Quality-Based Procedures Clinical Handbook for Chronic Kidney Disease

Ministry of Health and Long-Term Care March 2013

Table of Contents
1.0 Purpose .............................................................................................................. 3 2.0 Introduction ......................................................................................................... 4 3.0 Description of Chronic Kidney Disease (CKD) as a Quality-Based Procedure . 11 4.0 Evidence-informed practice guiding the implementation of CKD ...................... 14 5.0 How does CKD improve patient outcomes? ..................................................... 17 6.0 What does it mean for clinicians? ..................................................................... 18 7.0 Service capacity planning ................................................................................. 20 8.0 Performance, evaluation and monitoring .......................................................... 21 9.0 Support for Change .......................................................................................... 22 10.0 Frequently Asked Questions............................................................................. 23 11.0 Committees ...................................................................................................... 34

Quality-Based Procedures Clinical Handbook: Chronic Kidney Disease (CKD)

1.0 Purpose
This clinical handbook has been created to serve as a compendium of the evidencebased rationale and clinical consensus driving the development of the policy framework and implementation approach for Chronic Kidney Disease in 2013/14. The Ontario Renal Network (ORN) has played an integral role in the planning and development process and providing advice on best practice care in the delivery of renal services across Ontario. As well, ORN will continue to provide a key leadership role in the implementation of the CKD policy framework while working in close collaboration with the Local Health Integration Networks (LHINs) and all health sectors involved in the provision of CKD services. This clinical handbook is intended for a clinical audience. It is not, however, intended to be used as a clinical reference guide by clinicians and will not be replacing existing guidelines and funding applied to clinicians. Evidence-informed pathways and resources have been included in this handbook for your convenience.

2.0 Introduction
Quality-Based Procedures (QBP) are an integral part of Ontarios Health System Funding Reform (HSFR) and a key component of the Patient-Based Funding (PBF). This reform plays a key role in advancing the governments quality agenda and its Action Plan for Health Care. HSFR has been identified as an important mechanism to strengthen the link between the delivery of high quality care and fiscal sustainability. Ontarios health care system has been living under a global economic uncertainty for a considerable period of time. At the same time, the pace of growth in health care spending has been on a collision course with the provincial governments deficit recovery plan. In response to these fiscal challenges and to strengthen the commitment towards the delivery of high quality care, the Excellent Care for All Act (ECFAA) received royal assent in June 2010. ECFAA is a key component of a broad strategy that improves the quality and value of the patient experience by providing them with the right care at the right time, and in the right place through the application of evidence-informed health care. ECFAA positions Ontario to implement reforms and develop the levers needed to mobilize the delivery of high quality, patient-centred care. Ontarios Action Plan for Health Care advances the principles of ECFAA reflecting quality as the primary driver to system solutions, value and sustainability.

2.1 What are we moving towards?

Prior to the introduction of HSFR, a significant proportion of hospital funding was allocated through a global funding approach, with specific funding for some select provincial programs and wait times services. A global funding approach reduces incentives for Health Service Providers (HSPs) to adopt best practices that result in better patient outcomes in a cost-effective manner. To support the paradigm shift from a culture of cost containment to quality improvement, the Ontario government is committed to moving towards a patientcentred funding model that reflects local population needs and contributes to optimal patient outcomes (Figure 1). Internationally, PBF models have been implemented since 1983. Ontario is one of the last leading jurisdictions to move down this path. This puts the province in a unique position to learn from international best practices and lessons learned by others to create a funding model that is best suited for Ontario. 4

PBF supports system capacity planning and quality improvement through directly linking funding to patient outcomes. PBF provides the incentive to health care providers to become more efficient and effective in their patient management by accepting and adopting best practices that ensure Ontarians get the right care, at the right time and in the right place.
Figure 1: The Ontario government is committed to moving towards patient-centred, evidence-informed funding that reflects local population needs and incents delivery of high quality care

Current Sta State te

Based on a lump sum, outdated historical funding Fragmented system planning Funding not linked to outcomes Does not recognize efficiency, standardization and adoption of best practices Maintains sector specific silos

How do we get there?

Future Fut ure S St tate

Transparent, evidence-based to better reflect population needs

Strong Clinical Engagement

Supports system service capacity planning Supports quality improvement Encourages provider adoption of best practice through linking funding to activity and patient outcomes Ontarians will get the right care, at the right place and at the right time

Current Agency Infrastructure System Capacity Building for Change and Improvement Knowledge to Action Toolkits Meaningful Performance Evaluation Feedback

2.2 How will we get there?

The Ministry has adopted a three-year implementation strategy to phase in a PBF model and will make modest funding shifts starting in fiscal year 2012/13. A three-year outlook has been provided to the field to support planning for upcoming funding policy changes. The Ministry has released a set of tools and guiding documents to further support the field in adopting the funding model changes. For example, a Quality-Based Procedure (QBP) Interim list has been published for stakeholder consultation and to promote transparency and sector readiness. The list is intended to encourage providers across the continuum to analyze their service provision and infrastructure in order to improve clinical processes and where necessary, build local capacity. The successful transition from the current, provider-centred funding model towards a patient-centred model will be catalyzed by a number of key enablers and field supports. These enablers translate to actual principles that guide the development of the funding reform implementation strategy related to QBPs. These principles further translate into operational goals and tactical implementation, as presented in Figure 2.
Figure 2: Principles guiding the implementation of funding reform related to Quality-Based Procedures

