Podcast - Building Healthcare Models that Work for Patients

Do patients realize the difference between traditional care models and the support and services they receive as part of a value-based approach to care? Dr. George Hart and Jennifer Huneycutt, executive director at Metrolina Nephrology Associates, explore what it takes to create healthcare models that genuinely serve patient needs—not just check boxes. This candid conversation reveals the often-overlooked complexities of balancing value-based care and fee-for-service, and why educating and empowering patients is essential for better outcomes.

This episode of Kidney Health Connections also covers the value of comprehensive training programs to equip advanced practice providers (APPs) with the latest clinical knowledge and tools to deliver high-quality care. Jennifer shares lessons learned from Metrolina’s structured approach to APP onboarding and training and how the practice sets patient expectations on the role APPs will play in their care.  

Dr. George Hart: Hello, everyone and thank you for joining us today. As many of you know, on this podcast, we focus on value-based kidney care and how providers and health plans can improve outcomes for patients. But how do patients perceive value-based care? And how can we ensure we are constantly improving care to address the needs of the very people we're trying to serve?

In this episode, I'm joined by Jennifer Huneycutt, executive director at Metrolina Nephrology Associates, one of the largest nephrology practices in the country. Now, I've known Jennifer for some time now, and she has never been one to accept the healthcare system as it is, and she is always pushing for change to ensure that patients receive the very best care possible. We're lucky to have her with us today for an important conversation on keeping patients’ best interests front and center as we work together to transform how we manage kidney disease.

Jennifer, good to see you today and thanks for joining us. Before we dive in, can you tell us a little bit more about Metrolina Nephrology and your background and the role you now have at Metrolina?

Jennifer Huneycutt: Sure. Thank you for having me today. I'm really glad to be here and I'm excited to do this with you.

I'm the executive director, as Dr. Hart said, for Metrolina Nephrology. I've been here since 2008 and our practice has 40 physicians today and I want to say about 42 APPs, it might be 43 tomorrow. We continue to grow in that space.

In terms of value-based care, we have been participating in the programs as long as they've been around. We started in the ESCO in 2015 and today we participate in the CKCC model and several other payer models as well. We've been doing it for a while, we even did it a little bit before it started on the value-based care side. That's Metrolina in a nutshell today.

Dr. George Hart: Thanks for that, Jennifer. Now, for our listeners who have seen you present or who follow you on LinkedIn, they know that you believe strongly that we need to view value-based care through the lens of the patient. You've started using the phrase “very best care.” I like that phrase, by the way. What does that phrase mean to you and what can we do to make sure healthcare systems work best for patients?

Jennifer Huneycutt: This one really is kind of stuck in my brain right now, I would say. You know, I think we do a lot around the patient. We survey them constantly, and we check our boxes, and we make sure that we're doing the things that we know can change their outcomes and improve their care.

But I'm not sure that they know that we're trying to do all of those things in the same way. I don't know that they even know that there's a difference. And if you ask me, I would say that very best care is the one that the patient is actively engaged in, that they are partnering with their physician—their nephrologist, in this case—and their whole care team to get the outcomes that they want.

It's about them also knowing what they want and when. And what I mean by that is, you know, a patient gets a diagnosis of kidney disease, maybe the first thing they think about is, “Oh, do I need dialysis?” or, you know, something really catastrophic. And I think that we have a long way to go to educate the patients on what their treatment options are, what they really have in store.

I think it looks like education. I think it looks like frictionless access to us. You know, whether they can text us asynchronously; maybe they're accessing us through MyChart. But I would love to see a day where the patients are just proactively reaching out to us before something goes wrong. And I think we've got to deliver and create a way for them to do that.

Dr. George Hart: I couldn't agree more. And it really sounds like what you're describing is a more seamless care system where there's kind of bidirectional communication—not just between the patient and the physicians, but also between a value-based care provider such as Interwell and its partner practice like Metrolina. Is that kind of how you're thinking about it?

Jennifer Huneycutt: Absolutely, absolutely. I think that we need a streamlined, seamless care model across all the different things that touch our patients. I mean, there's so many things that touch our patients. And again, I don't—while they're at the center of it, I don't think they realize they're at the center of it. I don't think they realize; I think many of them don't realize that they have the agency to make a difference in their care. And I'm pretty passionate about helping them understand those differences. And I do think it means that we have to change how we show up as well.

Dr. George Hart: I mean, what I see from where I sit now is that patients can be bombarded with a lot of reach outs from entities they may not necessarily recognize. So this idea of being seamless with our physician partners makes a difference, because who do they trust? They trust you.

Jennifer Huneycutt: That's right. Again, I agree with that. I think that they do get survey fatigue. They don't understand: “You're asking me these questions, but how does this really change my care? How does this really change what you're going to do for me? You know, where do I see the value in any of this?” I just want them to be thinking more proactively also about their care. And that means that we have to do that too.

