The typical chronic kidney disease patient, if diagnosed before renal failure, learns about treatment options in a relatively quick meeting with their nephrologist, or in a one to two-hour class at a dialysis clinic. Still, many patients start in-center hemodialysis without learning first about transplant or home dialysis modalities.
Health care technology services company Cricket Health wants to help change all that. The company is currently pilot testing its new education platform, HOPE (Health Options Patient Education), that is designed to help late-stage CKD patients choose a renal replacement therapy and transition to ESRD.
Cricket Co-Founder and CEO Arvind Rajan said he set out to help people better understand their disease and make an informed, effective treatment choice.
“If you get patients the appropriate information at the right time, and the resources to go through making a decision, not a 10-minute meeting with your nephrologists, not an hour or two presentation from a dialysis company, we think those patients might want to make a different choice than what they are making now,” Rajan told NN&I.
Rajan spent six years on the executive team of LinkedIn, helping grow the company from a small startup to a global business, before founding Cricket Health with health care venture capitalist Vince Kim.
“I was interested in finding something I can work on next that was tackling a hard problem, where if you were successful, you can have a really big impact,” Rajan said. “And Vince pointed out that health care abounds with hard problems.”
The two wanted to find a place in health care where they can have a large impact on improving patient outcomes and reducing costs. After months of research, they focused on late-stage chronic kidney disease.
There’s no other part of health care where there is such a wide disparity between what should happen with patients and what actually happens, Rajan said.
Rajan and Kim worked with many nephrologists, including some at the University of California at San Francisco, Stanford, and the University of Pennsylvania, who pointed out areas where the current system of managing patients is broken.
“We begin with the fact that so many CKD patients are undiagnosed until they reach renal failure, and even when they are diagnosed, relatively little is done to help support the patients to slow progression of the disease,” Rajan said.
“And so few patients end up on home dialysis even though there is an effort to increase home dialysis utilization.”
Rajan and his team then worked with Danuta Trzebinska, MD, who runs the first Joint Commission-certified CKD clinic in the country at UC San Diego. Trzebinska was interested in taking what they do at the clinic and making it more scalable.
They also worked with Bijal V. Patel, MD, of Balboa Nephrology Medical Group, who has one of the highest number of peritoneal dialysis patients in the country. Rajan said Patel helped them understand what it takes to help patients make a confident and informed choice to do home dialysis, and to identify what kinds of patients can be successful doing home modalities.
“He pointed out that there is a bit of a perception that the only patients that can be successful at home are patients who are more affluent or better educated.” But Patel said he believes the only thing that makes a difference is motivation.
Stage 1: Treatment selection
Currently, the HOPE platform begins with helping CKD patients choose treatment options. The pilot program is working with a small group of nephrologists who refer their patients to the program.
Current participants are older than 18 years old, fluent in English (Rajan said they plan to roll out versions in other languages later), and have access to an Internet-connected personal computer or mobile device. Participants must be comfortable sending and receiving text messages.
First, the patient is introduced to a nurse, provided by Cricket, who will work with them through the whole process. Next the patient takes a short survey about their goals and their life. The nurse uses the survey to help guide the patient through the program and match them with a peer mentor.
The program includes a set of short videos that explain kidney disease and what treatment options exist, and show what each form of dialysis looks like. They feature patients going about their day and doing the different forms of dialysis. Videos also explain palliative care options. Rajan said the program also emphasizes preemptive transplant and the importance of getting on the kidney transplant waiting list.
Rajan said they complement the videos with detailed FAQS. Patients are connected one-on-one with a patient mentor with whom they can have private conversations. They are also included in a patient cohort that goes through the program together, and patients can join in discussions with each other.
“One of the big missing pieces in helping patients get to the decision is being able to talk to other people who’ve gone through this decision before and talk to other patients who are going through it at the same time,” Rajan said.
The program is structured on the back end so that the nurse working with the patient can see how the patient is engaging with the program, including which videos they watched and what FAQ content they read.
At press time, Cricket had data on 30 participants to share. Eighty-seven percent had engaged with the program, and 83% chose a home modality. Ninety percent of the participants who chose home therapy chose peritoneal dialysis. Ninety-four percent of participants chose to get a transplant referral. The average participant was 68, with a range from 43 to 78. Participants had varying levels of employment.
On average, it has taken 34 days for a patient to choose a treatment. Rajan said they want patients to take the time to reach a decision they feel comfortable with. When a patient decides what they want to do, Cricket provides the referring nephrologist with a summary report, and does the initial transplant screening, if the patient chose to get on the waiting list.
“We want to make sure that we aren’t just saying, ‘Hey you need to choose home dialysis’ because that’s not the right choice for some patients, even if we think the patient will do better on home dialysis. Getting them to make that choice without knowing what it will really entail is also a mistake.”
Stage 2: Condition management
Rajan said they also want to follow up, and help patients through the transition into dialysis by providing clinical and emotional support.
Leveraging the same platform and concepts (nurse, videos, FAQ content, patient mentors and cohorts), the second phase adds a social worker, dietitian, and pharmacist to work with each patient all the way through the transition to ESRD.
Rajan said they strive to keeps patients from events that will trigger a visit to the hospital or a crash start on dialysis. This phase varies by patient, and the care team relies on the referring nephrologists to set clinical goals for each patient. Some patients need to get their hyperkalemia under control, others need to manage fluid better.
This phase also includes ensuring the patients gets the appropriate access at the appropriate time. Videos show patients what the fistulas, catheters, and grafts look like.
Rajan said they plan to take a more upstream approach to CKD management, but they wanted to start with preparing patients for renal failure. He said they also plan on helping patients further downstream, by providing support after they begin dialysis or get a transplant, and eventually tackling the high drop-out rate among home dialysis patients.
“The entire model of managing CKD in this country is fundamentally broken. It needs to be flipped on its head. For many years, the entire system has been designed so that everyone but the patient does better as a patient does worse and worse, and the patient ends up on the most expensive form of care.”
The program is designed to be sold to payers. “We’re telling the payer, that by delivering this program, we can reduce the cost of this patient population,” Rajan said.
They aim to this by increasing the number of patients who get the right access in place in advance of ESRD, reducing the number of patients who crash into dialysis, reducing hospitalization rates and acute events, and in some cases, delaying the start of dialysis.
So far, Cricket has worked primarily with nephrologists to test the program and ensure that it works online. Recently, Rajan said, they have been talking to payers, primarily Medicare Advantage and risk-bearing plans, but he estimates they will be working with commercial patients soon.
“There is a big opportunity to reinvent what happens to patients. There are so many things that we know about today that can be implemented in practice and can have a meaningful impact on patient lives and can lead to cost savings as well, that are already being done in small bits around the country… There are so many opportunities that are meaningful for patients, payers and providers.”