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Comprehensive Kidney Care

Oct 3, 2022

Patients with chronic diseases such as chronic kidney disease (CKD) have complex needs that are often costly to manage. This can make healthcare delivery more challenging. Patient-centered care provides patients with holistic care management that reaches beyond healthcare systems. This approach reduces patient discomfort and fear and improves emotional and physical recovery. Implementing patient-centered care as part of a comprehensive care model in kidney care can improve clinical outcomes, staff and patient satisfaction, while reducing costs. 

Key Points: 

  • Patient-centered care (PCC) may provide a more individualized approach to patients with chronic diseases. 
  • A patient-centered approach is based on eight principles. 
  • Research shows that PCC positively influences the outcomes of patients with multi-morbidity and long-term conditions.

What is Patient-Centered Care, and Why is it Important?


The Institute of Medicine describes patient-centered care as providing shared decision-making and active collaboration between patients, families and providers. Patient-centered care models allow care teams and providers to fully treat the patient through individualized and comprehensive care plans. The eight key elements in a patient-centered approach or model include: 

  • Health care facilities have values, mission, leadership, and quality-improved drivers aligned with patient-centric goals.
  • Effective care is accessible, collaborative, and coordinated, ensuring that the proper care is provided at the right place and time. 
  • The patient and family are included in the clinical decision-making process and as part of the care team. 
  • Transparency and prompt delivery of patient health information so informed decisions could be made. 
  • Emotional support. 
  • Physical comfort.
  • Respect for the viewpoint of the patient and their family (cultural traditions, values, and socioeconomic status). 
  • An inviting environment is created for family members in the care setting. 

Why is Patient-Centered Care Important? 

For patients with comorbidities or chronic diseases, the physical and social well-being or the care they receive may influence disease outcomes. Reports show that care models that improve patients’ quality of primary care have better outcomes. Thus, making chronic kidney care patient-centered is predicted to help patients manage their quality of life and health. This positively affects the patient’s social and physical well-being and overall satisfaction with the care provided. 

The Benefits of Patient-Centered Care 

The main goal of PCC is not just to improve population health outcomes but also to improve individual health outcomes. PCC has been shown to benefit patients, health care systems, and providers. The benefits of PCC may include:

  • Improved patient satisfaction scores. 
  • Improved outcomes:
    • Faster recovery 
    • Lower hospital visits
    • Improved health outcomes 
    • Increased patient, care team, and family satisfaction 
    • Decreased utilization of healthcare resources 
  • Better job satisfaction for clinicians and ancillary staff.  
  • Improved reputation for the healthcare organization.
  • Increased financial margins and reduced expenses through the continuity of care. 

How to Successfully Implement Patient-Centered Care


Research shows that patients have better outcomes when they have the knowledge, skills, ability, and willingness to manage their conditions. Although patient-centered care is pretty straightforward, it may be difficult for healthcare organizations to translate the principles and concepts of patient engagement and PCC into daily practice. 

The successful implementation of this patient care model may require extensive training and digital tools. To help healthcare organizations implement PCC, researchers have standardized a set of evidence-based principles and best practices. These include:


    • John Hopkins University’s Center for Engagement and Patient-Centered Innovations developed the “Best Practices in Patient-Centered Care Research and Dissemination” to improve the patient experience. This center develops, implements, disseminates, and evaluates programs that are created in partnership with clinicians, patients, caregivers, and other stakeholders. These programs also facilitate mentorship and learning between patients with the same medical condition and caregivers.



When implementing PCC models, best practices encompass the patient’s family members, improving patients’ outcomes drastically. Harvard University recommends the following evidence-based directives to improve patient care:

  • Make healthcare accessible. 
  • Respect patients’ needs, values, and preferences.
  • Inform and educate patients. 
  • Coordinate care. 
  • Provided physical and emotional comfort.
  • Ensure continuity of care. 
  • Involve friends and family. 

How Patient-Centered Care can be Measured


In the U.S, the first standardized survey was published by the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (CAHPSⓇ). The Agency for Healthcare Research and Quality (AHRQ) and The Centers for Medicare & Medicaid Services (CMS) developed a data collection tool that measures patient experience by providing a survey to discharged patients. Possible questions asked in the survey include: 

  • Did the doctors, care providers, and customer service representatives communicate with compassion? 
  • Did the patient feel that they got the care they needed?
  • Did the patient feel that they got care quickly enough?

Barriers to Facilitating Patient-Centered Care


According to a 2016 study, the barriers to the successful implementation of PCC were identified and categorized into three topics: 

  1. Factors related to the development of person-centered interventions. 
  2. Traditional structures and practices. 
  3. Stereotypical attitudes from professionals. 

Healthcare workers reported that the traditional care pathways and structures restricted their ability to use different strategies or work flexibly as required for PCC. The existing power relationships within the clinical setting, the “high patient turnover,” and standardized prescribing also provided barriers to the successful implementation of PCC. Other barriers identified include: 

  • Time constraints. 
  • Professional attitudes. 
  • Population characteristics, documentation, and design. 
  • Organization and leadership. 
  • PCC training and education. 
  • Delivery of research to facilitate PCC.

Addressing the gaps that hinder the implementation of PCC models, such as lack of training and integrated care models, will help healthcare organizations gain further insight into understanding the role their Patient-Centered Care model plays in routine care and patients’ needs priorities. 

How Does PCC Work to Provide Comprehensive Kidney Care?


No one-size-fits-all patient-centered care model is available for chronic kidney disease patients. Different types of care are required for individual needs. For example, some CKD patients may benefit from educational interventions, while others may benefit from access to a care coordinator. Thus, efforts to improve CKD or ESRD patient outcomes through PCC should be created to suit individual preferences and needs while incorporating the eight principles of patient-centered care. 

Panoramic Health provides practices with patient-centric population health initiatives that are individualized to each practice’s delivery-care process. Panoramic Health’s comprehensive, value-based kidney care model results in patients experiencing improved outcomes through longitudinal care, including tailored interventions to manage acute events as part of Panoramic Health’s comprehensive care model. Through physician-led care coordination, patients are empowered to manage the full spectrum of their healthcare journey. 

Panoramic Health’s comprehensive, value-based care model includes: 

  • Renal dieticians
  • Pharmacist consultation
  • Medical assistants
  • Nurse practitioners
  • Clinical social workers

Primary Care Physician (PCP) coordination and Social Determinants of Health (SDOH) services manage the gaps in non-medical care that may impact the patient. 

SDOH are defined as the factors in the environment that affect the health, quality-of-life outcomes, functioning and risks of patients. PCP coordinates partners with patients, communities, and public health professionals to address the non-medical gaps identified in SDOH.

The non-medical gaps identified in SDOH include:

  • Economic stability 
  • Education 
  • Social and community context 
  • Neighborhood and environment

As the emphasis on medical care continues to become more patient-centric, successfully implementing care models with PCC is likely to result in improved patient relationships with care teams. 

In turn, patients become empowered through collaboration with care options, providing education, emotional considerations, and recognition of the role family plays in patient care. Chronic disease patient outcomes through Panoramic Health’s Care Model are expected to improve with an overall increase in quality of life.