Princ nci iples for developi oping QBP impl mplementa mentati tio on st str rate ateg gy
Cross-Sectoral Pathways Evidence-Based

Ope pera rat tional onalization of prin principl ple es t to o tac act tica cal li im mplem eme entation ( (e exam amp ples)
Development of best practice patient clinical pathways through clinical expert advisors and evidence-based analyses Integrated Quality Based Procedures Scorecard Alignment with Quality Improvement Plans Publish practice standards and evidence underlying prices for QBPs Routine communication and consultation with the field Clinical expert panels Provincial Programs Quality Collaborative Overall HSFR Governance structure in place that includes key stakeholders LHIN/CEO Meetings Applied Learning Strategy/ IDEAS Tools and guidance documents HSFR Helpline; HSIMI website (repository of HSFR resources)

Balanced Evaluation

Transparency

Sector Engagement

Knowledge Transfer

2.3 What are Quality-Based Procedures?

QBPs involve clusters of patients with clinically related diagnoses or treatments. Chronic Kidney Disease was chosen as a QBP using an evidence and quality-based selection framework that identifies opportunities for process improvements, clinical redesign, improved patient outcomes, and enhanced patient experience and potential cost savings. The evidence-based framework used data from the Discharge Abstract Database (DAD) adapted by the Ministry of Health and Long-Term Care for its Health Based Allocation Methodology (HBAM) repository. The HBAM Inpatient Grouper (HIG) groups inpatients based on the diagnosis or treatment responsible for the majority of their patient stay. Day Surgery cases are grouped within the National Ambulatory Care Referral System (NACRS) by the principal procedure they received. Additional data was used from the Ontario Case Costing Initiative (OCCI). Evidence such as publications from Canada and other jurisdictions and World Health Organization reports were also used to assist with the patient clusters and the assessment of potential opportunities. Specifically, for the Chronic Kidney Disease (CKD) QBP, Ontario Renal Registry System (ORRS) data in combination with NACRS and the Self-Reporting Initiative (SRI) data are used to track services. Additional data from OCCI and the Ontario Joint Policy and Planning Committee (JPPC) are also used. The evidence-based framework assessed patients using four perspectives, as presented in Figure 3. This evidence-based framework has identified QBPs that have the potential to both improve quality outcomes and reduce costs.

Figure 3: Evidence-Based Framework

Does the clinical group contribute to a significant proportion of total costs? Is there significant variation across providers in unit costs/ volumes/ efficiency? Is there potential for cost savings or efficiency improvement through more consistent practice? How do we pursue quality and improve efficiency? Is there potential areas for integration across the care continuum? Are there clinical leaders able to champion change in this area? Is there data and reporting infrastructure in place? Can we leverage other initiatives or reforms related to practice change (e.g. Wait Time, Provincial Programs)?

Is there a clinical evidence base for an established standard of care and/or care pathway? How strong is the evidence? Is costing and utilization information available to inform development of reference costs and pricing? What activities have the potential for bundled payments and integrated care?

Is there variation in clinical outcomes across providers, regions and populations? Is there a high degree of observed practice variation across providers or regions in clinical areas where a best practice or standard exists, suggesting such variation is inappropriate?

1. Practice Variation
The DAD has every Canadian patient discharge, coded and abstracted for the past 50 years. This information is used to identify patient transition through the acute care sector, including discharge locations, expected lengths of stay and readmissions for each and every patient, based on their diagnosis and treatment, age, gender, comorbidities and complexities and other condition specific data. A demonstrated large practice or outcome variance may represent a significant opportunity to improve patient outcomes by reducing this practice variation and focusing on evidence-informed practice. A large number of Beyond Expected Days for length of stay and a large standard deviation for length of stay and costs, were flags to such variation. Ontario has detailed case costing data for all patients discharged from a case costing hospital from as far back as 1991, as well as daily utilization and cost data by department, by day and by admission.

2. Availability of Evidence
A significant amount of research has been completed both in Canada and across the world to develop and guide clinical practice. Working with the clinical experts, best practice guidelines and clinical pathways can be developed for these QBPs and appropriate evidence-informed indicators can be established to measure performance.

3. Feasibility/ Infrastructure for Change

Clinical leaders play an integral role in this process. Their knowledge of the patients and the care provided or required represents an invaluable component of assessing where improvements can and should be made. Many groups of clinicians have already formed and provided evidence and the rationale for care pathways and evidence-informed practice. 4. Cost Impact The selected QBP should have no less than 1,000 cases per year in Ontario and represent at least 1 percent of the provincial direct cost budget. While cases that fall below these thresholds may in fact represent improvement opportunity, the resource requirements to implement a QBP may inhibit the effectiveness for such a small patient cluster, even if there are some cost efficiencies to be found. Clinicians may still work on implementing best practices for these patient sub-groups, especially if it aligns with the change in similar groups. However, at this time, there will be no funding implications. The introduction of evidence into agreed-upon practice for a set of patient clusters that demonstrate opportunity as identified by the framework can directly link quality with funding.

2.4 How will QBPs encourage innovation in health care delivery?

Implementing evidence-informed pricing for the targeted QBPs will encourage health care providers to adopt best practices in their care delivery models, and maximize their efficiency and effectiveness. Moreover, best practices that are defined by clinical consensus will be used to understand required resource utilization for the QBPs and further assist in the development of evidence-informed prices. Implementation of a price X volume strategy for targeted clinical areas will incent providers to: 9

Adopt best practice standards; Re-engineer their clinical processes to improve patient outcomes; and Develop innovative care delivery models to enhance the experience of patients.

