Stage of Change 5: Develop the Implementation Plan for Your CKD Intervention

Table of Contents

Consideration of local practice needs including workflows, patient panels, and available resources is an integral part of planning and development. Following are Resources and Tools that can support these processes.

Identify evidence-based implementation strategies based on published literature and organizational expertise.

Tools:

  • American Academy of Family Physicians (AAFP), Basics of Quality Improvement, a summary of quality improvement (QI) basics including benefits and proven QI models and tools.
  • American College of Physicians (ACP), Quality Improvement in Healthcare: ACP Resources and Programs, a succinct overview of QI resources that includes QI curriculum, training, coaching, and resources to improve patient outcomes, practice assessment tools and performance measures relevant to internal medicine.

Resources:

Ensure care team members executing the CKD intervention helped identify implementation strategies aligned with practice or clinic needs and requirements.

Tools:

  • Agency for Healthcare Research and Quality (AHRQ), EvidenceNOW Tools for Change, overviews tools and resources to help primary care practices, practice facilitators and others who support practices, make changes to engage in quality improvement activities.

Resources:

Consider Use of a Patient Panel as Part of an Intervention Strategy

“Take a panel approach: here’s all the patients that look like they have CKD but don’t have a CKD diagnosis. Let’s look through and get them a diagnosis if they need it. Here’s all the patients who do have CKD but aren’t getting evidence-based care (e.g., receiving an ACE inhibitor or ARB, avoiding nephrotoxins like NSAIDs). Let’s get them to the care that they should be on (unless contraindicated) and away from the care that could further harm their kidneys (e.g.,NSAIDs).”

Jenna Norton, PhD, MPH
National Institute of Diabetes and Digestive and Kidney Diseases, Director
Change Package Faculty

Consider implementation of an electronic health record-based CKD registry.

Resources:

Develop the recommended CKD care plan for your institution.

Resources:

  • National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Development of an Electronic CKD Care Plan, evidence-based suggestions for data elements and standards for building an electronic CKD care plan.

Consider developing CKD clinical decision support.

Resources:

Review / update diabetes and hypertension order sets to include agreed upon CKD parameters including assessment with the Kidney Profile, medication management, referrals.

Tools:

Resources:

Kidney Profile Order Set Example:

Order sets are adaptable EHR tools that facilitate ordering components of effective clinical care. The order set in the Example has been configured to accommodate institution preferences while still advancing guideline-concordant CKD testing: eGFR (part of the Renal Panel) AND uACR (listed individually with older nomenclature, Urine Microalbumin/Creatinine).

Consider embedding the CKD heat map in EMR tools to facilitate CKD staging/risk stratification.

Risk of Chronic Kidney Disease Progression and Frequency of Assessment

(according to estimated glomerular filtration rate (eGFR) and albumin-creatinine ratio (ACR))

Where appropriate create dot phrases to facilitate entry of CKD information.

Example of Public Dot Phrase for CKD:

When a dot phrase, often an abbreviation or acronym, is typed into the EHR, it triggers pre-saved components of effective care which are dropped into progress notes. The dot phrase example includes components of effective care for Stage 2 CKD.

Consider use of the Kidney Health Evaluation for Patients with Diabetes MIPS measure.

Tools:

  • Centers for Medicare and Medicaid Services (CMS), Kidney Health MIPS CMS951v1, details the Kidney Health Merit-based Incentive Payment System (MIPS) clinical quality measure.

Include social determinants of health assessment in the CKD intervention.

Tools:

Consider including resources to address identified social determinants of health needs in the intervention tools.

Resources:

  • UNITE US, supports cross-sector collaborative solutions among clinicians, payers, government, non-profits and others to improve health and well-being.
  • The 211 Network, confidentially connects those in need to expert, caring help in finding food and assistance with expenses for housing, utilities, healthcare, etc.

Within the context of available resources, consider novel community-level approaches for identified needs related to social determinants of health.

Resources:

  • Aunt Bertha, zip code directed search for food, health, housing and employment programs
  • SAHF: Stewards of Affordable Housing for the Future, advances creation, and preservation of healthy, sustainable, affordable rental homes for patients of limited economic resources
  • NeighborWorks America, drives change at the local level for individuals, families and communities through public and private partnerships
  • Community Housing Partners, a resource for quality-built, responsibly managed, service-enriched homes for low-income individuals and families across the Southeast and Mid-Atlantic

Outline a seamless communication strategy among patient care team members.

