOP’s direction (Brownson, Colditz, &
Proctor, 2017). These multiple streams include problems, policies, and politics. The MSF can
introduce a more definite conception of the problem and posit how these issues can be addressed
(Brownson et al., 2017). The MSF approach will be operationalized to display IOP
implementation because it could prove valuable in helping explain the policy dynamics and the
environment surrounding the IOP obstacles. The IOP implementation of MSF connects the
facilitators, dialysis operations structure, priorities of the business, readiness for change, and
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28
industry climate for the organizational characteristics that will be critical components for
streamlining the program (Appendix E). The multiple streams of the MSF have become standard
practice in policy sciences, including comparative analysis for proposed means of understanding
public policy-agenda setting (Brownson et al., 2017).
The IOP will require new policy and procedures to be acted upon to reroute our problem
of ESRD patients missing dialysis treatment leading to hospitalizations. Where to start involves
the "why" of the mission, which is a prevention method to the intractable problem of the
proposed innovation. Preventing missed dialysis treatments is the entirety of the IOP innovation.
The IOP is a program that will be acted upon and intended for the ESRD patient to engage in
before they even miss a dialysis treatment. The operations of IOP are predicated upon an intake
assessment that is to be initiated before a dialysis patient would miss a treatment. Through the
IOP artifact, a further breakdown of these action steps is explained (Appendix A). The IOP will
be considered as much of a necessity as it is for the patient to be receiving dialysis. When the
patient enters their respective outpatient center, the IOP services and dialysis are intended to be
in unison. Furthermore, the IOP will target existing ESRD patients on hemodialysis who miss
their treatment at a consistent rate of two to three times per month due to any reported barrier to
attending prescribed treatment, which would be categorized under the mental health consultation
practice of the IOP (enhancing health literacy related to their ESRD and treatment compliance).
Addressing systemic patient barriers that impede patients attending their regular scheduled
dialysis treatment of three times per week will reduce patient mortality (Chan, Thadhani, &
Maddux, 2014). This problem of missed dialysis treatment has created the political platform of
the MSF for implementation. Without addressing the problem through new policy changes for
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29
the IOP to operate as an integrated care function, patients will continue to experience
hospitalization admissions from missed treatments and acquire preventable medical conditions.
Capstone Practice Components
Chronic kidney disease is a multifaceted problem having both physical and psychological
connotations for the patient. A multidisciplinary team effort is often needed in the management
of such patients. Patients who suffer from renal failure often experience great psychological and
physical problems that are left unattended. ESRD patients on dialysis are in a situation of abject
dependence on a machine for the rest of his/her life; no other medical condition has such a
degree of dependence as dialysis (Swartz, Perry, Brown, Swartz, & Vinkour, 2008). With so
many complexities surrounding chronic kidney disease and the nature of its treatment procedure,
inadequate education and poor dissemination of practices do occur (Swartz et al., 2008). Patients
with renal failure suffer from many other medical conditions and are on many different
medications. Most notably, ESRD patients are highly susceptible to physical/mental agitation,
confusion, electrolyte disturbances, hypertension, hypoglycemia, aluminum toxicity, and uremia
(De Sousa, 2008). These mentioned traits act as antecedents to ESRD patient depression and
anxiety that exacerbate issues of health determination and receiving needed care (De Sousa,
2008).
Justifications For IOP Chiropractic Services
It has been widely observed by dialysis nurses that patients on treatment experience pain
that may not be adequately assessed or treated (Bourbonnais & Tousignant, 2012). ESRD
patient pain experiences were related to physical/joint pain as well as discomfort from being
immobile (Bourbonnais & Tousignant, 2012). As patient pain experiences required additional
assessment and intervention, Medicare instituted a required monthly pain assessment in 2016 to
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30
be given to all patients throughout the year (Personal communication, January 29
th
, 2019).
However, since that time in the selected pilot clinic for IOP, the Medicare patient pain
assessments have only been able to identify patient problems for referral. Once a patient reports
pain, the patient is prompted to seek medical attention from their PCP, which frequently leads to
opioid prescriptions or additional referrals to pain management services. The patient can rarely
follow up with the provided interventions from the initial conducted pain assessment (Personal
communication, January 29
th
, 2019). ESRD patients on dialysis treatment experience a variety
of pain symptoms, neuropathy and musculoskeletal pain (Bourbonnais & Tousignant, 2012).
Unresolved pain can have a profound effect on patient quality of life and most importantly,
become a deterrent for ESRD patients to maintain full adherence to their dialysis treatment
regimen of three times per week (Brkovic, Burilovic, & Puljak, 2016).
Pain is common in patients on dialysis with a particular focus on specific types of pain,
such as back, shoulder and neck pain, or musculoskeletal symptoms (Bourbonnais & Tousignant,
2012; Healio, 2018). Therefore, Activator Methods Chiropractor care is the suggested integrated
care method of the IOP to redirect physical pain ailments amongst our ESRD population in their
outpatient dialysis centers. The findings of how stimuli are engaged in mechanoreceptors of
human joints during Activator Methods from the hand-held activator device are clinically tested
and have proven results (Inami et al., 2017). For example, Activator Methods research has
shown positive results on brain processing mechanisms after the adjustment technique has been
administered. Such results exhibited physiological relaxation via a decrease in sympathetic
nerve activity, and regional brain deactivation and activation for improved neurophysiological
responses (Inami et al., 2017). Moreover, Activator Method application has resulted in glucose
metabolism increase in regions of the brain that lead to improved metabolic rates, muscle
CLOSING THE HEALTH GAP

31
plasticity, and glucose uptake in skeletal muscles indicating increased function (Inami et al.,
2017). Other measurements discovered pain relief from reported sites, relaxation of cervical
muscle tension, and suppression of sympathetic nerve activity (Inami et al., 2017). The IOP
innovation is warranted as an identified strategy to facilitate the comfort of ESRD patients in
their dialysis center by providing these pain reduction methods.
Justifications For IOP Mental Health Services
ESRD patients present a plethora of mental/cognitive barriers related to their kidney
disease, including social and emotional processing disturbances (Swartz et al., 2008).
Negatively, ESRD patient perceptions of their interpersonal environment have lead to various
mental health disorders that affect their well-being and influence their ability of self-
determination (De Sousa, 2008). The patient’s personal feelings in outpatient dialysis units
influence patient well-being and their mental health outlook for long-term effects playing on
medical conditions and situations (Cavanaugh et al., 2010). In short, a patient’s relationship with
their dialysis center and medical condition contributes to their well-being (Swartz et al., 2008).
The IOP has identified that ESRD patients will miss their prescribed dialysis treatments due to a
strong correlation of these factors, and limited health literacy is associated with their dialysis
lifestyle (Dageforde & Cavanaugh, 2013). Because of certain health literacy disparities that
encompass mental health and quality of life, ESRD patients are more likely to miss their dialysis
treatments and risk admittance to the hospital (Cavanaugh et al., 2010). ESRD patients being on
dialysis have limited strategies and resources to effectively redirect stressors associated with
being on dialysis that will exacerbate a misunderstanding of managing symptoms, fatigue, fluid
restrictions, and nutrition concerns (Dageforde & Cavanaugh, 2013). The IOP mental health
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32
service is a carefully crafted approach for the ESRD patient to facilitate their learning process to
counteract a difficult dialysis experience, effectively.
Obstacles
Before any integrated care movement or pilot initiation, the norm of conventional dialysis
treatment in outpatient dialysis centers merely is just providing a patient with dialysis treatment,
needed medications, and their blood-lab work. CMS justifiably restricts medical entities from
entering agreements with other medical providers to keep the best interest in mind towards the
patient. More specifically, similarly to Anti-Kickback Law and Stark Laws, this approach by
CMS is in place to avoid collusion and conflict of interest of dialysis providers that would place
monetary value as a priority over the lives of the patient. However, this translates to a strict
policy of not allowing integrated care services to flourish on a national level. CMS ruling will
not permit integrated care services to be operational in outpatient dialysis centers because of the
potential of collusion and conflict. These CMS restrictions are appropriate and necessary, but
are also a substantial obstacle for an integrated care approach to be implemented in outpatient
dialysis centers. In counteraction, the IOP is structured to avoid these CMS barriers that have
been in place to protect patient care. At this juncture, the IOP has an opportunity to showcase its
methods as an integrated care service that is free of collusion and conflict, and avoidant of CMS
provider restrictions that will allow it to lawfully operate in outpatient dialysis centers. The IOP
would operate as a conflict-free service if it were deemed a “necessary” action for the ESRD
patient to meet Medicare standards. If done so, the IOP operation and staff could be housed
under Medicare and CMS ruling and employed by the kidney care provider to provide services.