Clinical process improvement may include the elimination of duplicate or unnecessary investigations, better discharge planning, and greater attention to the prevention of adverse events, i.e., post-operative complications. These practice changes, together with adoption of evidence-informed practices, will improve the overall patient experience and clinical outcomes, and help create a sustainable model for health care delivery.

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3.0 Description of Chronic Kidney Disease (CKD) as a Quality-Based Procedure

The Chronic Kidney Disease QBP is applied to non-pediatric CKD patients based on the nature and progression of their renal impairment. This QBP relates to the provision of multiple services along the continuum of care for CKD patients, from early identification and management to severe CKD on dialysis. This includes 33+ funded services related, but not limited to, clinics and procedures. Additional services may be included within this framework in the future. CKD has been identified as a QBP using the evidence-based selection framework, as presented in Figure 4.
Figure 4: Evidence-based framework for Chronic Kidney Disease
Strong stakeholder support and interest for improving Chronic Kidney Disease services Ontario Renal Network, with its clinical leadership, is to provide leadership in the implementation of the change Expansion of current data and reporting structure to monitor performance and best practices Recognized best practices and clinical guidelines available

Provincial funding for hospital CKD services: over $500M (3.79% of global budget) Significant variation across providers in costs per service Integration of Chronic Kidney Disease services with other providers e.g. LongTerm Care Homes, CCACs

CKD patient-based payment model (bundled and unbundled services) based on best practice Endorsement of Clinical Practice Guidelines from Clinical Expert Group Costing and utilization information available to inform development of reference costs and pricing

First Ontario Chronic Kidney Disease Atlas released in November 2011, highlighting CKD services delivery in Ontario Opportunity to standardize practice and incorporate best practice across Ontario

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The CKD patient-based funding model, developed by the Ontario Renal Network (ORN), has two components: Patient Based Bundled Services, and the Service Based Funding. The PBF component is a bundled payment, based on best practice, which covers the costs of all services required by a standard patient for a years worth of a particular CKD treatment. The framework includes seven (7) annual patient-based payment bundles as follow: Bundle A - Pre-dialysis; Bundle B.1 - Home Peritoneal Dialysis - Automated Peritoneal Dialysis (APD); Bundle B.2 - Home Peritoneal Dialysis - Continuous Ambulatory Peritoneal Dialysis (CAPD); Bundle C - Home Hemodialysis - Daily/Nocturnal; Bundle D - Home Hemodialysis - Conventional; Bundle E - Chronic In-Facility or Satellite HD Daily/Nocturnal; and Bundle F - Chronic In-Facility or Satellite HD Conventional.

The services contained within the bundles for each of these modalities were determined by the ORN Clinical Advisory Committee (CAC) and the CKD Funding Working Group. The service-based funding is a fee-for-service model which pays for services that cannot be bundled because their occurrence and/or frequency cannot be predicted. This model works the same way as the current operating funding model. Examples of unbundled services in 2013/14 include: Home Visit Nursing Hours of Service; Home Visit Technician Hours of Service; Nephrology Clinic Visit; Education Clinic Visit; Central Venous Catheter-Temporary Insertion; Acute Hemodialysis Level III; Arterio-Venous Fistula Insertion; and Vascular Graft Insertion.

This model will be implemented over a four-year period. The first year of implementation started in 2012/13 with the four (4) related home bundled payments. The remainder of the bundles (i.e., Pre-dialysis and In-Centre) are to be implemented in 2013/14. CKD, within the QBP model, encompasses the management of the early stage of the chronic renal disease, the pre-dialysis, the body access insertions (abdominal and 12

vascular) and dialysis aspects of the disease, but excludes, at present, the early detection and prevention of CKD, or transplant-related services. The key objectives of this QBP are to: Be accountable to CKD patients Improve health outcomes, and Manage the costs of CKD care. The new funding framework for CKD provides payment which follows the patients in a way that supports integration, quality and efficiency throughout the entire patient pathway. Equitable access to care for patients across Ontario remains a strong priority. In addition, the implementation of this QBP discourages the over-provision of services. The funding framework provides funding aligned to best practice, appropriate provider reimbursement, and improved accountability for outcomes. The quality agenda for this QBP reflects four (4) clinical improvement priorities; Early detection and prevention of progression Independent dialysis Improvements in vascular access, and Research and innovation. The information and reporting systems for CKD services have undergone a transition as the QBP was implemented. The Self Reporting Initiative (SRI) has replaced the Web Enabled Reporting System (WERS) for managing CKD data reporting requirements and provides the financial and utilization data for the purpose of CKD service-based reimbursement. Additionally the Ontario Renal Reporting System (ORRS) has been further developed to better capture patient modality of care received and now acts as the key information source for CKD patient-based reimbursement. The CKD PBF model developed by the ORN has significant potential for positive change, particularly when integrated with related ORNs initiatives to improve access to needed services, develop an expanded performance measurement and reporting framework, and promote more evidence-informed practice and quality improvement across the CKD system in Ontario.

