Closing Care Gaps in a Safety Net Healthcare Setting: Leveraging Home-Based CKD Testing to Improve Healthcare Quality

Safety-net healthcare settings, such as Affinia Healthcare, bear a disproportionate burden of chronic kidney disease (CKD), as they serve patient populations with higher rates of diabetes, hypertension, and social deprivation, coupled with significant barriers to diagnostic testing that delay timely diagnosis and treatment.ⁱ As a trusted Federally Qualified Health Center (FQHC) in St. Louis, Missouri, Affinia plays a critical role in delivering essential health services to communities most impacted by these challenges. FQHCs have been a key part of the nation’s healthcare delivery system for nearly six decades and are a source of primary care health services in medically underserved areas, including medical, dental, mental health, and substance use services regardless of a patient’s ability to pay.^ii,iii

Despite vast guidelines recommending annual urine testing in high-risk populations to check for kidney damage, testing rates remain low, especially among people with diabetes or high blood pressure. Together with dedicated partners, NKF is working to address insufficient CKD care among disproportionately affected communities by advancing innovative strategies that expand access to testing, reconnect patients to primary care, and systematically close care gaps.

In 2023, Affinia Healthcare used NKF’s CKD Data Strategy within its electronic health record (EHR) to identify more than 4,600 high-risk patients and offer them at-home kidney test kits that use a simple urine sample and smartphone app.

The results showed that nearly 1,500 patients at risk for CKD completed a test kit and half of those tested (755) had early signs of kidney disease. Most patients were under the age of 60 and Black patients were more likely to have abnormal results which is similar to national trends. The testing results were automatically routed to the EHR, enabling Affinia providers to quickly coordinate necessary follow-up care. Subsequently, 84% of patients had follow-up visits and 32% completed appropriate follow-up testing based upon clinical guidelines.

The NKF and Affinia published "Closing Gaps in Chronic Kidney Disease Detection: Evaluating At-Home Targeted Testing in a Safety-Net Population" in the Journal of Primary Care & Community Health online ahead of print to highlight the quality improvements. 

“This partnership has allowed us to provide patient care and support in a way that encourages our clinicians and patients to collaborate for better health outcomes,” said Takisha Lovelace, COO, Affinia Healthcare. “Part of our mission is to eliminate barriers to better health, and this program has provided another way to help us accomplish this with our patients.”

Home-based kidney testing offers a practical, scalable way for community clinics to reach patients where they are and close care gaps for those facing barriers to in-person care. This model not only helps clinics meet quality goals but, more importantly, helps people access the necessary tests and follow-up as needed for improved kidney health. 

To learn more about this project or identify ways to implement this model at your institution, please reach out to NKF’s Population Health team.