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 in March 2024. NKF is now engaging a health system partner on a project to disseminate this awareness flyer to at-risk patients to encourage activation and discussion of CKD risk factors with their clinician, an intervention that has increased patient engagement in previous NKF programs.

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 accompanying 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

To address diverse linguistic educational barriers, NKF received grant funding to translate 5 flyers into the most commonly spoken languages across the Kansas City region, following Spanish: Arabic, Somali, Burmese, and Swahili. Additional funding allowed for NKF to partner with local Federally Qualified Health Centers to identify languages most spoken second to English in the St. Louis Promise Zone region. As a result, these 2-sided CKD educational flyers were also translated in Bosnian, Dari, Farsi, Kinyarwanda, Nepali, Pashto, and Vietnamese. Subsequently, through a content licensing agreement, one health system has integrated the flyers into their electronic health record and tied the materials to CKD related diagnosis codes to include in patient discharge summaries.

Public Health Professional CKD Educational Toolkit

Public health professionals serve as trusted messengers, effectively bridging the gap between community members and vital educational resources. This toolkit empowers public health professionals to enhance awareness of CKD and its interconnectedness with cardiovascular disease outcomes among both health professionals and the general public. The toolkit can be utilized independently or seamlessly integrated into existing cardiovascular disease programs and initiatives to facilitate appropriate testing and intervention for CKD. To receive this toolkit, please complete this brief form here.

CKD Workplace Wellness Toolkit

This toolkit was developed by the National Kidney Foundation for wellness engagement or human resources teams seeking a resource that can be woven into their existing health promotion efforts to improve CKD prevention and management. It functions as a catalog of educational information and resources pertaining to kidney disease for members who may be at risk for or living with CKD. Piloted with a national health plan, NKF will continue to work with payers and corporate partners to expand toolkit utilization and strategy adoption. For more information or to receive this toolkit, please contact Alexandra Garrick.

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 65 learners in this model across two 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 improvement of over 25% in patients with laboratory evidence of CKD who had an appropriate CKD diagnosis documented in their medical records. Learn more about the key program learnings here.

Following the June 9th convening, multiple institutions have expressed interest in participating in a learning collaborative. Spira Care, Mercy, and St. Luke's are now advancing this quality improvement model across their primary care clinics as well as various partners in other states. 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 resources, guidance, and support to institutions interested in learning more or implementing the Kidney Profile.