Dr. George Hart: Well, look, this conversation for me is particularly enjoyable because, you know, Jennifer, you and I have been friends and colleagues now, really since you joined Metrolina back in 2008. And we worked side by side until I moved to Interwell in 2022.

During all that time, I saw you and I really appreciated firsthand how you pushed Metrolina and the physicians there to adopt innovative clinical ideas as well as new business models even before the government came out with value-based care. I'd love to hear your perspective on, you know, how did you come to see it this way and see this need to evolve the model of care and how did all that unfold?

Jennifer Huneycutt: Thank you for that. It was certainly a team. It's a team sport over here, not just a Jennifer thing. But I would say when I first started in nephrology, I did start in private practice, and I was shocked by the fact that one day a patient is sitting in our office seeing our physicians, and then the very next day they're now needing dialysis and sitting in a dialysis unit. I mean, this was over 20 years ago, and I couldn't even believe it. I couldn't believe the patients had no exposure to what they were about to do. They had none of that. I mean, it was just, it was a shocking sort of transition.

I think we've made progress on that today. But at the same time, I'm also surrounded by passionate people. You know, we have a number of physicians here that started their journey in kidney treatment and kidney care because they had family members that also experienced kidney disease. We've had physicians that way, and we have also our advanced practice providers, and many of our employees here have been inspired to do this because of that.

And one of our team members in particular, Leah Smith, she went through this transition with her father through needing dialysis, getting transplanted, going back on dialysis, you know, all the things.

And she realized at the time—this was prior to her coming in—that there weren't resources for her dad and for her family at that time; this was many years ago.

She was pretty passionate and she was supported by the physicians here who were also passionate about developing a program and a structure that patients could receive, get a consistent care delivery system wrapped around them. And she worked with our physicians here to develop a structured program that we implemented back in 2011. We call it our PEAK program. And really it is—think of it as preventative care for patients with kidney disease. It really focuses around mid- to late-stage milestones and ensuring that patients are getting the options and the education and the treatments that they need all along the way at the right time. So that was pretty neat.

And it's been a journey also just in bringing the physicians along to see that we do need a structured process. We all deliver care amazingly in the individual conversations that we have with patients and that sort of thing. But it's easy to miss some of the key elements maybe that a patient needs if you don't have a system. I mean, when I think of airline pilots, they have a checklist. You know, we do too.

Dr. George Hart: I'm glad you brought up Leah and certainly value what she has brought to both Metrolina and the larger advanced practitioner community at large. I think, you know, Metrolina did a good job early on of embracing the need for an alternative way of practicing medicine—some to address the shortfall in the nephrology fellowship challenge that we have today. And I think what Metrolina's learned—and I'm going to have some questions for you later about the education program—is that there are some best practices that are out there. And I'm wondering if you could just share some of what you, you know, as you sit where you sit, see as some of the best practices out there which involve advanced practitioners.

Jennifer Huneycutt: I think one of the things that has helped us be successful with advanced practice providers—and you know, when I started, I think we had five, and today I mentioned that we have over 40—and that group is continuing to grow for us. And one of the things that enables our success there is having the structured PEAK program in the office, or the structured approach that we have to how we care for patients within dialysis units.

So, in having those standard type protocols, the standard way that we go about doing kidney care in those environments, it really does help create a consistent product across the system. It also creates a trainable and scalable model that we can reproduce. And it's certainly evolved over these last many years in terms of how we, you know, we train them and all. But their onboarding—the APP onboarding—is huge, and you can't onboard unless you have a way you do things. It just isn't as successful.

I would say, too, that the other thing that you have to have is—you have to have physician support. That's one of the things that I think—it’s not necessarily unique to Metrolina, and it may be a little bit of our just practice-wide, not just value-based care-wise—secret sauce, and that is that the physicians in this practice, they support the entire care team, whether that's APPs, nurses, medical assistants, administrative folks like myself. We all have our role, and we're all expected to perform it. And the physicians’ support; it doesn't happen if you don't have that buy in with the physicians.

Dr. George Hart: It's no secret to most of my colleagues across the country that I'm a big fan of what advanced practitioners can bring. But it does require trust, it requires delegation and the willingness to empower someone else. And the physicians aren't going to do that unless they have confidence in the background and the education of advanced practitioners. I think Metrolina learned that early on, which is part of why it developed this program for APPs, Interactive Nephrology or Ready for Rounds, many know it by that name. Maybe this is a good moment to kind of expand on what you guys are doing now with Interactive Nephrology and the impact it's having across the country with advanced practitioners.

Jennifer Huneycutt: Several years ago, when we noticed that we were onboarding all of these APPs, we definitely had to have a structured system. And we also noticed that folks were struggling with that, you know, out there in nephrology land.