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4.0 Evidence-informed practice1 guiding the implementation of CKD

4.1 How was the patient pathway defined?

Collaboration between medical leads, nephrologists and clinicians has led to the establishment of seven distinct categories of CKD patients based on their type of treatment modality. The clinical pathway for CKD patients can be summarized into the seven service bundles, which outline the best practice of care provided for each
1

Evidence-informed practice refers to a combination of best available evidence and clinical consensus

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category of CKD patient. The CKD funding framework currently encompasses dialysis and pre-dialysis care. The aim is to eventually cover most, if not all, aspects relating to the continuum of CKD. The funding bundles, as presented in Figure 5, provide a form of annual reimbursement which follows the patient and discourages over-provision of services. Figure 5: Funding bundles for CKD

Bundle A comprises the services for pre-dialysis patients as part of the clinic visits. Upon further deterioration of the kidney function, patients may move on to renal replacement therapies covered by bundles B1 through F. Bundles B1 and B2 are the groupings of services for peritoneal dialysis (PD) patients. PD is an independent dialysis modality performed in the patients home. PD can be classified into two subtypes, automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD). APD is performed at night while the patient sleeps, and is covered by bundle B1. CAPD involves a series of exchanges performed throughout the day, and is covered by bundle B2. 15

Bundles C and D are also comprised of services for independent dialysis. Bundle C is the package for patients performing nocturnal or daily hemodialysis at home. Bundle D provides services for patients undergoing conventional HD in their home, which is characterized by approximately 3 day time hemodialysis treatments per week. The last two packages, Bundles E and F, encompass services for patients receiving chronic in-facility or Satellite HD, either in a hospital-based or community-based facility. Patients who undergo daily or nocturnal in-centre HD are covered under Bundle E, while patients who receive conventional HD are covered under Bundle F. As the CKD strategy implementation evolves, the CKD funding framework will encompass most, if not all, aspects relating to the continuum of CKD. In addition, while fiscal year 2012/13 marked the initial implementation of CKD as a QBP, this was considered to be a starting point to the move towards evidence-informed pricing (Figure 6). In 2013/14, the remainder of the bundles will be implemented, some of which will be adjusted for specific provider or patient-level characteristics. Specifically, adjustments will be made to the hemodialysis treatments provided to older patient populations and performed in small satellites.

Figure 6: As implementation evolves, an evidence-informed price will be set for CKD services

40th Percentile Pricing 2012/13

Application to QBPs which show narrow variation between patient cases 2012/13 QBPs include: Primary unilateral hip replacement Primary unilateral knee replacement Cataracts Chronic Kidney Disease* 6.97 % **
* Interim price is based on actual direct cost retrieved from OCCI data ** In 2012/13, QBPs will comprise approximately 6.97% of the total hospital global budget *** At the end of 2014/15, QBPs will comprise approximately 30% of the total hospital global budget

Evidence-informed Pricing 2013/14+

Continue development of cross-sectoral clinical pathways with guidance from clinical expert panels Reconcile clinical pathways with availability of clinical/ administrative data Routine, iterative sector consultations for lessons learned to catalyze improvement

Application to QBPs which show wide variation and range of complexities across patient cases As implementation evolves, more QBPs will be introduced

30 % ***

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5.0 How does CKD improve patient outcomes?

At the request of the Ministry, ORN has developed a PBF model for accelerating quality improvement and access to CKD services while improving system value. The ORN has been working in close consultation with clinical, policy and financial experts to develop a framework that links funding to best practice patient care. This framework has been shaped from the work of six separate committees:

1. CKD Clinical Advisory Committee (CAC)

The CAC was the main contributing body comprising of a team of seven Ontario nephrologists. The primary role of the CAC was to provide advice regarding clinical practice and quality care.

2. The Provincial Leadership Forum (PLF)

PLF provides counsel regarding operational practice, system planning and quality care. The PLF is comprised of fourteen ORN Regional Directors (RDs) for CKD care in Ontario.

3. Funding Model Reference Panel

To keep funding policies up to date, a funding panel was established beginning in August 2010 and ending in May 2011. The framework validation for CKD was led by the Funding Model Reference Panel; a diverse committee which included CAC representatives, hospital administrators, RDs and members of the ORN.

4. Funding Model Working Group

The Funding Model Working Group was aligned with the Funding Model Reference Panel, but focused dominantly on framework development. The Working Group is comprised of clinical and administrative leaders (nephrologists, Regional Directors, MOH representation and CCO/ORN staff), to guide its work. During Phase 2, CCAC and LTC representation was added to the Working Group.

5. Regional Renal Steering Committee (RRSC)

Fourteen RRSCs have been established to participate in comprehensive and coordinated planning of CKD services in each respective LHIN. In particular, the 17

responsibility of each RRSC is to ensure that its respective LHIN is responsive to local needs and aligned with the ORN strategies and directions. Other aspects of each RRSC is to ensure optimal delivery of all CKD service levels across its LHIN, making recommendations and providing advice to the ORN to improve access and quality of care related to CKD. There are 14 RRSCs, corresponding to 14 LHINs. Throughout the development and implementation of the CKD Funding framework, the RRSC memberships have been informed.

6. CKD Funding Panel

The Funding Panel was established in part to provide an ongoing governance structure focused on the further development and implementation of the CKD funding framework. The CKD Funding Panel is chaired by Dr. Peter Magner, and provides expert advice to the ORN on matters related to the funding of CKD services in Ontario, including hospital funding allocation, system design, policy and quality of care implications, and related data and reporting issues. All of the CKD Funding Panel members are also representatives on the Working Group.

