CKD Population Health

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.
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.
Engage the practice team in tailoring the intervention to work best with their own practice workflows.
Use Data to Drive Improvements in CKD care
Implement parameters for nephrology referral and co-management of CKD