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33
Alternative Pathways
As DaVita is already in partnership with CMS and ESCO, the opportunity to expand the
current integrated care model and initiate IOP is possible. The national need for integrated care
services in outpatient dialysis facilities has already been identified, a bill is already in legislation
for integrated care services to exist, and now all that is needed is the further evidence to support
the need for integrated care being operationalized in dialysis centers. Therefore, in using the
existing partnership between DaVita and CMS, outpatient facility leadership can advocate for
IOP to prove the concept of why integrated care is vital for the health of ESRD patients on
dialysis. DaVita leadership members need to advocate for IOP services to test the efficacy rates
and acquire the data of outside services coming into dialysis facilitates to test the intervention
aimed at reducing missed dialysis treatment rates. Additionally, DaVita would be able to
facilitate a program like the IOP through an avenue within DaVita’s legal department. The
certain avenue would require the documentation of procedural steps with specific instructions of
service delivery to allow IOP staff (specifically the Chiropractor) to successfully work within the
dialysis center without CMS violation (Personal communication, January 10
th
, 2019).
IOP Financial Plans And Staging

The IOP would be requesting its funds to operate from DaVita. As DaVita has been
involved in the ESCO pilot for almost four years, it has since been granted the ability to engage
in various decisions to influence further efficacy to ESCO services. Moreover, DaVita is a
leading international, for-profit kidney care provider that generates large profit gains, annually.
With DaVita being a for-profit company, the IOP is uniquely positioned to meet the interests of
both business and Medicare outcomes. The IOP would be requesting DaVita to fund the
innovation in its entirety. The next planned financial stage for the IOP is to become a part of the
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34
Medicare bundle to affect future Federal payment structures. The IOP is seeking $175,000 from
DaVita for IOP operation. IOP operating staff members will consist of only two individuals: the
mental health professional (LCSW) and Activator Methods Chiropractor. The mental health
professional would be required to hold their LCSW. The LCSW will aim to enhance social and
emotional skillsets for patients and engage in psychoeducation around therapeutic modalities to
increase ESRD health literacy. The Activator Methods Chiropractor will be required to have
their doctorate in Chiropractic medicine, be a certified Independent Chiropractic Examiner from
the American Board of Independent Medical Examiners, and certified in Activator Methods
Chiropractic Technique (AMCT). The AMCT will be required to carry out spinal manipulation
techniques (SMT) through the activator methods device, providing orthopedic, chiropractic, and
neurological adjustments. The mental health consultant salary will be placed at $45,000
annually plus benefits, and the Chiropractor’s salary would be set at $50,000 plus benefits.
Furthermore, oversight of IOP will be the responsibility of the dialysis center’s Facility
Administrator (FA). At an estimated 10% of FA salary allocated to time going towards IOP
supervision, this would equal roughly $7,500 of the FA’s current annual salary. Evaluation of
the IOP will equivocate to roughly 9.5% of funds requested. The total cost from the IOP’s first
full year of operations is an estimated $172,682.10, from the requested $175,000 from DaVita.
The LCSW and Chiropractor salaries are based on the clinic investing in mid-level professionals
in their field of expertise with no dialysis experience required. Annual bonuses will be provided
up to five percent based on annual performance-development reviews. The two new DaVita
teammates for the IOP will require roughly 1,200 square feet of office space with an estimated
cost of $20,000 to construct the new space needed (Personal communication, August 6
th
, 2018).
In the first full year of operations, IOP personnel will need furniture, office supplies, DaVita
CLOSING THE HEALTH GAP

35
training, and computers, all costing roughly $10,500 (Personal communication, August 6
th
,
2018). For the Chiropractor, resources will require an adjustment table, activator device, and
Chiropractic liability insurance, all totaling an approximate amount of $10,800 (Personal
communication, September 29
th
, 2018). Other estimated costs can be found in the IOP line item
budget breakdown in Appendix F of the paper. Dialysis center budget projections were based on
discussions had with kidney care provider, FA personnel. Such personnel confirmed costs based
on current clinic expenses for equipment, teammate benefits, supplies, and contracting figures
for outpatient dialysis center operations. Additionally, research was collected on AMCT
Chiropractors regarding how much their services would render, and what equipment and
resources would be needed to operate their services in the clinical setting.
Revenue
With the IOP amount required to operate at $172,682.10, its selected pilot clinic made a
profit of $2,151,966.40 in 2018, from conducting dialysis treatments at a rate of ~$126.84 from
every treatment provided. In 2018, the average missed treatment rate in the pilot clinic was 7.1%
(1,209 missed treatments) out of 16,965 treatments provided. The DaVita national goal for
missed dialysis treatments is five percent, with 2.5% of a no-show rate and 2.5% hospitalization
rate (Personal communication, January 30
th
, 2019). If IOP were to be fully operational past its
pilot stages and allowed to function in the clinic without restraint, then it could meet DaVita’s
national missed treatment goal of five percent. To reduce the pilot clinic’s annual average
missed treatment rate by 2.1%, the clinic would profit $43,125.60 (1.6% reduction in no-shows
and a 0.5% reduction in hospitalizations), and achieve national healthcare savings of $212,000
from removed hospitalizations. However, the IOP will expect to go past these figures. Instead,
the IOP projected goals for the clinic would aim for a total missed treatment rate of three percent.
CLOSING THE HEALTH GAP