6.0 What does it mean for clinicians?

6.1 How does CKD as a QBP align with clinician practice?
The QBP for CKD provides funding to promote the provision of evidence-informed, best practice care. Each patient will not require the exact type and amount of services provided within this clinical pathway recognized as best practice. The bundles within the funding framework are meant to provide payments aligned to the appropriate level of care for a patient requiring the average quantity of services. In allocating funding for the average level of treatments defined by best practice, the funding framework will provide the appropriate counterbalance between patients requiring a greater or lesser amount of care.

6.2 Will this have any implications for clinicians?

The changes associated with QBPs focus on identifying and implementing evidenceinformed practice driven by clinical consensus. Clinicians will be tasked with identifying within their own practice standard treatment protocols and pinpointing where there are variances from such practice. Collaboration with their hospital and/or community based provider administration will assist both the clinicians in identifying the challenges within the service, opportunities and the feasibility for changes to the treatment protocols. 18

Clinicians will continue to play an essential role in guiding hospitals and community based providers to the needs of their patient population and ensuring that the highest quality care is provided for all their patients.

6.3 Will this change current practice?

The CKD PBF framework may create a change in current practice for certain clinicians in Ontario. The baseline data published by the ORN in the CKD Atlas identifies a practice variation amongst CKD care providers throughout Ontario. Those who are currently delivering services beyond the standards of evidence-informed practice will need to adopt greater efficiency and reduce the over-provision of services. On the other hand, CKD care providers who deliver fewer services than the standards of care, will be funded to increase their volumes up to the evidence-informed clinical practice. At this time, physician payment models and OHIP fee schedules, as they relate to QBPs, will remain unchanged. Physicians currently working under fee-for-service will continue to submit claims to OHIP for consultations, performing the procedure and follow-up.

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7.0 Service capacity planning

7.1 How will clinician volume management be affected by or affect hospital CKD volumes?
The volumes of CKD services in each modality bundle will be based on evidenceinformed practice, as determined by the ORNs CAC and other related expert groups. Though the number of services funded within the bundles is defined, there will be no patient volume caps due to the life-support nature of the CKD dialysis services. The CKD PBF, including the seven modality bundles, will be implemented over four years. Service volumes will align the number of services per patient according to the agreed-upon best practice set out in the funding bundles.

7.2 How will the new model of budget planning include clinicians?
Opportunities for clinicians to participate in the development and implementation of the new CKD patient-focused funding model are available at all different levels throughout the province. Clinical leaders may decide to have active participation on regional and provincial level working groups or within their respective organization. The new model for budget planning has included clinicians in the formulation of evidence-informed practice and standards of care.

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8.0 Performance, evaluation and monitoring

Improving the quality and access of CKD services is central to the implementation of CKD. Performance, evaluation and monitoring will be an essential aspect of the new CKD funding framework. The purpose of this QBP is rooted in providing quality CKD care that meets expected outcomes, goals and objectives. Building on the ORN quarterly performance management cycle, the ORN will measure, monitor and report on funding (bundled services) and services (provider practices) as well as clinical quality and patient outcomes. All CKD funding policy measurement and reporting will be tied to explicit goals and objectives and will help to inform a CKD Monitoring and Evaluation Framework (CKD MEF), which is being developed collaboratively by the clinician led Clinical Measurement Expert Group (CMEG) and the ORN. Part of the evaluation process regarding efficiency and remuneration involves the assessment of standards set in other jurisdictions. In addition, part of the process of assessing the impact of Health System Funding Reform on the health care system will be developing a set of indicators to track and evaluate the performance of the CKD patient-based funding model. Furthermore, the MOHLTC is leading the development of an integrated QBP scorecard that will track and assess the impact of QBPs against indicators of quality. This scorecard will be aligned with currently existing quality indicators used in other reporting processes.

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9.0 Support for Change

The ORN will provide input on the overarching HSFR strategy for system change and specifically, lead the change management related to CKD service delivery. The Ministry, in collaboration with its partners, will deploy a number of field supports to support adoption of the funding policy. These supports include: Committed medical engagement with representation from cross-sectoral health sector leadership and clinicians to champion change through the development of standards of care and the development of evidence-informed patient clinical pathways for the QBPs Dedicated multidisciplinary clinical expert group that seek clearly defined purposes, structures, processes and tools which are fundamental for helping to navigate the course of change Strengthened relationships with Ministry partners and supporting agencies to seek input on the development and implementation of QBP policy, disseminate quality improvement tools, and support service capacity planning Alignment with quality levers such as the Quality Improvement Plans (QIPs). QIPs strengthen the linkage between quality and funding and facilitate communication between the hospital board, administration, providers and public on the hospitals plans for quality improvement and enhancement of patientcentered care Deployment of a Provincial Scale Applied Learning Strategy known as IDEAS (Improving the Delivery of Excellence Across Sectors). IDEAS is Ontarios investment in field-driven capacity building for improvement. Its mission is to help build a high-performing health system by training a cadre of health system change agents that can support a approach to improvement of quality and value in Ontario

We hope that these supports, including this Clinical Handbook, will help facilitate a sustainable dialogue between hospital administration, clinicians, and staff on the underlying evidence guiding QBP implementation. The field supports are intended to complement the quality improvement processes currently underway in your organization.