Tools:

Resources:

  • National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Collaborate with a Registered Dietitian, overviews the role of the Registered Dietitian with extensive knowledge of CKD diet and nutrition in CKD patient care (includes a link to the Academy of Nutrition and Dietetics directory).
  • National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Professional and Continuing Education, a continuing education resource for CKD care team members, including pharmacists, physicians, and registered dietitians.

Make CKD patient education a convenient experience.

Tools:

  • NKF, Kidney Basics, various basic CKD patient education resources: Understanding Kidney Health, Risk Factors and Causes, Kidney Health Testing, and Kidney Stones.
  • NKF, Patient Education Library: Brochures, a library of patient education brochures that address kidney cancer; hyperkalemia; nutrition; living with kidney disease and kidney failure; kidney failure treatment (ESKD), and kidney disease treatment. (Important information on commercial use and copyright is also provided.)
  • NKF, Patient Education (2-Sided Flyers), patient education in a 2-sided flyer format: About CKD; CKD Risk Factors; Diagnostic Tests and Procedures; Diseases and Conditions; Nutrition-General; Nutrition-Superfoods; Living with Kidney Disease and Kidney Failure; Kidney Failure Treatment (ESKD); and Kidney Disease Treatment. (Important information on commercial use and copyright is also provided.)
  • Medical Education Institute, Inc., Kidney School, 18 modules of patient education with topics such as living with kidney disease, working with your care team, dialysis, heart health and more.

The Importance of Reputable, Evidence-Based Patient Education

“When you learn you’ve got a health issue, go to reputable sources for information. Don’t go to ‘Mr. Bob Talks about Kidney Disease’ on YouTube. Go to a site such as the National Kidney Foundation. You’re going to find information that’s factual and that’s going to help you along the way. I urge patients not to put everything on the doctor, and understand there are reliable sources of information available like the NKF. It’s up to us to educate ourselves so when we speak to our doctors it can be a dialog.”

Ann Dalin
Kidney Transplant Patient

Include referral information for local support groups or peer-mentoring programs.

Resources:

Patient Mentoring Facilitates Education and Empowers Patients to Participate in Their Care

“One of the things that really helped me was to be able to join a patient organization and listen to other patients share their experiences. Now I’m so inundated with information, you know, it allows me to be more comfortable in talking on the same level about disease management to my nurses, the techs and the physicians. And if something doesn’t feel right, if the medication isn’t working, it has encouraged me to be more vocal and more proactive.”

Patrick O. Gee, PhD
Kidney Transplant Patient

Utilize multiple channels of outreach to engage patients around CKD awareness and screening.

Tools:

  • National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Family Reunion Kidney Health Guide, suggested opportunities like family reunions to talk with family members about kidney health and the connection between diabetes, high blood pressure, and kidney disease.
  • National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Kidney Sundays: A Toolkit, provides a downloadable PDF for health ministry leaders or anyone interested in bringing health programming to their congregation.

Resources:

The Importance of Kidney Health Education for Kids in Communities Disproportionately Impacted by CKD

“We need to do a better job talking about kidney disease in communities where folks are more affected, at colleges, in high school, in middle school and even in elementary school—it’s not too early to teach kids about their kidneys and how to keep them healthy.”

Patrick O. Gee, PhD
Kidney Transplant Patient

Consider creating a primary care tool kit to address the specific care gap(s) targeted.

Tools:

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References

  • 71. R. Rubin. It takes an average of 17 years for evidence to change practice-the burgeoning field of implementation science seeks to speed things up. Medical News & Perspectives. JAMA 2023;329(16):1333-1336.
  • 72. Mendu ML, Ahmed S, Maron JK et al. Development of an electronic health record-based chronic kidney disease registry to promote population health management. BMC Nephrol 2019 20:72.
  • 73. Litvin CB, Hyer M and Ornstein SM. Use of clinical decision support to improve primary care identification and management of chronic kidney disease (CKD). J Am Board Fam Med. 2016 Sep-Oct;29(5):604-12.
  • 74. Mendu ML, Schneider LI, Aizer AA et al. Implementation of a CKD checklist for primary care providers. Clin J Am Soc Nephrol. 2014 Sep 5;9(9):1526-35.
  • 75. The role of faith-based models in community outreach and patient care. Symposium Recap. Am J Manag Care. April 2023.
  • 76. Cutts T, Gunderson G, Carter D et al. From the Memphis model to the North Carolina way: lessons learned from emerging health system and faith community partnerships. NC Med J. 78 (4): 267–72.