36
This means bringing the 2018 average of missed treatments down by 4.1%. The IOP innovation
will seek a stable hospitalization rate of 1.5%, and a no-show rate of 1.5% missed treatments
(Appendix G). If this goal were realized, the IOP would have generated an estimated profit of
roughly $86,250 from missed treatment recovery, and saved national healthcare costs of
$635,000 from one clinic alone. These financial figures would mean approximately 2.3 hospital
admits and 20.1 missed treatments (hospitalizations) would be prevented, per month. The IOP
financial projections are based on the current pilot clinic’s ESRD patient census and overall size
and ability to operate at its existing capacity. The IOP pilot clinic was selected to be able to
make these projections because the census will remain stable at 130 patients or more; max
capacity is 144. On a financial level, the IOP has a substantial opportunity to be profitable for
dialysis clinics and healthcare expenditures by creating sustainable health outcomes through its
methods.
Project Impact Assessment Methods
To capture the IOP outcomes for both the LCSW service and Chiropractic intervention,
the measurement tool that will be used to evaluate ESRD patient improvements in mental health
and pain status will be examined through the SF-36 quality of life scale. Mental health in the
context of the IOP will be investigating the patient ability to cope and process stressors
effectively, in order to enhance their health literacy. While the IOP will not treat, diagnose, or
prescribe patients psychotropic medication, it will instead strictly be a narrative intervention that
allows the ESRD patient to identify and deconstruct personal hurdles to attending their regular
scheduled hemodialysis treatments. The SF-36 can evaluate important outcome measures in
nutrition, hospitalization, and mortality in hemodialysis (Kalantar-Zadeh, Kopple, Block, &
Humphreys, 2001). The SF-36 is a well-documented quality of life scoring system that includes
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37
eight independent scales and two main dimensions (Kalantar-Zadeh et al., 2001). The SF-36
scales and dimensions in hemodialysis score elements between 0 and 100, by subjective global
assessment, identifies BMI (outlier to health outcomes/body pain) and can assess pertinent
laboratory values of a dialysis patient that include hemoglobin, albumin, and creatinine
(Kalantar-Zadeh et al., 2001). From the SF-36, it also can be shown that prospective
hospitalizations correlated its eight components and two dimensions, which determined the
mental health dimension showing the most robust predictive value for mortality (Kalantar-Zadeh
et al., 2001). Since the SF-36 dimensions have significant associations with measures of clinical
outcomes, the IOP will be using this measure to show the effectiveness of the mental health and
pain outcomes of IOP (Appendix H). Overall, the above outliers are the preferred metrics of
evaluation to examine whether or not the ESRD patient’s health literacy is showing improvement
through the IOP innovation. To measure the general health status of ESRD patients for IOP, the
SF-36 will be used as the measure to show improvement in patient experiences of physical pain
reduction. The SF-36 scales general health status, physical functioning, mental wellness,
general health perception, emotional wellness, role limitations due to physical and emotional
health problems, and social functioning (Hays, 1998). The SF-36 was normed on a national
standardization sample of 800 respondents representative of the U.S. population of adults aged
18-65+ years (Hays, 1998). The SF-36 Cronbach’s alpha ranges from .71 to .90 with reliability
coefficients for the composite scales ranging from .88 to .96, making the internal consistency
from “good” to “excellent” (Hays, 1998).
Strategy
The IOP interventions of mental health and Chiropractic services will be delivered to
patients for approximately eight to nine months to adequately show the reduction of ESRD
CLOSING THE HEALTH GAP

