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Recommendations from the Pilot Project

The Community Health Center CKD Pilot Project yielded clear recommendations 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.

Recommendations for centers integrating CKD into diabetes care:

  • Centers should select a limited number of simple data points to monitor improvements and engage providers.
  • Standing orders/lab slips with performance measures can improve data collection, particularly for UACR.
  • Lab integration streamlines data collection, avoiding manual data entry.
  • Before implementing the reporting process, centers need to examine desired data and EHR capabilities to ensure the data can be abstracted.
  • All levels of CHC staff should be engaged from the project start.
  • A start-up/kickoff event should be held with primary care providers and allied health professionals to share baseline data, explain center's plans to address data in context of the system, and provide CKD information from a local champion/nephrologist.
  • Staff should be properly equipped with knowledge and tools for CKD education.

Recommendations for QI programs implementing projects in CHCs:

  • Select centers with stable data systems, QI program experience, and sufficient staff/time for implementation.
  • Allow implementation to adapt to center strengths/needs.
  • Offer tools/training to meet common needs.
  • Consult with CHC advisors on implementation to ensure processes make sense.
  • Create a local/regional network to support center staff.

Recommendations for future research:

  • Impact of a national electronic data system with a lab interface and registry-like functionality on centers' ability to conduct QI projects.
  • Recommended data points to include in EHRs for CKD-related measures.
  • Recommended tasks to delegate across the healthcare team to improve workflow and ensure CKD education and testing are conducted.
  • Effective CKD training/tools for allied health professionals, who were particularly enthusiastic about conducting patient education.
  • Effective CKD patient self-management training/tools for providers. Providers wanted to teach CKD patient self-management but sought direction on how to do so.


The project included a small number of CHCs in one region; therefore, findings can't be generalized across the country. Additionally, NKDEP provided significant technical support, making this project hard to replicate; however, newer technologies (e.g., webinars/video conferencing) could help.

October 10, 2012


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