Missouri Ending Disparities in CKD Leadership Summit (Show Me CKDintercept Initiative)

It is estimated that approximately 694,000 adults in Missouri are living with chronic kidney disease (CKD), but only 83,000 are aware that their kidneys are impaired. Fewer than 17% of those at risk (people with diabetes and/or hypertension) are tested for CKD each year in Missouri.¹

As part of a national NKF Collective Impact strategy, Missouri stakeholders are implementing a roadmap to drive a cultural shift in primary care- toward increasing the early diagnosis and management of CKD, especially in communities disproportionately burdened by CKD.

NKF, in partnership with the Missouri Kidney Program, is employing a multi-phase stakeholder engagement process to create the conditions for Collective Impact - influential champions, adequate financial resources, and a sense of urgency for change ²- to drive change in Missouri.

Through a series of facilitated discussions in Spring 2022, health care and public health leaders identified barriers and solutions to improve CKD awareness, detection, and management in Missouri, including tools and strategies that could be implemented within stakeholders’ own institutions. Learning and action workgroups increased awareness and action amongst 58 participants across 40 Missouri institutions. The four workgroups convened covering the following topics:

Clinical Considerations for CKD in Primary Care

• Goal: To discuss strategies and approaches that can be employed to improve CKD recognition and care in primary care settings.
• Background: A large, national study illustrated that less than 12% of people with CKD were diagnosed in primary care.³ This included as many as 40% of people whose kidneys required specialty care.  With the advent of new therapies demonstrated to slow or stop the progression of CKD, there is very real opportunity to improve quality of care for people with CKD across the entire spectrum of disease.

Engaging Community and Community-Based Solutions

• Goal: To develop strategies to advance CKD awareness through community engagement and to ensure that health care providers are aware of the community resources available to delay CKD progression.
• Background: In the U.S. today, only 10% of people with laboratory evidence of CKD know that they have kidney disease.⁴ Improved patient awareness, engagement, and self-management are vital to successfully slowing CKD progression.  As diabetes and hypertension play significant roles in the development of CKD, working with community organizations that support individuals with chronic disease can be an important step toward raising public awareness of CKD among those at risk for CKD. 

Wellness and Prevention (CKD Population Health)

• Goal: To develop a strategy to incorporate CKD testing and diagnosis into wellness and prevention practices within the employer/commercial health plans, and the broader community.
• Background: To date, almost 90% of people living with CKD remain undiagnosed in the population and the majority will not receive guideline recommended annual testing.⁶ This breakout session discussed the strategies that can be developed and employed to ensure that CKD testing and diagnosis are included as part of the wellness and prevention services, including corporate programs, diabetes prevention activities, etc., that are available in the state.

Policy, Payment, and Quality Measurement

• Goal: To develop a strategy to streamline CKD testing in primary care from a policy and payment perspective.
• Background: In July 2020, the NCQA released the Kidney Health Evaluation for Adults with Diabetes HEDIS measure (KHE).5 This measure assesses the percentage of people with diabetes that receive both tests for CKD during the course of a year. When tested against over 70 claims datasets, this measure was achieved in only 35% of cases.  This measure began collecting data for public reporting in October 2021.

After 16 hours of facilitated discussion, 58 stakeholders identified 12 strategies to improve testing, diagnosis, and early management of CKD in Missouri. Read the roadmap summary here.

On June 9, 2022, NKF, in partnership with the Missouri Kidney Program and Missouri Department of Health and Senior Services, hosted a virtual summit to present the recommendations and engage partners in joining the Collective Impact Approach. Over 220 key healthcare and public health stakeholders registered, and 134 attendees participated in this convening. Of the 12 recommendations presented at this event, 71 individuals made commitments to advance one or more recommendations of the roadmap at varying levels of support.

2022 Show Me CKD Intercept Stakeholders Conference

Improve public awareness of CKD

Coordinate with Local Missouri Stakeholders to Customize and Expand NKF’s Awareness Campaign

In August and September 2023, NKF collaborated with local partners to engage community members at risk for CKD (with diabetes and/or hypertension) to understand the most effective content, delivery, and dissemination strategies for the NKF Risk Quiz and accompanying awareness resources. Three focus group discussions engaged low-income/Medicaid eligible and Hispanic participants across the St. Louis Promise Zone region as well as rural participants in Randolph County. In collaboration with Puente Marketing & Advertising, NKF analyzed the dialogue and compiled recommendations to increase quiz and resource engagement, CKD understanding, and patient activation. Minor recommended changes were made as necessary, beginning with one enhanced flyer for National Kidney Month awareness efforts. NKF is exploring additional funding opportunities to track patient activation from the risk quiz and accompanying materials within a federally qualified health center setting.