38
patient missed dialysis treatment events. To show the GC problem being solved, the IOP will
utilize a standard single-group, pre-post design. Even though the design shares data only where
participants were at in the beginning and where they were at in the end of the program, it can
help determine what particular things have happened. The IOP wants to examine whether there
has been a reduction in the level of missed dialysis treatments based on IOP services provided.
This design will measure the application of the IOP intervention to the selected group of dialysis
patients, pre-post-IOP initiation. This type of design assumes that a difference in the pre-post
observations will show whether there was a change over the period between them, and also
assumes that any positive change was caused by the IOP (Ruben & Babbie, 2013). A pre-post
test of the SF-36 survey will also be conducted. The sampling of IOP patients will be Medicare
beneficiaries with ESRD, chosen from the piloted DaVita clinic that has an operational census of
135 ESRD patients. To show immediate results, the IOP approach will be taking 10 existing
ESRD patients who have two or more missed dialysis treatments and/or who have been to the
hospital one or more times per month within the last 12 months. These selected patients will be
a part of the IOP research design receiving the IOP innovation. However, the intention of the
IOP as a standard clinical practice is to be operational before dialysis treatment is missed by the
prospective patient, and would be initiated to new dialysis patients via assessment before
services started. Once the IOP has passed its pilot phase, the IOP would also be initiated to
existing patients following the criteria the IOP pilot phase is engaging in for its data collection
(see Appendix A). Once the IOP is initiated, each selected patient will receive mental health
consultation care at least one time per week, but not limited to that amount (additional sessions
will be held at the discretion of IOP providers, or by patient request). Activator Method services
will be given one to three times per week for 20 to 30-minute sessions. The desired outcomes
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39
and success of the IOP will be dependent upon the measured missed dialysis treatment rates of
the selected IOP patients. IOP efficacy will be measured in the reduction of patient missed
treatment and hospitalization rates, each month. IOP will be examined through a course of 12
months, starting January 1 to December 31, 2020.
Stakeholder Engagement Plan
Agency stakeholders for the IOP would include the Renal Physicians Association (RPA),
CMS, ESRD Network Organizations, Medicare/CMS, and the American Society of Nephrology
(ASN). These listed stakeholders are contracted entities of the ESRD Network of America to
meet performance objectives for dialysis patients. With the IOP innovation needing to appeal to
these stakeholders, as they contribute to ESRD patient and patient-centered care to reduce costs
of ESRD services (National Institutes of Health, 2017), the vital stakeholders for the innovation
are between DaVita, Medicare/CMS, and the ESRD patient. The IOP patient, CMS, and
Medicare are the primary concern and focus of approval of the innovation. The required
involvement of the patients being a part of changing healthcare for themselves and for the
community is a foundational aspect to the implementation of the IOP and acts as a catalyst for
Medicare/CMS involvement. The Medicare role is essential because the IOP is aiming to change
policy around its bundled payment structure in ESRD. The IOP will eventually be requesting to
qualify itself as a necessary service of the Medicare bundle for ESRD patients. Until that time,
the IOP has to rely upon Medicare to make precise adjustments for integrated care actions to be
acceptable in outpatient clinics for any integrated care efforts to exist.
Communication Strategies And Product
To remove any stigma and/or negative perception away from what has been perceived
from the DPDA (allowing large providers to monopolize the dialysis market), the IOP is going to
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take a vastly different approach. The personal campaign for integrated care and IOP would aim
to publicize why universal integrated care for dialysis centers is vital for the survivability of all
dialysis clinics nationwide. Communication as to why ESRD patients need more than just
dialysis to sustain their quality of life is the driver to the innovation. In doing so, removing the
financial aspect away from large dialysis corporations is important, and placing more priority on
the individual on dialysis is the critical communication component. This allows for the
integrated care message to share its approach that focuses on the whole patient in its intended
holistic manner, versus the perception of what the DPDA is believed to do in monopolizing
dialysis treatment for larger providers that would leave smaller, private/non-profit dialysis clinics
out of business—the IOP innovation does not endorse that action. With patients on dialysis in a
situation of dependence on a machine for the rest of his/her life, the IOP will be communicated
as the thoughtful approach to why integrated care in outpatient dialysis centers matter to the
country and every provider giving life, via dialysis. As ESRD patients on dialysis affect roughly
470,000 people in America and an estimated two million people worldwide with an ESRD
diagnosis, the IOP campaign design speaks to everyone on dialysis around the globe. However,
the realistic target population is ESRD patients in America already receiving dialysis, its
stakeholders in the renal community. These entities would be the foundational receivers of the
communication plan for operationalizing IOP.
Communication Effectiveness
The effectiveness of the IOP communication plan will rely heavily upon creating the
intended outcomes for the ESRD patient and the relationship between DaVita and CMS. With
DaVita housing the existing national integrated care program (ESCO) and taking on the risks and
benefits of the pilot, DaVita has been granted specific immunity points of failure in order to get
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41
to successful results. In essence, DaVita ESCO markets have been given the ability to test out
new innovative ideas that can go past certain, but not all, conventional boundaries of policy that
are still acceptable by CMS (Personal communication, March 22
nd
, 2019). To avoid violating
Stark/Anti-Kickback laws and to allow integrated care to operate without these challenges,
outside-providers could permanently work in a ESCO outpatient dialysis center so long as
provider prompts and treatment plans were not given as official written orders from the dialysis
center or from the IOP provider (Personal communication, January 10
th
, 2019). Therefore, with
the IOP proposing to operate as a pilot and to capture needed data from outside services working
in outpatient dialysis centers, the innovation will plan to avoid the use of provider prompts from
the Chiropractor, which should allow the AMCT services to provide care within the selected
pilot clinic. The IOP’s LCSW service is already an approved action by CMS because it is
considered a necessary service under the Medicare bundle (Personal communication, February
27
th
, 2019). The proposed IOP communication plan for initiation would first investigate
partnership with DaVita leadership to coordinate care with DaVita’s legal department and
construct a written policy for ESCO units to support the outside provider operating in-center.
The LCSW of the IOP will be presented similarly, but does not have the CMS restrictions as its
AMCT counterpart. Initiating the IOP’s LCSW for mental health consultation services will be
presented as an action step that can happen immediately without limitation, so long as DaVita
wants to pursue the option. Communicating the need of an additional social worker (LCSW) to
engage in a strengths-based approach to help patients develop healthy balances in their life,
enhance self-determination, decision-making, and assist the patient in establishing an action plan
to maintain adherence to their healthcare is a beneficial pitch to the DaVita leadership (given the
outcomes it can provide). The IOP as a whole will be delegated to the DVP for the innovation to
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42
be rolled out to maintain patient health stability, manage troublesome symptoms, and help find
the patients’ purpose for attending dialysis with the ultimate goal of closing the health gap
through reducing the prevalence of ESRD patients missing dialysis treatment. Moreover, the
communication plan will speak solely to the drive of integrated care to reduce healthcare
spending in the Medicare sector and being a profitable venture for the for-profit kidney care
provider of DaVita if it was allowed to practice in its facilities.
IOP Ethical Considerations
Ethical issues have been considered with the IOP in both its approach to general research
principles and its implementation to the ESRD population on dialysis. The ethical principles of
the IOP innovation were primarily centered on considering the protection of the research
participants and the guiding principle of not causing any harm, distress, duress, or hardships
(Wilson, Kenny, & Dickson-Swift, 2018). Because the IOP is working with a vulnerable
population in both the severity of illness and with senior citizens, the respect for persons, their
autonomy, decision-making, and dignity was made a priority when constructing the innovation.
The ESRD patient will have the right to choose to participate in IOP services to minimize all
perceived risks on a psychological, social, and physical level (Wilson, Kenny, & Dickson-Swift,
2018). The IOP will look to maximize the benefits to research participants through the output of
the innovation to improve the lives of the respondents of the program. In conjunction, IOP
participants are being selected from groups to where the research is aiming to benefit multiple
communities with the potential to create causality and generalizability across larger ESRD
populations. In addressing these considerations and other issues using the IOP human subjects in
ESRD, the IRB has been examined for any further implications to help ensure the safety of the
IOP innovation subjects in this pilot program. Based on IRB guidelines, the IOP research
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subjects are not in violation of human rights and no legal implications from the IOP innovation
are deemed unethical (Wilson, Kenny, & Dickson-Swift, 2018). Therefore, no IRB involvement
will be needed at this time given the nature of the research design and its methods (single-group
test subjects/no control group). The IOP is considered to be regular operations and a standard
scope of practice. The data obtained from the IOP research design will provide further
evaluation steps to move forward with, and how to better implement further instructions to
practice for the benefit of future ESRD patients on dialysis.
Summary of Project Plans
The IOP innovation concludes with the consideration of the implementation challenges
that lay ahead. With several elements in healthcare reform law preparing to address these issues
for the integration of physical and behavioral health for ESRD patients, the IOP is projected to
have sweeping impacts on the provision of care for individuals with behavioral and physical
health needs in the public sector of dialysis. The IOP elements will increase integration in the
areas of access to care, financing, and infrastructure of how dialysis is delivered to the ESRD
patient. Integrated care in outpatient dialysis centers enhances usual care and decision-making
for ESRD patients and is a critical factor for patient experience and cost (Croft & Parish, 2013).
In the context of mental health services within the IOP, patient health literacy of their condition
will be assessed to achieve treatment compliance with dialysis. To reduce physical pain
experienced by patients, Activator Methods Chiropractic services will be utilized to conduct
body adjustments to a patient’s target area of pain. The IOP is preventive care for the ESRD
patient to have the opportunity to combat missing dialysis treatments before the patient has the
chance to miss a treatment.

