NKDEP supports addressing chronic kidney disease (CKD) in the primary care setting, as managing CKD prior to referral can improve outcomes. Many CKD interventions are similar to those for diabetes (e.g., glucose control), and other key interventions (e.g., co-morbidity screening) can be handled in primary care settings. Equipping providers in those settings with resources to better detect and treat CKD is an NKDEP priority.
The Community Health Center CKD Pilot Project
NKDEP implemented a pilot project in community health centers (CHCs) to test effective strategies for improving CKD detection and care in primary care settings, focusing primarily on integrating CKD into diabetes care. The project involved six centers in the Northeast that worked collaboratively with NKDEP to design, implement, and monitor performance improvements. CHCs implemented a range of clinical interventions tailored to each center's needs and found several to be both effective and sustainable across centers.
Interventions identified as effective and sustainable
- Creating prompts in EHR for elevated BP and abnormal/missing labs.
- Creating CKD and/or CKD-HTN specific templates in EHR, including recommended testing/treatment.
- Delegating tasks for reception, medical assistants, nurses to help in care management; Integrating team "huddle" to review necessary patient testing/vaccination.
- Developing algorithms for CKD labs and annual screening for diabetics; developing standing orders for annual UACR for diabetic patients.
- Performing automated monthly reporting; Developing custom clinical reports.
- Conducting patient education using self-management strategies with NKDEP's Explaining Your Kidney Test Results tear-off pad for appropriate patients.
Learn more about the CHC CKD pilot project, including:
Project Implementation— how centers were recruited, what participation in the project involved, and data collection
What We Learned— common successes and challenges, particularly related to effective interventions, patient education, project implementation, and data collection/reporting
Recommendations and Limitations— for centers interested in integrating CKD into diabetes care and QI programs interested in implementing projects in CHCs, as well as areas of future research
October 10, 2012