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10.0 Frequently Asked Questions

Question 1: How can I obtain more information about this?
Helpline o Email: HSF@ontario.ca o Phone: 416-327-8379 The ministrys public website: www.health.gov.on.ca Access the Health Care Professionals page o Excellent Care For All (www.health.gov.on.ca/en/ms/ecfa/pro/) o HSFR (http://www.health.gov.on.ca/en/ms/ecfa/pro/initiatives/funding.aspx) Password protected website for provider: www.hsimi.on.ca o Repository of HSFR resources, including HBAM results and education materials

For further information, please visit: Ontario Renal Network http://www.renalnetwork.on.ca/ Cancer Care Ontario https://www.cancercare.on.ca/ Excellent Care for All Act http://www.health.gov.on.ca/en/ms/ecfa/pro/about/ Health System Funding Reform http://www.health.gov.on.ca/en/ms/ecfa/pro/initiatives/funding.aspx Ontario Medical Association https://www.oma.org/Pages/default.aspx Health Quality Ontario www.hqontario.ca Canadian Institute for Health Information http://www.cihi.ca/CIHI-ext-portal/internet/EN/Home/home/cihi000001 Institute for Clinical Evaluative Sciences http://www.ices.on.ca/ 23

Section A: Bundled vs. Unbundled Services, Service Volumes, Service Definitions

Question 2: What were the criteria upon which some services remain unbundled?
Unbundled services are those services that will continue to be reimbursed on a fee-forservice basis, similar to the current funding arrangement. Below are the criteria used for unbundling a service: Volumes per patient vary considerably across providers (e.g., home nursing visiting hours per home dialysis patient); It cant be predicted which patients will be receiving the service (e.g., hemodialysis [HD] treatments for peritoneal dialysis [PD] patients, or in-hospital PD exchanges); The service tends to take place in facilities that are different from where the patient usually receives dialysis services, making it difficult to align patients and providers of care (e.g., vascular procedures); or Services are provided to patients visiting from other hospitals, but not recorded as transfers (short vacations or admissions to other hospitals).

Question 3: What if six follow-up visits per PD patient per year, as estimated by best practice, are not enough?
Based on the Clinical Advisory Committees recommendations regarding best practice volumes and data regarding the number of follow-up visits provided to home PD and home HD patients, the annual volume has been set at 6 follow-up visits per year. Certain patients may require more visits (e.g., 8 visits) or fewer visits (e.g., 4 visits), but the providers total annual volume of follow-up visits should average out to 6 visits per year. Some new PD programs with a high proportion of incident patients indicated that they may need to follow up on their patients more often than once every two months. The annual number of follow-up visits per PD patient will be monitored on an ongoing basis to determine if the best practice volumes need to be reassessed.

Question 4: Are vascular access services bundled or unbundled?

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Vascular access services are unbundled because they tend to occur in facilities that are not necessarily the same facilities where patients receive dialysis services and because the annual service volumes per patient are unpredictable (vary across patients and providers). Also, see answer to Question 2.

Question 5: Why is home HD training a bundled service, but PD training is not?

Analysis to date revealed that PD training per patient varies considerably across hospitals.

Question 6: Would home HD retraining be funded as a bundled or unbundled service?

While the home HD initial training days are bundled (21 initial training days), retraining for home HD remains unbundled because the available evidence does not allow the prediction of the percentage of patients that will require retraining, how often they will require retraining and for how many days. This will be subject to ongoing monitoring and evaluation.

Question 7: Why are follow-up dialysis patient clinic visits included in Bundles B1. (Home PD [APD]), B2. (Home PD [CAPD]), C. (Home HD Daily/Nocturnal) and D. (Home HD Conventional), but not in Bundles E. (Chronic In-Facility or Satellite HD Daily/Nocturnal) and F. (Chronic In-Facility or Satellite HD Conventional)?
In-centre conventional HD patients visit the dialysis centre three times a week and incentre nocturnal/daily HD patients visit the dialysis unit several times a week. It is expected that ongoing patient follow-up is included as part of these visits.

Question 8: What team members are included in the definition of pre-dialysis visits?
A pre-dialysis visit requires that the patient be seen by at least three of: Nurse Dietician Social Worker

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Pharmacist/Pharmacy technician Physician (associated pre-dialysis funding does not cover physician reimbursement).

Question 9: What about In-Centre Conventional patients that receive treatments four times per week instead of three times per week?
The number of HD treatments per week for In-Centre Conventional HD patients is three, based on best practice. This number recognizes that certain patients may require four treatments per week, others may require less than three treatments per week, and some may also miss treatments. Our most recent analysis shows that only two providers slightly exceeded the average of 156 treatments per conventional HD patient. This number will be re-evaluated on an ongoing basis to determine if the best practice volume of 156 treatments per year needs to be re-adjusted.

Question 10: What about HD treatments that are provided to home PD or home HD patients? How will these be funded?
Because it is difficult to predict if and when HD treatments will be provided to home PD and HD patients, this is an unbundled service and will be funded on a fee-for-service basis. Please refer to question 2 for criteria specifying what services are to be unbundled.

