HJNO May/Jun 2024

HEALTHCARE JOURNAL OF NEW ORLEANS I  MAY / JUN 2024 29 To understand how the past two and a half years since that first visit on Nov. 19, 2021, have unfolded for her, you need to first un- derstand the design of this “special” clinic. It is comprised of a team of individuals with an integrated licensed clinical social worker/be- havioral therapist, a dietitian, a nurse practitio- ner, and a health coach, all working together to co-produce desired health outcomes in partnership with the patient. We have the luxury of longer visits made possible by the gift of time because we are not beholden to a transactional care model that is based on fee- for-service reimbursement from a commercial payer. Instead, our care model is relational in nature where we co-locate the right sources of talent, each with their own discrete area of domain knowledge, while utilizing technology to track and hold ourselves accountable for the outcomes we co-produce with patients. And on our first visit with any patient, our pri- mary goal is to earn their trust. We avoid labels such as compliance or adherence and instead seek to understand the barriers, obstacles, and challenges that have impeded their prog- ress in achieving their health-related goals. In reviewing my progress note from that first visit, I documented that I spent 90 minutes with her, something almost unheard of in today’s vol- ume-driven model of primary care. Subsequent visits do not require nearly that much time and can often be completed in under 20 minutes, but that initial longer visit is well worth the time to help build rapport with them, thereby earn- ing their trust, and deeply exploring the sum of their cumulative experiences that have gotten them to where they are at that point in time. One health plan benefit at the time, primarily determined by a partnership with our pharma- cy benefit manager (PBM), did not provide cov- erage of a class of medications known as the SGLT2 inhibitors because of their exorbitant expense. But in our clinic, these medications were made available to patients for free, with the realization that these drugs are not only ef- fective diabetic agents but also excellent medi- cations for slowing the progression of CKD. Without going through a detailed explana- tion of the clinical and operational processes that got her to where she is now, suffice it to say that she is now in much better health. Her A1c came down to 8.6 by June 18, 2022, 7.3 by Aug. 10, 2022, and 6.5 by Dec. 2, 2022, achiev- ing perfectly controlled diabetes a little over a year after starting in our clinic without any bouts of hypoglycemia and with a large reduc- tion in her total insulin dose. She had been very poorly controlled for many years previously, despite the care of a very good endocrinol- ogy department, which was constrained by the transactional fee-for-service-driven care model. Treatment of her blood pressure eventually required a multi-drug regimen comprised of amlodipine, valsartan, chlorthalidone, and spi- ronolactone, as well as the implementation of a digital hypertension solution. Now, her blood pressures are routinely in the 110-120s/70s range. Through dedicated care team support and disciplined efforts on her part, she was able to achieve > 15% reduction in her weight. Through facilitated weight loss, she no longer needs a proton pump inhibitor for acid reflux, which is a medication potentially toxic to the kidneys, and yet another element involved in slowing the progression of her CKD. She is also no longer experiencing any symptoms of neuropathy. We were also able to put her on an SGLT2 inhibitor, which, in addition to good BP control, has helped her UACR go from 1217 to 17.5, with her eGFR increasing to 58 mL/min, moving her from CKD G3a/A3 to CKD G3a/A1 on the KDIGO heat map (depicted in the last article in this journal). Her LDL is down to 62. And we know that for every 40 mg/dL reduction in LDL we have achieved a 20-30% reduction in future ASCVD risk, meaning that we have suc- ceeded in reducing her future 10-year risk of an adverse cardiovascular event risk by about 50% (remember that cardiovascular events are the leading cause of death in patients with CKD). But since the topic of today is CKD, the most important numbers are the recalculation of her risk for kidney failure with her new KFRE yield- ing estimates of two- and five-year scores of 0.23% and 0.71% respectively. Let’s put that into perspective. She went from a 14.4% risk of kid- ney failure at five years to a 0.71% risk, a 2028% reduction in her risk of progressing to ESKD over the next five years. For the health plan, al- though it would take a detailed actuarial analy- sis to calculate, we predict that the extra cost of the care model is more than offset by savings “The smallest replicable unit of care delivery is the clinical microsystem, which is comprised of the patients, providers, processes, patterns, and purpose of that microsystem — known as the ‘5Ps.’”