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Contextualizing The Problem
Inadequate health literacy and physical pain ailments cost this country nearly one billion
dollars in care, annually (Edwards, Wood, Davies, & Edwards, A., 2015; Alonso-Zaldivar,
2016). ESRD patient experiences are generally disrupted by lifestyle choices that act as barriers
to treatment attendance. ESRD patients frequently experience pain while at home or on the
dialysis chair. This pain can be due to the loss of mobility over time, internal organ failure
(kidneys), and overcompensation of the human system attempting to maintain balance. ESRD
patients who missed one dialysis treatment increase their risk of being admitted to the hospital by
40% and the cost of a dialysis patient admitted to the hospital for an approximate six-day stay
costs ~$15,000 (Personal communication, January 29
th
, 2019). ESRD patients’ poor adherence
to hemodialysis treatment is a significant barrier to achieving desired patient outcomes and leads
to patient hospitalization (Chan, Thadhani, & Maddux, 2014).
Conclusions, Implications, Future Practice
In the spirit of integrated care, the IOP would implement healthcare services within
outpatient dialysis centers to allow the patient to receive a multitude of services, all in one
medical destination. The IOP consists of mental health consultation (LCSW) services to
troubleshoot patient lifestyle choices and deleterious life events by enhancing health literacy and
will offer specialized Chiropractic care to counteract physical pain experiences of patients. The
primary future of the IOP action steps is to see an integrated care model in U.S. healthcare that
will be effective in reducing all medical costs and improve patient outcomes in every area of
disease and illness. Moreover, getting the IOP in the ESRD Medicare bundle will be pursued, in
order to change the payment structure of services as a recognized integrated care-billable service
that will be cost-effective. The IOP’s initial challenge to such goals will first be proving the
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concept in ESRD, and show the innovation can reduce missed dialysis treatment rates and
hospitalization admits. IOP has the task of highlighting the significant effects that mental and
physical health intervention can have on ESRD patient adherence to dialysis, and its positive
impacts for patients on health literacy and experienced physical pain. In time, IOP’s methods to
address these factors need to be billable services with Federal funding as a part of patient care in
these areas of treatment. Although Medicare billing exists for mental health and Chiropractic
services, both service reimbursement rates are considered inadequate for the tasks being
performed to serve a dialysis patient in the capacity that the IOP intends. Furthermore, for a true
integrated care model to take shape in U.S. healthcare, an appropriate measure would be for IOP
services to be bundled into the dialysis care package of a Medicare beneficiary. This bundle goal
is not yet a reality, but is a future priority for the IOP to achieve over time. If IOP services were
to be a part of the ESRD-Medicare bundle, it would change the landscape of dialysis and Federal
funding for the betterment of overall healthcare delivery.
Limitations
The primary obstacle of the IOP to operate on a national scale is going to come from
CMS. As CMS controls and provides oversight for all dialysis centers across the country (policy
and procedure) and without the approval of CMS, the IOP cannot operate. The reality of
collusion, conflict of interest, Stark Laws, Anti-Kickback Laws, and other Fraud and Abuse
Laws will continue to restrict outside medical providers from entering an outpatient dialysis
center to provide care (Personal communication, July 11
th
, 2018). In addition, services cannot be
provided to ESRD patients in outpatient dialysis centers that are not considered by Medicare as,
“necessary” to renal failure, and therefore will not be covered under the Medicare bundle
(Personal communication, February 27
th
, 2019). For true integrated care services to
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operationalize and demonstrate patient outcomes to create national savings in healthcare
spending, CMS must change Federal policy and procedures around the delivery of dialysis in
outpatient treatment centers. The IOP operating as a pilot program will provide the data to
suggest such changes can be made. The IOP pilot will help confirm the full-scale
implementation of the innovation and serve as a trial run to help determine if any adjustments to
its implementation plan or adaptations are necessary (Ruben & Babbie, 2013). As a pilot, the
IOP can also reveal unforeseen challenges that might arise during implementation (more
training/staff needed, issues with the IOP setting, additional activities may be necessary) and
help teammates be better prepared to handle issues during the full-scale initiation (Ruben &
Babbie, 2013).
Next Steps
The entirety of the IOP innovation would be presented to senior leadership at DaVita, as
it has already been stated by certain leadership members that the elements of the IOP could be an
appropriate/realistic project for implementation. However, it has been reported by DaVita senior
leaders that the LCSW service of the IOP is more realistic for initiation at this time, due to the
profession being covered under the Medicare bundle for ESRD patients. In addition, the
Chiropractic service under the IOP was stated as an “idea of the future,” only because a service
of its magnitude has never been investigated nor implemented to dialysis patients in an outpatient
setting (Personal communication, January 29
th
, 2019). Nonetheless, the IOP’s full-scale services
have been reported by DaVita leadership as “interventions worth checking out” because of the
innovative aspects in healthcare and matching up with DaVita’s goal to achieve integrated care
as a staple in the outpatient setting (Personal communication, January 29
th
, 2019). Firstly, the
Arizona region DVP, Regional Operations Director, ESCO Director, and Regional Operations
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47
Manager would be approached with a communication plan to present the IOP activities to
highlight the problem, solution, outcomes, and projected success. The IOP presentation would
encompass the evaluation plan that is thoughtful in measuring the desired outcomes in the best
way possible, per DaVita expectations. The pilot test would give the evaluation and
implementation team a chance to work together before full implementation and troubleshoot any
logistical issues that might arise with the distribution and collection of evaluating data. The IOP
pilot would be requested to test the program within DaVita to determine the efficacy of the stated
objectives, assess current service provision, and to develop a permanent service plan that could
be operational on a national scale. The IOP should be handed over to the guidance and direction
of the DVP and corporate headquarters at DaVita. The Arizona DVP would best be served for
the implementation of the IOP to introduce a formal procedure through DaVita’s legal team to
reflect the IOP intervention. Hypothetically, once DaVita’s legal department would complete a
written review of recommendations, justifications, and continued improvement of IOP
management, the delivery of services could be initiated to operate as a pilot. The IOP innovation
would be written as a clinic policy to include aspects and restrictions of communication,
management, activity reporting, its intervention programs, evaluation, and further development
for patient care.
Artifact
The presented artifact for the IOP is a constructed manual intended for the use of internal,
DaVita staff members. The IOP manual should display the IOP intention, messaging, purpose,
reasoning, guidance for use, and tools for the IOP implementation for in-center dialysis patients.
This approach was taken to co-exist with the current integrated care pilot of ESCO within the
IOP’s outpatient dialysis center in Phoenix, Arizona. The IOP manual correlates with the real-
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time analysis of the existing ESCO pilot intervention, making each component of the manual
operational at this time. The IOP manual would be considered staff-friendly, regarding being in
alignment with the dialysis teammate understanding of reducing missed treatments, the service
expectations, the culture of prevention, and the purpose behind integrated care in the dialysis
setting. In essence, the steps of the artifact align with what is already happening (mindset) and is
operational for full use for the specific selected clinic. The pilot staff already has the comfort
and familiarity of integrated care in dialysis centers, and understands integrated care as a part of
the process to achieving outcomes. In addition, the IOP artifact was constructed to connect with
the understanding of the patient-community-connection to resolving missed dialysis for patients.
The IOP manual is a tool of understanding and an explanation of implementation steps for
program initiation and should reflect the Capstone innovation in its entirety. The artifact
provides additional training measures and is a prevention scale to assist ESRD patients from ever
missing a dialysis treatment. The IOP will create multidisciplinary professionals to share “non-
traditional” treatments for patients with ESRD and should influence necessary procedures that
would become evidenced-based if proven successful.

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Appendices (A).

IOP Artifact

IOP Playbook Manual

The training module for the Intangible Outcomes Program:
Prevention care methods in Hemodialysis for DaVita

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What We Are All About

I. Integrated care services in outpatient dialysis settings are our method of choice. The
Intangible Outcomes Program (IOP) is a prevention care method for End Stage Renal
Disease (ESRD) patients on dialysis who require additional medical support and care, to
help them create the most significant impact they can make in their lives. The IOP
interventions are thoughtfully designed to improve the conditions of ESRD patient lives.
It is vital to address our patients’ mental and physical determinants of health inequities
that become barriers to attending their life-saving dialysis treatment. Our patients engage
in daily activities in which environmental, organizational, and personal factors interact
and affect their health and well-being. The IOP is a team approach where staff members
will actively use the dialysis environment as a catalyst to begin solving our patients’
health problems. That specific catalyst will also open a pathway for our staff to
incorporate our patients’ family members/caregivers to ultimately integrate the dialysis
community as additional helping measures for our ESRD patients. America is
experiencing a health crisis and our dialysis community has an opportunity to create a
new paradigm that shifts the approach of how healthcare is delivered. The IOP’s starting
place is to build the change process from the bottom up, and to facilitate the development
of new initiatives that stop the ESRD patient from missing their life-sustaining treatment.
The IOP is set to increase the probability of achieving positive outcomes through keeping
patients 100% adherent to their regularly scheduled dialysis—it starts with us.

II. First, we need to understand why we are here and what our message is to our dialysis
patient. Answer: we are healthcare professionals giving life. This is an enormous gift
and responsibility we have the honor to be a part of for others. Health is a state of
complete physical, mental, and social well-being—it is not just the absence of sickness or
frailty. This approach considers individual health as a whole, mind-body experience that
should be comforting for our patients who are experiencing life stressors that are
unimaginable. The IOP interventions are set to tap into our patients’ needs by making
them the number one priority in our work. The IOP is a cultural mindset. It requires the
DaVita teammate to co-exist with the ESRD patient mindset and live their life with them
in the dialysis center. If patients miss a dialysis treatment, the IOP is suggesting this not
only hurts patients physically, but it also hurts the team that serves them. The IOP will
treat the whole person and support them every step of the way to optimize their complete
adherence to their dialysis treatment.

