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Stage of Change 4: Convene a Multi-disciplinary Leadership Team

Table of Contents

A CKD quality improvement strategy that yields actionable results requires input and perspective from various healthcare professionals and sources. Following are suggested Team participants and resources to help achieve that objective.

 

Broadly define your planning Team.

Consider including representatives from primary care, nephrology, informatics, population health, quality, pharmacy, health equity, nursing, pathology, diabetes care and education specialists, community outreach, dietitians, etc. on this team.

 

Primary Care

Resources and Tools:

 

Pharmacy

Resources and Tools:

Clinical Pharmacists are Widely Under-recognized in their Clinical Expertise as a Resource for Primary Care

"The pharmacotherapy clinic leader said we’re (clinical pharmacists) the best kept secret in the institution. We’re here to address many of the barriers facing primary care physicians and to initiate guideline directed therapies in CKD, including working through prior authorizations that take time and burdens on the primary care clinic."

Joshua J. Neumiller, PharmD, CDCES, FASCP, FADCES
Washington State University
Change Package Faculty

Pathology

Resources and Tools:

  • NKF, Laboratory Engagement Initiative, developed by clinical laboratorians and physicians, this overviews guideline-concordant testing for CKD diagnosis and management as well as resources for patients and healthcare professionals.

 

Informatics

Resources and Tools:

 

Community Outreach/Community Health Workers

Resources and Tools:

  • NKF, Community Health Workers, a resource that advances Community Health Workers and their role in connecting patients to health care resources via identification, prevention, and risk management associated with CKD.

Review population health data to identify care improvement opportunities.

Screening and Diagnosis:

  • Electronic Health Record (EHR) and/or claims data to determine rates of guideline-concordant CKD testing (eGFR and uACR) among patients with hypertension and/or diabetes
  • Available EHR laboratory data to assess rates of CKD diagnosis among patients with hypertension and/or diabetes and existing laboratory evidence of CKD
  • Available EHR laboratory data to determine rates of CKD testing (eGFR and uACR) among patients with a CKD ICD-10 code in their medical record (e.g., BMP with eGFR results <60 mL/min/1.73m2)
  • Annual CKD testing (eGFR and uACR) and risk stratification in at-risk populations—those with diabetes and/or hypertension and/or other risk factors

A1C and/or Blood Pressure Goal Attainment:

  • Percentage of patients with CKD and diabetes with A1C within recommended range
  • Percentage of patients with CKD whose blood pressure is within recommended range

Preventing CKD Progression and/or Reduce Cardiovascular Risk:

  • Percentage of patients with CKD and Type 2 Diabetes prescribed GLP-1 RAs
  • Percentage of patients with diabetes and/or hypertension on problem list/encounter with a uACR ≥ 30 who were prescribed an ACE inhibitor or ARB medication
  • Percentage of patients with Type 2 Diabetes and CKD on problem or encounter list with an eGFR ≥ 20 who were prescribed an SGLT2i medication
  • Percentage of patients with Type 2 Diabetes and CKD on problem or encounter list with an eGFR ≥ 25 and uACR ≥ 30 who were prescribed a non-steroidal MRA medication
  • Percentage of individuals aged 18 years and older with a diagnosis of CKD who were prescribed select SGLT2i therapy within a 12-month period
  • Percentage of individuals with heart failure, Type 2 diabetes/atherosclerotic cardiovascular disease and CKD prescribed select SGLT2i therapy within a 12-month period

Resources and Tools:

Build consensus on evidence-based, guideline-driven interventions/quality metrics.

Consider evaluation and selection of interventions/quality metrics on the basis of what is appropriate for clinic locations, patient panels, resources, and workflows.

 

Identify evidence-based recommendations and guidelines that support CKD recognition and implementation of interdisciplinary patient care for CKD

Resources and Tools:

 

Annual CKD testing (eGFR and uACR) and risk stratification in at-risk populations—those with diabetes and/or hypertension and/or other risk factors

Resources and Tools:

The Role of Testing in Kidney Disease Progression and Concomitant Risk for Cardiovascular Disease and Mortality is Underappreciated

"With regard to highlighting the importance of both eGFR and uACR screening in primary care, explaining the independent association with these markers for both kidney disease progression and cardiovascular disease risk is often a lightbulb moment for providers. Both are important, but there is a bit of confusion about the need for screening both parameters and additional education is often needed."

