By Renee George, Senior Vice President of Market Operations

Early detection and intervention in kidney disease can slow progression to end-stage kidney disease (ESKD), save healthcare costs, and make people’s lives richer and happier. Still, patients with chronic kidney disease (CKD) often fall through the cracks. 

Reimbursement systems have tended to emphasize treatment over limiting disease progression. And a certain fatalism about kidney disease has, in the past, limited innovation.

That is changing. Strive Health is redefining the kidney care experience and proving that patient engagement is a powerful way to slow disease progression, limit costs and, most importantly, return hope and better health to our patients.  

How We Define and Deliver Patient Engagement in Kidney Disease Care

Patient engagement covers a range of activities and interventions that lead to patients:

• Learning more about their disease and what can affect it 
• Committing to behavioral changes that contribute to better health 
• Becoming engaged in decision-making about their care and treatment 

Sounds simple, but entrenched issues make it challenging. For patients, kidney disease is usually not their only chronic disease or condition. For doctors, educating patients and enlisting them in their care takes time and resources they often don’t have.   

Patient engagement requires expertise from many disciplines besides medicine: behavioral health, pharmacy, dietetics, physical health and more. And it takes developing trusting, caring relationships guided by patients' needs and wants in an unhurried atmosphere.

‍Patient Engagement in Action  

Patients receive support from Strive Health through one of our partnerships. We begin by calling patients to explain the program, how we work with their doctors, and the benefits and support they can expect. Many greet us with excitement and relief that they finally have an ally. When we can connect with patients, they become involved 60% of the time.

Our Kidney Heroes™ are at the center of patient engagement. This team of diverse professionals meet patients where they are and build from there, discussing and setting goals such as:  

• More physical activity
• Better diet and eating habits
• Taking prescribed medicines as directed
• Keeping appointments with their primary care providers and nephrologists
• Attending dialysis sessions as prescribed
  

People with kidney disease often experience depression and anxiety, which can interfere with making lifestyle changes or becoming engaged in their health. Strive’s licensed clinical social workers provide counseling, and care coordinators coach patients to identify and overcome barriers — behavioral, physical, economic, social — to achieving their goals.

The Kidney Heroes™ perform another critical function: Closing gaps in communication and care that have unintended but serious consequences for patient health.

For example, kidney disease patients often have multiple prescriptions from different doctors. Strive Kidney Heroes™ review medications, raise a flag and follow up with patients’ prescribing doctors when they spot contraindications, nephrotoxic medications or evidence that people aren’t using their medicines appropriately. 

If patients miss any scheduled doctor visits or tests, with any provider, the Kidney Heroes™ follow up to help reschedule and make sure that there’s nothing, like a lack of transportation, preventing them from getting the care they need.

Strive professionals visit patients in their homes, use telehealth and, in some locations, operate clinics. As they get to know patients and their families, Strive clinicians ask about factors that can affect health, such as:

• Is there enough healthy food in the refrigerator and cupboards?
• Are family or neighbors available for support or in an emergency?
• Do they have transportation to medical or dialysis appointments?
• Are they lonely, depressed or anxious? 
• Are there any other environmental factors that pose risks, such as stairs, pets, lighting?  
  

The intensity of engagement increases for patients with multiple comorbid conditions and complex needs. In those cases, team members are in contact multiple times per week with the patients and their doctors.

The technology underlying the Strive Care Model helps make patient engagement more timely, targeted and effective. Predictive analytics delivers risk scores that forecast patients at the highest risk of crashing into dialysis or are predicted to be readmitted after a hospitalization. The analytics can even identify patients with undiagnosed kidney disease.

Patient Engagement Adapts to Kidney Disease Progression

Many patients eventually reach a point when it’s time to prepare for dialysis or a kidney transplant. The Kidney Heroes™ educate patients about options so they can make choices — not in an emergency room crisis — but in a thoughtful, informed way to consider what it will mean for them and their families.

For patients preparing for transplant, we help them understand what to expect in the days and months before and after surgery. In some cases, we can help patients with disqualifying conditions, such as a smoking habit or elevated weight, make lifestyle changes and become eligible for transplants. 

Patient Engagement Achieves Its Goals: Better Health, Lower Costs

Emergency room visits, hospital readmissions, dialysis — many of these costs that burden the healthcare system are avoidable or can be delayed when patients are engaged in their health and care. 

The results among Strive Health patients are attributable in part to our patient engagement activities that are a vital component of our care model:

• 67% increase in optimal startsⁱ — patients plan to and start dialysis or have preemptive transplants
• 14% increase in visits with nephrologists during the first year when patients remain enrolled for three months or longer² 
• 36% reduction in 30-day hospital readmissions³
• 49% reduction in hospitalizations among the highest risk patients⁴

 It matters to us how our patients feel about their care and the support they receive. In our 2021 patient experience survey, patients gave Strive a 61% Net Promoter Score℠ with a 97% overall rating of the Strive Care Team and 90% saying they are “likely to recommend” Strive Health.

Helping patients understand their disease, supporting them in changes that can slow its progress and making their lives happier and fuller — those are our goals. Patient engagement provides that, along with a strong dose of hope.

To learn more about our patient engagement practices or about partnering with Strive, email us or complete our contact form.

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