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What Is The IOP

III. The IOP will be the prevention care method comprised of two additional medical
professionals in the field of pain management and mental health to operate in the
outpatient dialysis setting. They will be alongside the in-center interdisciplinary
teammates and ESCO providers. On the mental health side, the mental health consultant
(LCSW) will address mental health issues to enhance the efficacy of patient health
literacy. This is a new approach to healthcare, as the patient is not receiving conventional
counseling for reportable issues, but will be receiving life counseling and consultation
that encompasses any issue that has held the patient back from understanding their
physical and emotional environments. On the pain management side, a specialty
Chiropractor will be deployed to provide Activator Methods Chiropractic care to address
physical pain measures that are debilitating, inhibiting, and/or troublesome to the patient.
The primary function of these two IOP services is to maintain the ESRD patient adherent
to treatment, and to keep patients healthy and out of the hospital. The IOP is an offered
service to those patients who have exhibited difficulties attending their regularly
prescribed dialysis treatments. The entire dialysis team plays a vital role in the ongoing
success and service to the IOP—it truly is a collaborative effort from start to finish.

IV. The mental health consultant (LCSW) will have the task of meeting with patients in the
context of investigating a person and their ability to cope and process stressors
effectively, in order to enhance their health literacy to make optimal choices related to
their healthcare. Health literacy in this context describes the patient’s inability to identify
what is needed in their healthcare to achieve medical outcomes, and how to go about
achieving goals to accomplish necessary tasks. America spends between $100-200
billion on health literacy disparities, annually. The mental health consultant will not
treat, diagnose, or prescribe patients psychotropic medication. Instead, the mental health
consultant will strictly be a narrative intervention that allows the ESRD patient to identify
and deconstruct personal hurdles to attending their regular scheduled hemodialysis
treatments and strengthen their self-awareness and determination skills for effective
conflict resolution. On the Chiropractic side of IOP, the ESRD patient will be provided
Activator Method sessions, post-dialysis treatment, to help improve pain management for
reported symptoms. America spends over $600 billion in treating physical pain
symptoms, annually. Because physical pain can affect an individual and their mental
health status, the IOP needs to take the holistic stance in treating the physical and mental
health of the ESRD patient, which has never before been done. We are the first.

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IOP Initiation

V. The IOP will have two phases of initiation. Phase one will be reliant upon an IOP
assessment for new patients diagnosed with ESRD and requiring dialysis. Before their
very first dialysis treatment, the new patient IOP assessment will be given during their
admission/intake. Patients who have a certain indicator score on this assessment will be
offered IOP services. Phase two will be acted upon differently. For existing dialysis
patients, if they experience consistent trends of missing two or more treatments per
month and have one hospitalization at any time, they will be offered IOP services. For
phase one of IOP initiation, if after one month of treating the patient with IOP and the
prospective patient has never had a missed treatment, the program can be discontinued if
the professional deems it appropriate. However, if the patient is an existing dialysis
member and has a history of missed treatments and/or hospitalizations, the IOP should
only be discontinued after three months of a patient experiencing no missed treatments or
hospitalizations. A dialysis participant in the IOP can discontinue its interventions at any
time they choose.

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IOP New Patient Assessment

VI. The new patient IOP assessment will ask a series of questions that are based on prevalent
renal treatment behaviors, physical ailments that can be present to an individual with
ESRD over time, uncover health literacy with their disease and interpersonal being, and
address deterrents that act as barriers to adherence to dialysis. The assessment questions
are also catered to IOP services that the mental health consultant can have ongoing
discussions around, and the Activator Methods Chiropractor can provide physical
treatment for. The IOP assessments will overview a patient and their physical and mental
well-being to reveal problems the patient may or may not be aware of. The IOP
assessment questions are also meant to influence the assessor to be mindful of prevention
and how to approach the patient in an “upstream manner” before problems occur. This
action step is to help the patient avoid a future missed dialysis treatments.

IOP Patient Assessment

Patient Name _________________________

Co-Morbidities _________________________

Care Physician _________________________

Prevention Care Scale

Neurological___________________________________________________________________
1. Have you experienced numbness or tingling throughout the body lately?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

2. Do you experience dizziness?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

3. Do you have balance or gait issues at home?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

4. Do you experience falls at home?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

5. Do you have any difficulty with manual dexterity?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

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Cardiac_______________________________________________________________________
1. Do you ever feel shortness of breath?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

2. Do you ever think about your blood pressure?
(1)Never (2)Occasionally (3)Sometimes (4)Often (5)Always

3. Do you monitor your blood pressure?
(1)Never (2)Occasionally (3)Sometimes (4)Often (5)Always

4. Do you use oxygen at home?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

5. Are you ever bothered by chest pain?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

Nutrition______________________________________________________________________
1. Do you check your blood sugars?
(1)Never (2)Occasionally (3)Sometimes (4)Often (5)Always

2. Do you have an appetite?
(1)Never (2)Occasionally (3)Sometimes (4)Often (5)Always

3. Do you experience, nausea/upset stomach?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

4. Do you enjoy drinking fluids?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

5. Do you experience frequent weight gains/loss?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

Medication____________________________________________________________________
1. Do you know what your medications are for?
(1)Never (2)Occasionally (3)Sometimes (4)Often (5)Always

2. Do you know the correct time to take your medications?
(1)Never (2)Occasionally (3)Sometimes (4)Often (5)Always

3. Do you take your medication as prescribed?
(1)Never (2)Occasionally (3)Sometimes (4)Often (5)Always

4. Do you have issues learning about your medical condition or with written instructions?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

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Psychosocial___________________________________________________________________
1. Do you know why you are on dialysis?
(1)Never (2)Occasionally (3)Sometimes (4)Often (5)Always

2. Are you able to read, write, and follow medical instructions that are given to you?
(1)Never (2)Occasionally (3)Sometimes (4)Often (5)Always

3. Do you feel in control of your life and can make decisions you feel are good for you?
(1)Never (2)Occasionally (3)Sometimes (4)Often (5)Always

4. Do you have trouble achieving goals or meeting expectations you have of yourself?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

5. Do you have problems making decisions, or have issues handling emotions to situations?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

6. Do you have access to resources for travel in the community/social support to assist you?
(1)Never (2)Occasionally (3)Sometimes (4)Often (5)Always

Pain__________________________________________________________________________
1. Do you experience physical pain?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

2. Do you have neck, upper, and/or lower back pain?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

3. Do you feel you have other health issues that would stop you from attending dialysis?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

4. Do you have mobility/flexibility issues?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

5. Do you have any muscle soreness and/or cramping?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

6. Do you experience anxiety of any kind, from pain, emotional, or social concerns?
(1)Always (2)Often (3)Sometimes (4)Occasionally (5)Never

Is there anything else you would like to share regarding your healthcare and give the team
an opportunity to assist/provide you resources with?