One of the things that we know is that APP training programs, they just don't, they're not training their APPs in nephrology; they don't come ready to just jump in and do what a physician who's been fellowship trained in nephrology can do. So we've built the only comprehensive fast track APP training program that I think is available in nephrology. It's been adopted by a number of practices. We've actually served over 100 practices now. Over 300 APPs have gone through this program, or these programs, actually.

The first one that we launched was called Ready for Rounds. It fast tracks the knowledge that is necessary to treat patients in dialysis units. It comes with competency testing, a clinical checklist; it's a very comprehensive and in-depth approach to the care that is being delivered by the clinicians in the dialysis setting.

And then we also built on top of that another program, it's a little bit shorter, called Cleared for Clinic. And this one enables the APP to have the knowledge that they need in order to contribute meaningfully to the patients that are in the CKD clinic.

Dr. George Hart: How do you think patients are reacting to having APPs so involved in their care? Do you get any pushback from patients spending more time?

Jennifer Huneycutt: I would say initially we had more pushback from physicians who thought their patients would push back on the APP. At the end of the day, the patients, as long as they're prepared that they're going to be seeing an APP, as long as the physician is saying, “Hey, I want to be able to see you this many times or at this frequency, but I can't see all those patients, you know, I can't see everybody. And I need you monitored a little bit better and more closely. You're going to see my APP, Susie or Jim or whatever, and they're going to do your next visit and then I'll see you again the visit after that.” And I think that the more that the physician leans into that, the better.

But truly, once our patients see an APP, they love seeing that APP. The APP actually has more time to spend with them than our physicians do in the course of any visit. So it is not a problem, at all.

Dr. George Hart: One of my favorite anecdotes from when I was still in clinical practice was making rounds in a dialysis unit and wanting to make some changes. And the patient looked at me and just very simply said, “Well, Dr. Hart, have you checked with Holly to make sure that it's okay?” And Holly was my advanced practitioner. And I think it just spoke to the trust that, you know, he had in her and recognizing that she spent more time involved in his care than I was. So to me, that was kind of the perfect confirmation of how this can work.

Jennifer Huneycutt: That's right. And I don't think yours was a unique experience.

Dr. George Hart: Shifting gears for a second, a healthcare trade publication, Healthcare Innovation, recently recognized Metrolina as an Innovator Awards Program winner for your outstanding results in the CKCC value-based kidney care model, where Metrolina earned a perfect Total Quality Score for the first year of the program, had some of the highest optimal start rates in the nation, and notable cost savings in the program's first year. How'd you do this, Jennifer? What's the secret sauce?

Jennifer Huneycutt: The secret sauce is the team. I think another piece of that is that we have had what, I will say, a way of caring for patients with kidney disease for a long time. I think that when we put the PEAK program in, in 2011, we didn't know that value-based care was going to be a thing called value-based care. We did anticipate that quality would become important along the way. And so we focused our efforts, for a while now, on honing the systems that support patients to meet the milestones that they need to meet. So that is a big piece of that.

At the same time, I do have to kind of tip my hat to Interwell as well, because there's a lot that goes into being successful in a program. We don't have to put our attention on: What are the details of the program? What has to be signed when? What moves the needle from the data standpoint? Somebody else is doing those things for us and helping guide us. And then, you know, what we are really responsible for here is that direct patient care. And so I think that's a big piece.

The other piece that we cannot speak enough about here is just our reliance on our APP model. You know, they really are—I mean, I'm going to call them the backbone of what we do—because they have so many touches with the patients. I would say those three components—being prepared in advance, having a great partner like Interwell, and then our APP workforce—I think have been the three elements that I would lean into the most.

Dr. George Hart: I think those are good call outs. What I'm really hearing is that this partnership requires investment from both sides. Right? And that understanding your role and the niche that each side brings to this partnership is really important for success. Does that sound fair?

Jennifer Huneycutt: We only have so many patients that we could even possibly take risk on; we can't get bigger than our own population, which you may need in order to be successful, to spread risk around. We don't have actuaries, we don't have social workers on staff, we don't have dietitians on staff, we don't have the regulatory expertise. We, at this point, don't even know how to negotiate with payers for value-based care programs in a way that we don't hurt ourselves. I mean, we need somebody with that level of expertise. I think that's where, that's where Interwell really shines. They show up and take those elements off.

Interwell has the Acumen Epic EHR that they make available to nephrology practices, and we recently went live on that. And the difference and where we can direct our time is just phenomenal because, you know, having an Interwell aligned EHR where Interwell can set it up and do the things that support value-based care—we don't even have to think about that. I mean that's huge. It's easier for them to deploy a risk model to help us identify our patients and figure out who needs what when, and who's at a higher risk of hospitalization or a bad outcome.