Engage Community Health Workers, Community Paramedics, and other frontline staff

Following key informant interviews, a Community Health Worker (CHW) workshop at NKF’s Spring Clinical Meetings, and engagement of a CHW committee, NKF developed a CHW educational module series and is in the process of adding tools for supporting patients at-risk of or living with kidney disease. The NKF’s Community Health Worker hub features specific trainings with a certificate of completion available for learners. Future strategy goals include exploration of pilot interventions engaging CHWs in improving screening rates, supporting care coordination and follow-up CKD care, and increasing CKD knowledge and self-efficacy. 

Translation of CKD Educational Materials

NKF partnered with local Federally Qualified Health Centers to identify languages most spoken second to English in the St. Louis Promise Zone region. As a result, 2-sided CKD educational flyers were translated in Arabic, Bosnian, Dari, Farsi, Kinyarwanda, Nepali, Pashto, Somali, Spanish, Swahili, and Vietnamese. 

Clinician and Health System Opportunities - Deploy tools and systems change approaches to improve CKD diagnosis and Management

Expand NKF's CKD Learning Collaborative to engage more health systems and primary care clinicians in an active process of change

NKF’s CKD Learning Collaborative is a quality improvement initiative to improve clinician awareness and routine testing for CKD and ensure that people with laboratory evidence of CKD are appropriately risk stratified and receiving guideline concordant care. NKF partnered with University Health in Kansas City to engage 66 learners in this model. Following engagement of 3 pilot clinics over the course of a 1-year intervention, the safety net healthcare system demonstrated an over 60% improvement in guideline concordant testing among the populations at-risk for CKD. Further, there was a statistically significant decrease of over 25% in patients with laboratory evidence of CKD who did not have an appropriate CKD diagnosis documented in their medical records.

Following the June 9th convening, multiple institutions have expressed interest in participating in a learning collaborative. Please contact NKF Population Health Partnership Director, Megan Schultz, to explore implementing a Learning Collaborative at your institution.

Implement the Kidney Profile in all healthcare institutions in Missouri

The “Kidney Profile” combines two lab tests, the estimated glomerular filtration rate (eGFR), which assesses kidney function, and urine albumin-creatinine ratio (ACR), which assesses kidney damage. This combination streamlines test ordering and ensures guideline concordant testing. On April 18, NKF virtually convened national Kidney Profile implementers and prospective adopters to discuss uptake, challenges, and opportunities to leverage CKD clinical decision support tools to increase guideline testing for kidney disease. Two institutions provided a case-study on organizational changes and tool integrations that resulted in improvements in CKD testing. NKF continues to provide guidance and support to institutions interested in learning more or implementing the Kidney Profile. 

Increase clinician participation in the Show-Me Kidney Disease ECHO

The Show-Me Kidney Disease ECHO aims to increase clinician participation in team-based care conversations to optimize support and facilitate care management in CKD. This interdisciplinary opportunity offers CME and MOC II credits at no cost to attendees. Since the Leadership Summit, participation has diversified across healthcare professionals, including CHWs, nurses, and other members of the care team.

Convene a Missouri Payer Roundtable

NKF held an in-person meeting on November 16 with 7 health plans and 3 health systems to advance provider and member CKD engagement strategies. Following the Missouri Payer Roundtable discussions, 4 payers have conducted a CKD Data Analysis strategy, and 2 payers are in the initial discussions of data review. Next steps include payer interest in development of a provider CKD scorecard and a statewide CKD Learning Collaborative model with identification of value-based care partners. There is also interest in virtual bi-annual payer meetings for ongoing alignment on upstream strategies to improve early CKD testing and diagnosis, tentatively beginning in June 2024. 

