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

Table of Contents

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

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, and others on this team.

 

Primary Care

Resources:

 

Pharmacy

Resources:

 

Pathology

Tools:

  • NKF, Closing the Testing Gap by Implementing the Kidney Profile, a virtual meeting of laboratory, IT, data informatics, and quality improvement leaders that highlights successful strategies for implementation, discusses and trouble shoots challenges, and identifies strategies to ensure the Kidney Profile is utilized by clinicians once it is implemented

Resources:

  • 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

Tools:

  • PheKB, Chronic Kidney Disease, the Phenotype KnowledgeBase resource for those interested in using data algorithms to enhance genomic and clinical research including that for CKD.

Resources:

 

Community Outreach/Community Health Workers

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

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

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

Tools:

 

Attainment of blood pressure target

Tools:

 

Attainment of A1c target

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

Tools:

 

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

Tools:

 

Use of Statins

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.

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

Tools:

 

Medical nutrition therapy referral

Tools:

 

NSAIDs avoidance

Tools:

Resources:

 

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

Tools:

Resources:

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

Tools:

Resources:

Characterize the impact of social determinants of health within geographies considered for your program.

Tools:

  • Agency for Healthcare Research and Quality (AHRQ), SDOH Data and Analytics, provides access to various datasets and tools for SDOH analysis
  • PRAPARE, Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences, The PRAPARE Screening Tool, a national standardized patient risk assessment tool to engage patients in assessing and addressing social drivers of health (SDOH).
  • 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.

Resources:

  • 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)
  • 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.

Tools:

Resources:

Identify an implementation framework to assess implementation strategies/associated interventions and their outcomes.

Below are some widely used implementation frameworks for consideration.

Tools:

Resources:

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References

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