CKD Population Health

CKD Change Package Main Page

Engage a broad, multi-disciplinary team in the development of a chronic kidney disease strategy for the institution. This team may include representatives from primary care, nephrology, quality, data analysis [populytics or population health], accountable care, EMR design/development, nursing, etc. For integrated institutions it is also recommended to include representatives from emergency medicine, nutrition, etc. Include IT resources in the conversation to leverage technology to make the process as dynamic as possible.

Identify guidelines for CKD care to be implemented into primary care

Build internal consensus regarding the CKD metrics to be evaluated in primary care

Implement a program that supports CKD recognition in its earliest stages. Start by running a small trial before widening to the entire practice or network. Align the strategies proposed with appropriate practice resources. Make the program design flexible to allow for variation within the practices.

Clearly define the intervention to be employed and develop supporting materials

Engage the practice team in tailoring the intervention to work best with their own practice workflows.

Use population health data to engage clinicians in the need for improvements in CKD care delivery.

Engage the practice staff in education regarding CKD assessment and management.

Use Data to Drive Improvements in CKD care

Establish a CKD registry within the EMR system

Implement CKD care pathways to support ongoing management

Implement electronic decision support for CKD

Incorporate CKD metrics into ongoing feedback on quality performance

Implement parameters for nephrology referral and co-management of CKD

Clearly articulate the parameters for appropriate collaboration with nephrology

Create a strategy for seamless communication among various members of the advanced CKD care team