Question 11: What if an In-Centre HD patient exceeds best practice numbers? Will these volumes be funded on a fee-for-service basis?
Best practice has been set to156 treatments a year for In-Centre Conventional patients and 260 treatments a year for In-Centre Daily Patients. Some In-Centre Conventional patients may require more treatments per week, while others may require less (or miss treatments). As a result, the average number of treatments per week should reflect the best practice volumes. For providers that exceeded or provided less than the best practice number of treatments per patient, funding will still be set at the best practice level. 26

The set volumes will be carefully monitored in the future and if the average volumes per patients are systematically higher for some providers and are associated with improved patient outcomes, the best practice levels will be revised.

Question 12: If bundled service volumes are not achieved, will funding be clawed back?
Funding will not be clawed back, the same standard bundle reimbursement rate will be provided for every annualized patient, based upon best practice. Bundled reimbursement is tied to and based upon the count of annualized patients in each bundle, not on the delivery of specific components or services within the bundles. Reported volumes will continue to be monitored and our Expert Panel will continue to evaluate and refine the bundles based upon new and up-to-date data and their expertise.

Question 13: Why is there no cost adjustment for Academic Health Science Centres for dialysis care when there is an adjustment for acute inpatient services in HBAM?
Please refer to question 23. Analysis of provider characteristics has not provided evidence to support a cost adjustment for academic health science centres for dialysis services. Further analyses will be carried out when improved data become available.

Section B: Modality and Location Switching

Question 14: What happens if a patient needs to move? What about patients who switch types/modalities during the year?
The count of patients in ORRS takes into account modality changes, provider changes, transfer-outs, deaths and file closures. Prior to May 2012, changes in modality and provider reported only after 30 days. As of May 2012, the ORRS reporting requirement is that ALL modality and provider switches will need to be reported, including those that took place within less than 30 days. For example, Mrs. Smith starts on home PD with provider A and after five months she transfers to In-Centre HD Conventional for three months, also with provider A. After 27

three months, the patient moves and transfers to another provider (provider B) and begins In-Centre HD Conventional at the new location for the remainder of the year. Funding would flow as follows: Provider A would be reimbursed based on: - Five months of PD patient care (annual cost of PD x 5/12) - Three months of in-centre HD patient care (annual cost of HD x 3/12) - Fee-for service reimbursement for all unbundled services the patient received throughout the eight months Provider B would be reimbursed based on: - Four months of in-centre HD patient care (annual cost of in-centre HD x 4/12) - Fee-for-service reimbursement for all unbundled services the patient received throughout the four remaining months

Question 15: What happens if a patient receives hemodialysis treatments at another hospital on a long-term basis? On a short-term basis?
Patient receiving services from another hospital - Long-term basis Patients that receive hemodialysis treatments from another hospital on a long-term basis would be considered transfer patients. Money would flow to the hospital providing the treatment. Patient receiving services from another hospital - Short-term basis For patients that receive hemodialysis treatments from another hospital on a short-term basis, the hospital providing these treatments would be reimbursed for those HD treatments on a fee-for-service basis. Hemodialysis treatments for transient patients from other hospitals is a line item included with the unbundled services. The patients PRIMARY provider (where the patient usually receives HD treatments) would NOT be required to report the missed treatments, and payment for the primary provider would not be reduced.

Question 16: How will you know when the patient got sick and stopped being in the Home PD modality and was in an inpatient setting?
ORN will track each patients start and end dates on each modality, as captured in ORRS. When a home PD patient gets sick and goes to an inpatient setting, a modality change from PD to inpatient will be recorded in ORRS for the duration of the inpatient stay. 28

Section C: Reimbursement Rates and Funding

Question 17: Will the proposed reimbursement rates be assessed on an ongoing basis?
Yes, the reimbursement rates will be continuously re-assessed and adjusted. The availability of case costing data will be particularly useful for this purpose.

Question 18: Will there continue to be funding for acute dialysis?

Yes, acute dialysis services will continue to be funded on a fee-for-service basis.

Section D: Patient and Provider Characteristics (Adjustors)

Question 19: Why are there no proposed cost adjustors at the provider (hospital) level? Would the bundled reimbursement rates vary, according to distance travelled by providers or patients, or according to the distance(s) between the regional centre and its site(s)?
Extensive analysis has been completed to explore associations between provider characteristics and service costs. The evidence gathered from the analysis completed to date does not demonstrate any consistent impact of provider characteristics on cost. Provider-level characteristics explored included the following: Isolation/Rurality: Distance between satellites and corresponding Regional Centre (in km) Patient travel time from residence to hospital (in minutes) Program size Number of dialysis operating stations Dialysis unit total expenses (MIS) Peer Group 29

Academic Health Sciences Centres, Large and Small hospitals Regional centre vs. Satellite

Additionally, there are a number of services that remain unbundled, which reduces the risk to providers that may be providing a greater VOLUME of services due to their isolation. For example, nursing hours of service for home visits remain unbundled. As such, providers that are more isolated and require more nursing time to travel to the patients home would NOT be penalized and would be reimbursed for the number of hours reported - which may be much higher than other providers that are not isolated.

Question 20: Was data analyzed at the regional centre level only, or were satellites included?
Where data were available, the analysis has been completed at the satellite level. Additionally a survey was sent out to all providers requesting data pertaining to provide details on their expenditures, human resource complement, patient activity and the number of dialysis machines in order to conduct supplementary satellites-level analyses.

