Integrated care team gives hope back to dialysis patient

(BPT) – Six years ago, Francis Hogan was doing what he loved most: playing golf. After his usual game, his ankle was swollen and painful. When he visited the doctor, he discovered the swelling wasn’t because of an injury. Something was seriously wrong.

Hogan’s kidneys were failing. He was diagnosed with focal segmental glomerulosclerosis, a condition that scarred his kidneys, leading to kidney failure. He needed to start dialysis or receive a transplant to survive. After a failed transplant, Hogan began dialysis treatments.

“Dialysis patients like Mr. Hogan typically spend 12 hours a week on a machine that cleans their blood because their kidneys can’t,” said Bryan Becker, MD, a nephrologist who leads DaVita’s integrated kidney care (IKC) programs. “This will likely be his reality for the rest of his life.”

With kidney failure, Mr. Hogan’s risk for hospitalizations increased: Most dialysis patients spend about 11 days a year in the hospital. Hogan also struggled to track his more than 20 pills — the average daily number of pills for dialysis patients.

Hogan gained access to DaVita’s ESRD seamless care organization (ESCO), an IKC program for Medicare patients, in Warminster, Pennsylvania. ESCOs are groups of dialysis centers, nephrologists and other clinicians working together to coordinate care across the health care continuum for dialysis patients.

Hogan’s care team includes a nurse practitioner and registered nurse in addition to his nephrologist and dialysis center staff. Care team coordination is an essential aspect of the ESCO care model, especially for interactions between dialysis center staff and care team members outside the center.

Teams have frequent meetings to discuss each patient’s health and mitigate potential issues. For example, Hogan’s team was able to reduce his daily pills in half by coordinating with his other specialists to create a better prescription plan.

DaVita, in particular, focuses on caring for the whole patient, a benefit Hogan saw after transitioning back to his dialysis center from a routine surgical procedure. In addition to managing Hogan’s post-discharge follow-up for a seamless transition, the team noticed something was different about him.

“He wasn’t interested in conversation and wouldn’t say his usual ‘Good morning!’” said Debbie Abbonizio, Hogan’s nurse practitioner. “He often lost his words, wasn’t hungry and couldn’t walk short distances without stopping.”

The care team met consistently to identify the root cause of his symptoms. After ruling out several possible diagnoses, the team realized Hogan’s recommended target weight for post-dialysis treatment was too high. Extra fluid was accumulating in his body and toxic waste was gathering in his bloodstream, causing his symptoms.

The care team slowly decreased the extra fluid in Hogan’s body. Hogan soon regained his health and began to greet his care team with a cheerful “Good morning!” again. Without the additional resources provided through DaVita’s ESCO, Hogan may have slipped through the cracks and been hospitalized repeatedly.

“I feel fortunate to be a part of the ESCO, where I have a team observing and supporting me daily,” Hogan said. “It gives me confidence about my ability to manage my condition. Every patient should get this kind of care.”

Hogan is grateful to feel better so he can spend more quality time with the love of his life, Carol, his wife of 57 years.

“Currently less than 10 percent of dialysis patients on Medicare have access to IKC programs such as ESCOs,” said Dr. Becker. “Yet these programs can make a significant impact on patients’ health-related quality of life. Why not make them available to all Medicare patients on dialysis?”

To learn more about DaVita’s IKC programs, visit

The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.