Stage of Change 3: Building the Business Case to Improve CKD Care
Table of Contents
Solid organizational support facilitates a successful care improvement program. The following offer data, quality improvement goals, evidence-based papers, and other approaches to help build a compelling case for change.
Compare institutional data gathered in Stage of Change 2 to national benchmarks.
Resources and Tools:
- U.S. Department of Health and Human Services, (HHS) Healthy People 2030, Increase the proportion of adults with diabetes who get a yearly urinary albumin test (uACR), Baseline: 48.4% (Medicare beneficiaries with diabetes mellitus who had uACR in 2016), Target: 66.4%, national benchmark for increased uACR testing in Medicare beneficiaries with type 2 diabetes.
- U.S. Department of Health and Human Services, (HHS) Healthy People 2030, Increase the proportion of people on Medicare with chronic kidney disease who get recommended tests, Baseline: 36.6%, Target: 49.5%, national benchmark for increased eGFR and uACR testing for Medicare beneficiaries with CKD.
- U.S. Department of Health and Human Services, (HHS) Healthy People 2030, Increase the proportion of adults with chronic kidney disease who know they have it, Baseline: 7.3% (adults ≥ 18 years with CKD who knew they had reduced kidney function 2013-16), Target: 10.1%, national benchmark to increase the number of adults ≥ 18 years with CKD who know they have reduced kidney function.
- Diabetes Care, 2021, Chronic Kidney Disease Testing Among At-Risk Adults in the U.S. Remains Low: Real-World Evidence from a National Laboratory Database, national clinical laboratory study found sub-optimal guideline-recommended CKD testing (eGFR and uACR) in at-risk patients.(12)
- Am J Manag Care, 2019, CKD Quality Improvement Intervention with PCMH Integration: Health Plan Results, a quality improvement study that yielded improved patient outcomes as well as net medical cost savings of $276.80 and $480.79 per-member per-month for CKD classes 3 and 5, respectively.(31)
- Prepared for the Centers for Medicare & Medicaid Services (CMS) by the National Committee for Quality Assurance (NCQA), Chronic Kidney Disease Disparities: Educational Guide for Primary Care, approaches to reducing disparities in CKD identification, treatment and monitoring, and patient-centered care.(32)
- Clin J Am Soc Nephrol, 2019, Trends in Quality of Care for Patients with CKD in the United States, study of office-based ambulatory care for adults with CKD found a high prevalence of uncontrolled hypertension and diabetes and low use of statins.(33)
- J Am Soc Nephrol, 2016, Social Determinants of Racial Disparities in CKD, examines significant disparities that exist in black and white Americans in rates of CKD and outcomes as well as the impact of social determinants of health on both.(34)
- Semin Nephrol, 2019, Social Determinants of CKD Hotspots, examines CKD hotspots (areas with above average CKD) in connection with poverty, homelessness, food insecurity, other social determinants of health and race/ethnicity.(35)
- Semin Nephrol, 2021, Social Justice as a Tool to Eliminate Inequities in Kidney Disease, examines societal barriers, their relationship to social determinants of health, and resulting health care disparities and poor outcomes.(36)
- Semin Nephrol, 2013, Socioeconomic factors and racial disparities in kidney disease outcomes, reviews socioeconomic factors in relationship to the disproportionate burden of kidney disease experienced by Blacks and their likely influence on outcomes.(37)
- U.S. Department of Health and Human Services, (HHS), Health Equity in Healthy People 2030, An overview of the program’s focus including overarching goals, health literacy, social determinants of health and tools for action.
The Critical Role of Institution Leadership in Quality Improvement
“Culture is ultimately what drives continuous improvement. Quality improvement frameworks matter. Understanding the problem matters. Analyzing data matters. These things are all essential. But culture is foundational. Leaders at all levels, whether clinic medical directors or system CMOs, must invest in improvement, believe in improvement, and ‘rally the troops’ around a vision of improvement. This needn’t be rocket science…it starts with humility and an attitude that ‘we can and should do better.’ The specific tools and methods follow from that.”
Blake Cameron, MD, MBI
Duke Health, Practicing Nephrologist
Change Package Faculty
Build a business case for deploying CKD care improvement activities.
Resources and Tools:
Consider all possible leverage points for leadership buy-in:- Laboratory: access to laboratory information system (LIS) data and advocacy for setting up the Kidney Profile
- Risk Adjustment: provide insight into return on investment (ROI) calculations for care improvement
- Primary Care: often the first line of CKD care and vested in leading improvement, offer sound practical implementation ideas and are essential to discussions with leadership
- Pharmacy: valuable resource to primary care for patient engagement and education and possibly test orders
- Nephrology: credible feedback regarding program impact on nephrology referrals, patient outcomes, specialty collaborations, and co-management improvements
- Diversity & Equity: provide insights to internal and external resources to address social determinants of health
- Population Health & Quality: essential insights to existing workflows, implementation models, design for programs and outcomes, and can serve as internal facilitators
- Payers & Contracting: insights for alignment of new interventions and reimbursement, value-based care models
- Health Equity: provide insights on health equity in the Joint Commission, American Hospital Association, Centers for Medicare and Medicaid and other accreditation organizations
- Informatics: instrumental to LIS and electronic health record (EHR) data extraction, clinical decision support, and other related tools
Engage support from primary care, nephrology, quality, population health, pathology, and other disciplines.
Resources and Tools:
- Intermountain, The Benefit of Interdisciplinary Teams in Healthcare, describes interdisciplinary care and its functionality in a nonhierarchical manner to intervene, assess, diagnose, and create a plan for optimal care that is shared by all.
- J Ambul Care Manage, 2009, Transforming Care Teams to Provide the Best Possible Patient-Centered, Collaborative Care, reviews how to create and assess a high functioning multidisciplinary healthcare team and how such a team successfully redesigns care delivery.(38)
References
- 12. Alfego D, Ennis J, Gillespie B et al. 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 Sept;44(9):2025-2032
- 31. Vassalotti JA, DeVinney R, Lukasik S et al. CKD quality improvement intervention with PCMH integration: health plan results. Am J Manag Care. 2019 Nov 1;25(11):e326-e333.
- 32. Scholle SH, Ontad K, Hart A, Hwee T. Chronic kidney disease disparities: educational guide for primary care. Prepared for the Centers for Medicare and Medicaid Services (CMS) by the National Committee for Quality Assurance (NCQA). 2021 April:1-19.
- 33. Tummalapalli SL, Powe NR, Keyhani S. Trends in quality of care for patients with CKD in the United States. Clin J Am Soc Nephrol. 2019 Aug 7;14(8):1142-1150.
- 34. Norton J, Moxey-Mims MM, Eggers PW et al. Social determinants of racial disparities in CKD. J Am Soc Nephrol. 2016 Sep;27(9):2576-95.
- 35. Crews DC and Novick TK. Social determinants of CKD hotspots. Semin Nephrol. 2019 May;39(3):256-262.
- 36. Tucker KJ. Social justice as a tool to eliminate inequities in kidney disease. Semin Nephrol. 2021 May;41(3):203-210.
- 37. Crews DC, Pfaff T, Powe NR. Socioeconomic factors and racial disparities in kidney disease outcomes. Semin Nephrol. 2013 Sep;33(5):468-75.
- 38. Sevin C, Moore G, Shepherd J et al. Transforming care teams to provide the best possible patient-centered, collaborative care. J Ambul Care Manage. 2009 Jan-Mar;32(1):24-31.