Bay Area Ending Disparities in CKD Stakeholder Summit

In the nine-county Bay Area¹, 430,832 Medicare beneficiaries are at-risk for chronic kidney disease (CKD) and of this population, less than 28% have been properly tested. 

Recognizing that a community-based, multi-dimensional approach is necessary to overcome this challenge, the National Kidney Foundation (NKF) launched the Bay Area Ending Disparities in CKD Stakeholder Summit. As a part of the national NKF Collective Impact strategy, Bay Area stakeholders are implementing a roadmap to drive a cultural shift in primary care toward increasing the early diagnosis and management of CKD. 
 

¹The nine county Bay Area is defined as the following counties: Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, and Sonoma. 

While we refer to the listed counties above as the Bay Area, we recognize that the Bay Area stands upon the ancestral and unceded territories of the Coast Miwok, Pomo, and Ohlone peoples. We recognize both the historical and ongoing injustices experienced by Indigenous communities—including the impacts of settler-colonization and genocide—as well as their resilience and achievements.

In the spirit of continuous learning and accountability, we humbly offer the following resources for further exploration:

• Sogorea Te’ Land Trust
• The Association of Ramaytush Ohlone
• San Francisco State University’s American Indian Studies Department
• UCSF Land Acknowledgement and Resource

Through a series of facilitated discussions, occurring in January through early March of 2024, leaders in health care and public health will identify barriers and solutions to improve CKD awareness, detection, and management in the Bay Area, and especially tools and strategies that can be implemented within stakeholders' own institutions. Four workgroups will convene covering the following topics:

Clinical Considerations for CKD in Primary Care

• Goal: 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. 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 a very real opportunity to improve quality of care for people with CKD across the entire disease spectrum.

Community-Centered Engagement and Solutions

• Goal: 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 US today, only 10% of people with laboratory evidence of CKD know that they have kidney disease. 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 people with chronic disease can be an important step toward raising public awareness of CKD among those at risk.

​Policy, Payment, and Quality Measurement

• Goal: 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). This measure assesses the percentage of people with diabetes that receive both tests for CKD during the course of a year. 2021 reporting year data shows average measure satisfaction of only 33-45% across payer types.

​Wellness and Prevention

• Goal: Develop a strategy to incorporate CKD testing and diagnosis into wellness and prevention practices within employer/ commercial health plans, and the broader community.
• Background: To date, almost 90% of people living with CKD remain undiagnosed and the majority will not receive guideline recommended annual testing. This workgroup will craft and propose the strategies that can be implemented to ensure that CKD testing and diagnosis are included as part of population health approaches (e.g., corporate wellness programs, disease prevention activities, payer-led prevention strategies) that are available in the Bay Area.

Anne Davidson Barr, MBA
Managing Partner
Counterpoint Advisors, LLC
Read full bio here

Rita Nguyen, MD
Assistant State Public Health Officer
California Department of Public Health
Read full bio here

After 16 hours of facilitated discussion, 59 workgroup members representing 43 organizations, identified 13 strategies to improve testing, diagnosis, and early management of CKD in the Bay Area. Read the executive summary here.

On March 27, 2024 NKF serving CA, NV, OR, and WA hosted a virtual summit to present the final recommendations and engage partners in joining the Collective Impact Effort. 115 registered and 77 attended the live summit with 123 commitments from 32 individuals to support implementation of the 13 recommendations.

During the learning and action workgroups, stakeholders identified several barriers to CKD testing, diagnosis, and management.
Barriers Identified:

• Lack of Systemic Focus on Preventative Health and Wellness
• Lack of Person-Centered Education and Awareness
• Structural Barriers that Disproportionately Impact Underserved Communities
• Competing Priorities in Clinical Quality Improvement
• Primary Care Capacity

Please see Executive Summary for more details regarding recommendations.

Disseminate NKF's CKD patient education to individuals with risk factors
In partnership with the Alameda County Community Food Bank (ACCFB), we developed an education resource (in English and Spanish) on CKD for patients who are living with diabetes. This flyer will be included in the medically tailored food boxes that ACCFB provides through CalAIM. We look forward to evaluating this pilot and are grateful to ACCFB for their partnership! We welcome additional community nutrition partners to join this initiative. 

Train Community Health Workers (CHW) and Patient Navigators 

According to the National Center for Farmworker Health, common diagnoses among agricultural workers include obesity, diabetes, and hypertension, all of which are risk-factors for CKD. With one third to half of all agricultural workers in the US residing in CA, we are seeking funding to tailor and deploy the NKF's CHW training modules to better support those CHWs who work with this population. 

Sources: 

• NCFH. A Profile of Migrant Health: 2022 Analysis of HRSA Health Center Data.
• NCFH. Farm Labor Data Dashboard. Date Accessed: 06 August 2024. https://ncfh.org/dashboard.html.

Leverage team-based care models to provide holistic care for patients

The NKF CNOW (CA, NV, OR, WA) team hosted a pilot presentation on co-management at our Journal Club. Brian Brady, MD--one of our Summit partners--and Jo-Anne Suffoletto, MD from Stanford University presented on Partnering with Primary Care and Considering Non-Steroidal MRAs in the Chronic Kidney Disease Treatment Armamentarium. Watch the recording here. 

We are seeking partners to implement similar workshops throughout our CNOW region. Contact nina.sherpapine@kidney.org if you'd like to learn more! 

Develop shared messaging and health promotion or wellness programs 

To better identify shared messaging opportunities on chronic disease, we are participating in local health promotion and wellness coalitions. We participated in the California Department of Public Health's Healthy Hearts California Learning Collaborative and will be joining the San Francisco Department of Public Health's Shape Up San Francisco Coalition. We are also seeking opportunities to support additional chronic disease prevention coalitions or collaborate on health promotion activities. 

The NKF CKDintercept team has developed a Public Health Professional CKD Educational Toolkit, which empowers public health professionals to enhance CKD awareness and its interconnectedness with cardiovascular disease outcomes. 

Improve primary care workflows and tools to support testing and management. 

We are connecting with health systems across the Bay Area to engage in the NKF's Data Strategy and Learning Collaborative. These resources have helped other institutions improve guideline concordant testing by as much as 60%. Contact mallory.caron@kidney.org if you'd like to learn more! 

Summit partner, Delphine Tuot, MD, is supporting Oregon Community Health Information Network and the San Francisco Community Clinic Consortium in leveraging Epic to increase uACR testing for patients with hypertension. 

We are collaborating with the Purchaser Business Group on Health's California Quality Collaborative on technical assistance for a payment model demonstration project by providing our CKD Change Package resources. 

The NKF is committed to advancing population health initiatives focused on CKD and chronic disease prevention, and prioritizing the well-being of our communities. Achieving sustainable system change requires careful planning, collaboration, and time--and we need your support! 

If you're interested in partnering on any of the recommendations currently in progress or other ideas, please reach out to us. Thank you for your commitment to this vital work! 

• Nina Sherpa-Pine (she/her/hers/any pronouns used respectfully), Director of Community Impact and Health Partnerships: nina.sherpapine@kidney.org
• Mallory Caron (she/her/hers), Senior Manager Population Health Partnerships, mallory.caron@kidney.org

1. 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  
2. 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
3. “Chronic Kidney Disease (CKD) Surveillance System: Awareness.” Centers for Disease Control and Prevention. https://nccd.cdc.gov/ckd/detail.aspx?QNum=Q97#refreshPosition
4. Brock, Matt. “Kidney Health: A New HEDIS Measure.” NCQA Blog, 16 Jul. 2020. https://blog.ncqa.org/kidneyhealth/
5. “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