Question 21: How does the framework account for patients with unique challenges who require greater treatment resources? Examples include patients with diabetes and patients with gambling and food addictions who miss appointments.
The new funding framework would provide reimbursement to hospitals for treating incentre HD patients based on a best practice annual service volume (156 treatments per year for in-centre conventional and 260 treatments per year for in-centre daily). Missed treatments would not result in a reduced reimbursement. This recognizes that resources are still used when patients do not show up for a treatment, and providers should therefore be compensated accordingly.

Co-morbidities are important patient-level characteristics which will be further examined as soon as better data become available.

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Question 22: Other research/studies have shown that other patient characteristics, including socio-economic status, may be associated with higher costs. Why are these not taken into account?
To conduct this analysis, patient-level data on socio-economic status will need to be combined with patient level cost and utilization data. This information is not currently available and is unlikely to become available in the near future.

Question 23: Does the proposed funding framework take into account the distance that providers (e.g., nurses) travel to deliver certain services?
Nursing hours of service are unbundled. As such, providers that are more isolated and that require more nursing time to travel to the patients home will be reimbursed for the number of hours reported - which may be much higher than other providers that are not isolated. This ensures that isolated hospitals are not penalized for using more nursing and technician hours for home visits.

Question 24: Will the bundles and proposed reimbursement rates apply to all sites/satellites, not just regional centres?
Yes, bundled and unbundled services, as well as the proposed reimbursement rates, will apply equally to patients of satellites and regional centres.

Question 25: What are BMI and BSA, and why were they explored as patient characteristics that could be associated with HD treatment cost?
BMI (Body Mass Index) and BSA (Body Surface Area) were explored as patient characteristics that could potentially impact the cost of a treatment, or that could impact the number of hemodialysis treatments required by a patient. The model adopted by the Centre of Medicare and Medicaid System (CMS) adjusts for these factors for the following reasons: 31

Low Body Mass Index: Individuals with a body mass index below 18 have higher levels of acuity and frailty. As a result, the HD treatments they receive require more nursing and non-nursing resources. However, the analysis of Ontario renal data has shown no variation in the percentage of patients with low BMI across hospitals. Body Surface Area: in the U.S., individuals with a high body service area usually need to be dialyzed for a longer period of time, resulting in a higher cost per treatment. In Canada, however, everyone is dialyzed for three to four hours, regardless of their size. As a result, this variable was not used in Ontarios CKD proposed funding framework.

Question 26: Will the age adjustment to the in-centre HD treatment proposed reimbursement rate apply to sites/satellites, as well as regional centres?
Yes, each satellite and each regional centre has a unique patient age mix, based upon which the age adjustment will be determined. The age adjustment will apply to the cost of an in-centre hemodialysis treatment only. None of the other services will be affected.

Question 27: What happens when patients get older from year to year? Does the age adjustment get updated?
Yes, the age mix for each provider will be recalculated yearly and the adjustment will be updated accordingly.

Question 28: Is the age adjustment for in-Centre HD treatments meant to encourage providers to assign younger patients to home modalities?
No. The age adjustment for in-centre HD treatments is strictly meant to account for the higher level of patient acuity and resource usage required by older patients, to ensure providers are compensated accordingly.

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Question 29: Can hospitals get bumped up for BMI and down for Age?
Age has been the only adjustor incorporated into the model, for in-centre HD only, and will be implemented when the in-centre HD bundles are implemented in 2013/14.

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11.0 Committees
11.1 CKD Clinical Advisory Committee (CAC) Membership
Dr. Peter Magner Provincial Lead, Funding, ORN Regional Medical Lead, Champlain LHIN, ORN Associate Professor of Medicine, University of Ottawa Head, Division of Nephrology at The Ottawa Hospital Director of Hemodialysis, The Ottawa Hospital Member, ORN Clinical Advisory Committee Dr. Mark Benaroia Nephrologist, Grand River Hospital Corp. Member, ORN Clinical Advisory Committee Dr. Andrew House Associate Chair, London Health Sciences Centre, Division of Nephrology Associate Professor, University of Western Ontario Member, ORN Clinical Advisory Committee Dr. William McCready Associate Dean -Faculty Affairs, Senior Associate Dean-West Campus at the Northern Ontario School of Medicine Nephrologist, Thunder Bay Regional Hospital Member, ORN Clinical Advisory Committee Dr. David Berry Division Head of Nephrology & Medical Director of the Renal Program, Sault Area Hospital Member, ORN Clinical Advisory Committee Dr. Paul Tam Division Head of Nephrology, The Scarborough Hospital Medical Director, Scarborough Regional Dialysis Program Member, ORN Clinical Advisory Committee

11.2 CKD Funding Panel

Dr. Peter Magner Provincial Lead, Funding, ORN Regional Medical Lead, Champlain LHIN, ORN Associate Professor of Medicine, University of Ottawa Head, Division of Nephrology at The Ottawa Hospital Director of Hemodialysis, The Ottawa Hospital Member, ORN Clinical Advisory Committee

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Dr. Al Kadri CKD Funding Panel member, Erie St. Clair LHIN Regional Medical Lead Division Head, Nephrology, Hotel Dieu Grace Hospital Dr. Chris Rabbat CKD Funding Panel member; Hamilton Niagara Haldimand Brant LHIN Regional Medical Lead Associate Professor, Division of Nephrology, Department of Medicine, McMaster University Peter Varga Regional Director, ORN for the Waterloo Wellington LHIN Program Director, Renal Dialysis, Grand River Hospital

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