Execute pilot programs to explore novel approaches to improve CKD testing rates

Pharmacy-Pilot Project

The National Kidney Foundation (NKF) and the Community Pharmacy Enhanced Services Network of Missouri (CPESN MO) received funding from the Missouri Foundation for Health to demonstrate that a pharmacy-driven approach to improved CKD testing is feasible and can improve disease awareness and medication optimization for people living with CKD. Following project training and dissemination of a CE program for pharmacists, three Missouri community-based pharmacy sites will provide CKD risk education and refer a total of 300 patients to testing from August 2023-April 2024. As a part of this collaboration, two County Health Departments have established a standing order for CKD testing for all individuals at risk for CKD who utilize their site. As of April 2024, the preliminary results reflect that approximately 28% of at-risk patients identified through the program have received abnormal laboratory results, underscoring the critical role of early detection in mitigating CKD progression. Project outcomes will be utilized to advocate for advancing the role of the pharmacist in ways that help improve access to quality care in collaboration with the patient's other healthcare providers, particularly in underserved communities.

CKD Home Testing Project

NKF partnered with Healthy.io to evaluate the efficacy of distribution of home CKD test kits in increasing awareness and improving early CKD diagnosis. In Missouri, NKF identified several partners to support dissemination, including a Federally Qualified Health Center who engaged in a CKD data strategy to identify low levels of CKD testing among patients at risk for CKD and distributed Healthy.io at-home urine albumin-creatinine ratio (uACR) test kits to nearly 5,000 patients. Currently, the partners are conducting a retrospective analysis to understand the impacts and effectiveness of the quality improvement project on improving the quality of care and clinical outcomes within a safety-net health care setting. The project outcomes will be disseminated through a forthcoming publication slated for release in 2024.

Increase available data on CKD testing in Missouri

Nationally, the National Kidney Foundation is advancing the development of a CKD data dashboard. There will be a tentative launch in fall 2024. More data is essential to fully understand the impact of the social determinants of health on chronic diseases and the health disparities in Missouri.

Establish a cohesive Chronic Disease improvement strategy for clinicians and community partners

Potential avenues to develop this strategy could include a statewide Chronic Disease Conference or other engagement strategies amongst organizations and community partners working in Chronic Disease. Planning has not yet begun, but if you are interested in supporting this strategy to develop comprehensive messaging for chronic disease awareness and improvement, please contact us.

For more information about this initiative or to get involved, please contact:

• Kathleen Davis, Executive Director of the NKF Serving Eastern Missouri, Metro East, and Arkansas | kathleen.davis@kidney.org | 314.961.2828
• Alexandra Garrick, Collective Impact Director | alexandra.garrick@kidney.org | 913.262.1551
• Megan Schultz, Population Health Partnership Director | megan.schultz@kidney.org | 212.889.2210 x239 

1. Alfego D, Ennis J, Gillespie B, Lewis MJ, Montgomery E, Ferrè S, Vassalotti JA, Letovsky S. Chronic Kidney Disease Testing Among At-Risk Adults in the U.S. Remains Low: Real-World Evidence From a National Laboratory Database. Diabetes Care. 2021 Sep;44(9):2025-2032. doi: 10.2337/dc21-0723. Epub 2021 Aug 5. PMID: 34353883; PMCID: PMC8740927.

2. Hanley Brown, F. Kania, J. and Kramer, M. Channeling Change: Making Collective Impact Work. Stanford Social Innovation Review. 2012. https://doi.org/10.48558/2T4M-ZR69  

3. Szczech, Lynda A., et al. “Primary Care Detection of Chronic Kidney Disease in Adults with Type-2 Diabetes: The ADD-CKD Study (Awareness, Detection and Drug Therapy in Type 2 Diabetes and Chronic Kidney Disease).” Public Library of Science, 26 Nov. 2014. https://doi.org/10.1371/journal.pone.0110535

4. “Chronic Kidney Disease (CKD) Surveillance System: Awareness.” Centers for Disease Control and Prevention. https://nccd.cdc.gov/ckd/detail.aspx?QNum=Q97#refreshPosition

5.  Brock, Matt. “Kidney Health: A New HEDIS Measure.” NCQA Blog, 16 Jul. 2020. https://blog.ncqa.org/kidneyhealth/

6.  “Chronic Kidney Disease in the United States, 2021.” Centers for Disease Control and Prevention, 4 Mar. 2021. https://www.cdc.gov/kidneydisease/pdf/Chronic-Kidney-Disease-in-the-US-2021-h.pdf

7.   Vassalotti, J. A., DeVinney, R., Lukasik, S., McNaney, S., Montgomery, E., Voss, C., & Winn, D. (2019). CKD quality improvement intervention with PCMH integration: health plan results. The American journal of managed care, 25(11), e326–e333.