______________________________________________________________________________

CLOSING THE HEALTH GAP

56
Assessment Processing/Phase 1

VII. The IOP rating scale numerically categorizes the severity of patient symptoms and will
act as indicators of when and when not to initiate the IOP intervention for the ESRD
patient before they embark upon their dialysis journey. The scale ranges from 30 to 175
and summarizes in number values of how well the person is functioning overall
(regarding IOP prevention to missed treatment). A general outline of this scale is as
follows:

IOP Scoring Values-

175: No alarming symptoms or causal for IOP (121-175)

120: Minimal symptoms with appropriate functioning. IOP can be used as an option, but
not warranted at this time (91-120)

90: Transient symptoms that are expected reactions to psychosocial and physical
stressors. IOP is warranted, or the patient needs further follow up if determined
IOP will not be used at this time (75-90)

60: Moderate symptoms for difficulty towards achieving the treatment goal. IOP to be
initiated (60-74)

30: Severe symptoms indicating mental and physical stressor to affect functioning and
achieving treatment goals. IOP to be initiated (30-59)

CLOSING THE HEALTH GAP

57
IOP “Rules Of The Road”

*Additional, helpful hints for informal assessment of ESRD patients on a daily basis

RANGE OF PATIENT FUNCTIONS TO CONSIDER
Physical Functioning
Be watchful for patients to be limited in performing physical activities and who report or show
difficulty in performing their activities of daily living.
Bodily Pain
Be watchful for patients reporting debilitating pain of any kind. Capture patient perceptions of
where they are functioning to complete necessary tasks.
General Health
Be watchful if a patient is tired and worn out. Try to capture patient symptoms getting worse
before they actually do.
Vitality
Be watchful for patient fatigue, weakness, and loss of strength. Capture patient energy levels
and endurance towards tasks.
Social Functioning
Be watchful of patient social functioning and emotional processing. Capture patient behaviors
due to physical or emotional problems. Examine whether or not the patient can perform
normal social activities without interference.
Mental Health
Be watchful for patient feelings of nervousness, depression, anxiety, and confusion. Capture
patient feelings of being able to achieve peace, calmness, and relaxation.
Reported Health
Be watchful for patient beliefs on their overall general health. Capture where the patient feels
they are at this very moment.
CLOSING THE HEALTH GAP

58
Phases Of IOP Process

IX. IOP measures will focus mainly on the intervention phases of the intake, treatment,
maintenance, and termination events of the IOP. The IOP wants to be ahead of the
reasons behind noncompliant behaviors and hospital events for our ESRD patient
population. During the treatment phase, the program will measure how many patients
will have increased their health literacy in conjunction with ESRD, other co-morbidities,
and experienced decreased pain measures. The IOP phases of maintenance and
termination will look at the increase in health literacy and mental health competence and
pain reduction.

The phases of intervention are fundamental elements of patient
behavioral development. Most importantly, through the treatment phases of IOP, the
ESRD patient will be given psychosocial, nutrition, medical, and pain management
services to deconstruct the antecedents to missing dialysis treatments.

• Intake: the new ESRD patient will be given the IOP assessment (phase one patients).
Existing ESRD dialysis patients (phase two patients) who miss more than two treatments
per month and enter the hospital one time (at any time) will be offered IOP services.

• Treatment: its providers will evaluate the IOP's efficacy, and examining full compliance
with their treatment schedule. The effectiveness of the program will show data on patient
behavior changes, reduced pain, and renal health changes with improvements in patient
blood pressure, bone mineral disease, and fluid retention. IOP will have the patient
receive LCSW services at a minimum of one time per week at one-hour sessions. The
Activator Methods Chiropractor will be performed one to three times per week for 20 to
30-minute sessions. This phase will show improvements in patient health literacy, mental
wellness, emotional processing, decision-making skills, and experienced pain. These
experiences of the patient are crucial to getting patients to reduce their missed treatment
rate and hospital admissions.

• Maintenance: IOP will conduct ongoing sessions for patients who are meeting their
goals in renal health (fluid retention, blood pressure, phosphorus control, pain
stabilization, and psychosocial distress). This phase will measure the number of patients
with improved perceptions of dialysis and lifestyle changes. Showing these positive
changes will suggest the patient is effectively coping with life stressors and their ESRD,
which will contribute to the real understanding of attending dialysis treatments, thus
improving patient missed dialysis treatment rates.

• Termination: for any patients who may receive a kidney transplant, transfer units,
graduate from IOP, or becomes deceased, the IOP will discharge those patients and revert
to the intake stage with new patient admits. The termination phase will be able to reveal
data to show program efficacy for repeated services. This phase will also allow the IOP
to review what patient metrics remained the same, improved, or made no improvement
for future changes to be made accordingly.

CLOSING THE HEALTH GAP

59
Why It All Matters

X. If ESRD missed treatment events have been lowered, then ESRD patient compliance,
perception, and understanding of dialysis and their disease will have improved. Patients
will be spending less time in the hospital and more time at home living their life.
Dialysis gives life. The IOP gives meaning back to life. We are here to stop patients
from missing dialysis treatment—it is senseless and preventable. DaVita teammates are
here to facilitate that process via the IOP.

This is why we have chosen our career path in renal care. It is time to reframe our process to
reframe our culture in how we deliver care to ESRD patients-

MISSING TREATMENTS=INADEQUATE DIALYSIS

RISKS AND COMPLICATIONS OF INADEQUATE DIALYSIS INCLUDE:

Clotting of vascular access

Worsening of anemia and bone disease due to not receiving intravenous
medications as scheduled

Fluid overload leading to shortness of breath requiring treatment in the emergency
room and emergent dialysis. Severe cramping and hypotension during
the treatment following the missed appointment due to the need to pull
extra fluid

Cardiac complications leading to cardiac arrhythmia, cardiac arrest, and death
due to high potassium

Cerebrovascular complications leading to stroke, permanent disability, and
death due to hypertension

MISSING 1 TREATMENT A WEEK = 52 TREATMENTS IN A YEAR
THIS IS THE SAME AS MISSING 4 MONTHS OF TREATMENTS

INADEQUATE DIALYSIS WILL SHORTEN LIFE EXPECTANCY
CLOSING THE HEALTH GAP

60
The Intangible Outcomes Program

ALL FOR ONE AND ONE FOR ALL
Tools:
IOP Playbook
IOP assessment
SF-36 Scale
IOP Treatment Phases
LCSW/
Chiropractor
DaVita
ESCO
Patients
Financial Stability in
U.S. Healthcare
Increased Health Literacy and Decreased Physical
Pain
LCSW/Activator Method Chiropractor
Integrated Care in Outpatient Dialysis Centers
CLOSING THE HEALTH GAP

61
Appendices (B).

IOP Gantt Chart

First Full Year Of Operations 2020 (Fiscal Year Jan.1-Dec.31)
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

TASKS
IOP Comm. Plan
IOP Patient Intake
IOP Pre-Test
IOP Intervention
IOP Analysis/Post-Test
CLOSING THE HEALTH GAP

62
Appendices (C).

IOP Conceptual Framework
System Challenges
Individual and Family
Challenges
System has not addressed the
integrated level of healthcare
needed for individuals with
ESRD
System has challenged policies
that do not support preventative
measures, such as increasing
the health literacy of patients
System has fixed and limited
options
System is challenged by the
cost of providing care to
individuals with ESRD
Individuals are challenged by
poor health outcomes and
multiple co-morbidities
Individuals are challenged by
the barriers encountered by
coordinating care between
providers for their personalized
care and treatment of ESRD
ESRD patients experience
higher rates of hospital
admission, readmission, and a
higher mortality rates than the
general Medicare population
System Barriers Personal Outcomes
Failure to recognize the
importance of recognizing that
the physical and mental health
of patients are important
components of treating people
with ESRD
Failure to communicate with
multiple disciplines to provide
integrated systems of care
Failure of public
policy to support
prevention and
treatment modalities
that will address the
multiple complications
presented by patients
Federal and state spending for
ESRD care in dialysis is
overwhelming
Mental health
disorders
Adverse health
events
Increase in
hospitalization
Failure to
adhere to
dialysis
regime
Increased
mortality
Increase in
pain
Loss of
independence
CLOSING THE HEALTH GAP

63

Project Goals
Develop an integrated
care model for individuals
with ESRD
Create a program for
kidney care providers in
dialysis centers
Develop material to
increase the health literacy
of individuals with ESRD
Provide training to
personnel within multiple
disciplines treating
patients with ESRD
Introduce legislation that
would provide funding for
evidence based “non-
traditional” treatment that
is successful
Develop the dialysis floor
operations for
multidisciplinary
professionals to share
“non-traditional”
treatments for patients
with ESRD
Running head: CAPSTONE

64
Appendices (D).
IOP Logic Model

Inputs:
-Dialysis center
funding.
-Trained mental
health staff
providing mental
health
consultation.
-Trained
Chiropractic staff.
-Coordinated care.