Dr. George Hart: Jennifer, okay, you and I go back a long time, we've known each other forever, and you’ve got to level with me here. It's hard to strike the balance between fee-for-service and value-based care. Even a large practice like Metrolina, who's really immersed in value-based care, it's only a minority of your patients that fall under a VBC environment. How does Metrolina approach the sweet spot for balancing fee-for-service and value-based care?

Jennifer Huneycutt: If you know where the sweet spot is, I hope you will tell me. I hope you figured that out.

You know, you're right, maybe 6 to 7 percent of our entire population is in a value model. And today, I would say we spend disproportionately more time and effort on achieving the goals of value-based care in that population. In many ways what we do today applies to all patients. Like I said, we've been doing a lot of it since 2011, and that happens for all patients.

But it is tough to strike the balance. When you think about, maybe, in some ways it's easier and harder in a smaller practice than Metrolina. But for us with multiple locations and multiple people to educate and all, we're still challenged to educate physicians and patient-facing staff on value-based care today. I mean it is a real challenge because the people that are delivering care want to deliver great care to every patient. Every patient. And convincing them that we're trying to live in both worlds and doing things differently, that's a hard ship to turn. These folks have been delivering great care for a long time.

Dr. George Hart: Great care for everybody, or best care for everybody, is a lofty goal that I think we would all like to see happen.

Metrolina's had a head start in value-based care with over, gosh, close to 10 years now of experience. Tried a lot of things, failed at a lot of things, been successful at a lot of things, a lot of lessons learned. What advice would you give to another practice that wants to make the leap into value-based care but they just kind of don't know where to start?

Jennifer Huneycutt: The easiest place to start, and the clearest place to start, is number one: I think you have to have someone in your practice that's focusing on it. Without that, you know, the day to day and your whirlwind that you're living in, it's just going to keep on going.

The second thing I would start to maybe chase or try to do, is look at my current practice workflows and I would identify areas where there may be gaps that are existing that would help me achieve the goals of value-based care. One of the very first things that we did back in a long time ago was have an individual who was primarily focused on chasing the access for someone transitioning and, you know, that would need to transition into dialysis. We worked on that ahead of time. And we have somebody really focusing—you may call it a renal care coordinator or something like that—but it's somebody that's helping the patient meet those milestones, they know what the milestones are, and they can help fill those gaps in care.

I think those are two areas that I would really focus.

The third is I would identify areas of overlap. So, there are some things that you can do in a fee-for-service world that overlap with value-based care, and that's delivering services like advanced care planning, transitional care management, there's also chronic care management that you can do. And I'm a firm believer—and I think some of the data is starting to bear out, especially on transitional care management, and also I think there are examples in advanced care planning, for sure—where these services that you can provide and be reimbursed for in a fee-for-service model actually support the goals of value-based care. And so I think, you know, I'm always about double dipping and trying to figure out where we can, you know, align our efforts around both payment models.

Dr. George Hart: So, Jennifer, last question. It's a perfect world. You're in charge. What does the future of kidney care look like?

Jennifer Huneycutt: Well, first of all, there's going to be seamless coordination, you know, between primary care, between nephrology, the dialysis units, and transplant care. That's going to be seamless.

Also, here's an idea that I thought about, and I don't know if—well, again, I get to pick—so I'm going to decide that nephrology care in a nephrologist office has no coinsurance or copay. How about that? There is no financial barrier to the patient receiving kidney care from their nephrologist. I think that's a really interesting, if I do say so myself, I think that's a very interesting concept because that's what we're being asked to do. It's preventative kidney care. Right?

Dr. George Hart: I think you're plugging for another opportunity to do a show with me where we can flesh that out.

Jennifer Huneycutt: Wouldn't that be something? I just came up with that one. I mean, I don't know if it's an original idea, but it's original to me.

Dr. George Hart: Stay tuned, everybody.

Jennifer Huneycutt: And then, I think, we've got the care model also. Whatever the payment and care model is, it has a way of recognizing the value that the nephrologist can play further upstream. I wish I knew exactly what that was so I could tell everybody. But I don't know what that looks like exactly yet, but that definitely is something.

And last: kidney patients understand their disease, they know what their options are, they feel heard and seen by their providers, and they believe they're getting the very best care.

Dr. George Hart: Amen to that, Jennifer. Not surprising to me that this was a fun conversation. It is always a pleasure to speak with you.

For our listeners, we hope today's conversation provided some insights on how practices view the world of value-based care and, even better, helped remind us all that our decisions should improve outcomes and allow patients to live their best lives.

I also hope you'll join us for more conversations on the future of kidney care by subscribing to Kidney Health Connections and visiting our website at interwellhealth.com.