Joshua J. Neumiller, PharmD, CDCES, FASCP, FADCES
Washington State University
Change Package Faculty

Attainment of blood pressure target

Resources and Tools:

Patients Often Share What They've Learned about Blood Pressure and CKD with Other Patients

"Bring the connection between blood pressure and kidney disease to the patients earlier and you’ll be surprised how many hang on to that, and they help each other in the group patient education sessions to kind of keep that in mind."

LaTasha Seliby Perkins, MD
Georgetown University School of Medicine
Change Package Faculty

Attainment of A1c target

Resources and Tools:

 

Use of ACE Inhibitor or Angiotensin Receptor Blocker in patients with diabetic kidney disease, CKD and HTN, and/or CKD and uACR > 30 where tolerated and appropriate

Resources and Tools:

 

Use of an SGLT-2i in patients with CKD and eGFR >20 where tolerated and appropriate

Resources and Tools:

 

Use of Statins

Resources and Tools:

 

Use of Non-steroidal Mineralocorticoid Receptor Antagonist (ns-MRA) in patients with Type 2 diabetes, normokalaemia, and residual albuminuria despite other standard-of-care therapies.

Resources and Tools:

 

Use of long-acting GLP-1 Receptor Agonist in patients with Type 2 diabetes not meeting glycemic targets despite first-line SGLT2 inhibitor ± metformin, ideally one with proven CVD benefit

Resources and Tools:

 

Medical nutrition therapy referral

Resources and Tools:

There is Little Recognition that "Food is Medicine" When it Comes to CKD

"It’s amazing to me how few people have any knowledge about nutrition interventions that can be done to slow the progression of CKD."

Karen Greathouse, RD, CCTD
Fellow, National Kidney Foundation, University of Michigan Health System
Change Package Faculty

NSAIDs avoidance

Resources and Tools:

 

Use of a risk prediction model (i.e., the Kidney Failure Risk Equation)

Resources and Tools:

Prioritize social determinants of health and CKD care disparities within the program.

Resources and Tools:

Outcomes are Influenced by Understanding which Social Determinants of Health Impact the Patient and How They Do So

"Making that connection between the association of certain SDOH with outcomes–what’s related to access–what’s related to biology–and having a validated and consistent way of identifying connections–that’s the challenge and it might be different for different diseases."

Christine Chang, MD, MPH
Agency for Healthcare Research
Change Package Faculty

Use electronic health record or other data to characterize the impact of social determinants of health within geographies considered for your program.

Resources and Tools:

  • Agency for Healthcare Research and Quality (AHRQ), SDOH Data and Analytics, provides access to various datasets and tools for SDOH analysis
  • Social Interventions Research & Evaluation Network (Siren), 2022, SCREEN Report: State of the Science on Social Screening in Healthcare Settings, aims to improve health and health equity by advancing high quality research on health care sector strategies to improve social conditions(64)
  • PRAPARE. Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences. Data, tools, and evidence derived from ongoing collaborations among health centers, community organizations and others with the shared goal of improving health equity by addressing social determinants of health.
  • Confluence HL7.org, 2019, The Gravity Project, a collaborative public-private initiative launched in 2019 to develop consensus-driven data standards that support collection, use, and exchange of data to address the social determinants of health (SDOH).
  • U.S. Department of Health and Human Services, National Institutes of Health, PhenX Social Determinants of Health (SDOH) Assessments Collection, catalog of recommended data measurement protocols to assess individual and structural factors that shape behaviors and health outcomes.
  • UNITE US, Cross-sector collaboration software to assist providers, health plans, government, and non-profits in identifying and delivering solutions and services that impact whole-person health.

Clearly communicate collaboration parameters between primary care and nephrology as determined by your Team.

Resources and Tools:

Collaboration between Primary Care and Nephrology are Important to Outcomes because Primary Care Usually Extends Care Delivery Prior to Referral

"The majority of patients we see as nephrologists are first seen by primary care physicians, so we really depend on them to make critical decisions in terms of how care is delivered, because it impacts what happens in a patient’s life down the road."

Susanne Nicholas, MD, MPH, PhD
David Geffen School of Medicine at the University of California, Los Angeles
Change Package Faculty

Identify an implementation framework to evaluate proposed CKD interventions/quality metrics, implementation strategies and track outcomes.

Below are some widely used implementation frameworks for consideration.

Resources and Tools:

References

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