Activities:
-LCSW enhance
patient decision-
making, problem-
solving, emotional
stability, and health
literacy.
-Evidence-based
Chiropractic
adjustment methods
to reduce physical
pain measures.

Outputs:
-ESRD patients
engaging in
phases of
innovation
treatment.
-ESRD patients
experiencing
improved
outcomes from
intervention,
weekly.
Effects:
-Reduced rate of
missed dialysis
treatments.
-Reduced rate of
hospital admission
events.
-Increased health
literacy to healthy
living.
-Lowered
healthcare costs.

Context: A dissipating infrastructure for ESRD patients is a correlation to
incomplete Federal interventions that lead to inadequate healthcare. ESRD
patients do not attend their hemodialysis treatment for a multitude of
reasons and lifestyle events. Therefore, increased healthcare costs mount,
and patient health is compromised. The dismissal of integrated care in
healthcare/dialysis settings is furthering the culture/norm of increased
expenditures and decreased health outcomes of ESRD patients.
Goal: To reduce missed treatments of ESRD patients, lower healthcare costs,
and improve patient health outcomes.

CLOSING THE HEALTH GAP 65

• Inputs: DaVita funding, investigating potential grants as needed, facility use, equipment,
staffing, assessments, Federal/state involvement, stakeholders, patients, community,
family members.
• Activities: Training, LCSW mental health consultation, Activator Method Chiropractor,
pre-post test scale, IOP playbook manual, monthly missed treatment assessments, weekly
interdisciplinary team meetings.
• Outputs: 25 hours of IOP training to LCSW and Activator Method Chiropractor, provide
weekly support groups for IOP trained staff, 60-180 minute LCSW patient sessions one
time per week, 20-30 minute Activator Method Chiropractor sessions for patients at one
to three times per week.
• Outcomes: Integrated care in outpatient dialysis centers, enhanced ESRD patient health
literacy, improved patient dialysis acumen, lowered patient physical pain experiences,
lowered patient missed treatment events, monetary profit to dialysis centers, decreased
healthcare spending due to lowered hospitalization rates of ESRD patients.

CLOSING THE HEALTH GAP 66

Appendices (E).
IOP problem, policy, political stream

Problem
ESRD patients miss life-
sustaining dialysis
treatments due to various
lifestyle antecedents and co-
morbidities. Missed
treatments are correlated
with poor health outcomes
leading to increased
healthcare costs.

Policy
Inner Context Factors:
-CMS policy makers
-Attitudes toward
integrated care,
effectiveness
Outer Context Factors:
-CMS licensing
restrictions
-DaVita funding
Political
Inner Context Factors:
-National healthcare spending
-Medicare reimbursement

Outer Context Factors:
-Renal community reception
to integrated care practices
Support For IOP Integrated Care Implementation Improved Care For ESRD
Patients
Support For IOP Integrated Care Implementation Improved Care For ESRD
Patients
Support For IOP Integrated Care Implementation Improved Care For ESRD Patients

CLOSING THE HEALTH GAP 67

Appendices (F).
IOP Line Item Table
Key Costs of Year 1 for the Intangible Outcomes Program
DaVita Contributions: $175,000
Item Description Cost
Wages LCSW, Activator Methods Chiropractor, Facility
Administrator (oversight), bonus allocations
$107,250
Benefits Fringe, Chiropractic liability insurance, DaVita
trainings
$18,732.10
Operating Costs
Office Space IOP staff offices, furniture $21,000
Equipment Computers and work stations, adjustment table $9,600
Supplies Project-specific, work station supplies $900
Pilot Evaluation Evaluation consultant and interview stipends $15,200
Total Program Costs $172,682.10
Annual Clinic Revenue $2,151,840.60

CLOSING THE HEALTH GAP 68

Appendices (G).
IOP Revenue Table
Revenue Projections of Year 1 for the Intangible Outcomes Program
Missed Treatments
2018
Description Cost
No-Shows 1209 missed dialysis treatment events $153,349.56
Hospitalizations 86 hospital admissions $1,272, 499.90
Financial Gains from IOP
No-Shows Reducing no-show rate to 1.5% annual rate $86,250
Hospitalizations Reducing hospitalization rate to 1.5% annual rate $635,000
Total Revenue From Lowering Missed Treatments $721,250

CLOSING THE HEALTH GAP 69

Appendices (H).
IOP Pre-Post Test Assessment

Short Form (SF)-36 Specific Measures and Assessment Tool
Measures
Point of Measurement
Vitality 0-100
Physical Functioning 0-100
Bodily Pain 0-100
General Health 0-100
Emotional Functioning 0-100
Social Functioning 0-100
Mental Health 0-100
The SF-36 has eight scaled scores. The scores are weighted sums of the
questions in each section. Scores range from 0-100
Lower scores = more disability, higher scores = less disability

The SF-36 is an indicator of overall health status. Most of these studies
that examined the reliability of the SF-36 have exceeded 0.80. Estimates
of reliability in the physical and mental sections are typically above 0.90.
The SF-36 is well validated.
CLOSING THE HEALTH GAP 70

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Abstract (if available)

Abstract Healthcare spending in the United States is becoming unsustainable. Federal funding and Medicare/Medicaid reimbursement rates for medical services are showing consistent downward trends, as monetary resources are difficult to come by for several populations across America. There is a financial dilemma in the field of kidney care, particularly in the treatment of End Stage Renal Disease (ESRD). Predominantly, the Federal insurance program of Medicare covers dialysis in America, which has proven to be problematic due to the rate of people diagnosed with ESRD, annually. There is a need for preventative and cost-effective interventions for dialysis patients. Lowering the prevalence of missed dialysis treatments will naturally reduce deleterious health outcomes that lead to hospitalization events for ESRD patients, thus dissipate nationwide healthcare costs. Patients with renal failure missing their dialysis treatment is life threatening as it is financially burdening. Proactive interventions to redirect ESRD patients missing dialysis treatment can prove beneficial to address this Grand Challenge. This paper proposes an innovation to examine ESRD patient missed treatment events. More resources are needed in the dialysis sector that will enhance the health of an ESRD patient on dialysis.

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Asset Metadata

Creator Levinson, Aaron (author)

Core Title Closing the health gap: the case for integrated care services in outpatient dialysis centers

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 05/14/2021

Defense Date 04/11/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag dialysis spending,integrated care,missing dialysis treatment,OAI-PMH Harvest

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Lee, Nani (committee member), Manderscheid, Ronald (committee member), Singh, Melissa (committee member)

Creator Email aalevins@usc.edu,alevya526@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-170367

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Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA