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Integrated Kidney Care

Jan 6, 2023

The disease burden of renal failure, chronic kidney disease (CKD), and end-stage kidney disease (ESKD) is a significant challenge for healthcare systems. CKD patients have complex needs, and care is often fragmented, with missed opportunities to improve overall patient care and reduce costs.

Globally, there has been a push to create new integrated service models for CKD patients, with an increased emphasis on care coordination and prevention. Integrated kidney care through collaboration across the kidney care continuum has proven to provide patients with coordinated care, reducing costs and improving patient care and outcomes.


Key Points:

  • Integrated kidney care should address CKD patients as individuals with important clinical needs.
  • Critical goals for integrated kidney care are to avoid or delay dialysis, improve end-of-life care, and increase nondialytic care, transplantation, and home dialysis.

What is Integrated Kidney Care?


Integrated care is also known as coordinated care, comprehensive care, integrated health, or seamless care. It is a concept introduced into healthcare that significantly focuses on providing a more coordinated and integrated form of patient care to combat rising costs and poor outcomes for those with CKD and ESRD.

This concept comprises two principal characteristics. First, it must bring together crucial aspects in the delivery and design of healthcare systems that are fragmented. For example, many patients only receive a referral from primary care to a nephrologist late in their progression of CKD, and the rate of patients starting dialysis within a year of seeing a nephrologist is very low. Second, the concept must deliver care to the patients. Patients need a pathway to get the care they need, when they need it.

Ultimately, integrated care is an approach designed to overcome fragmented care by improving the general population’s health, continuously improving the patient’s care experience, and reducing healthcare costs per capita.

How Does Integrated Kidney Care Work?


Integrated kidney care collaborates with providers to coordinate patient care across all aspects of their care journey to improve patient outcomes and reduce healthcare costs.

Currently, the proposed care models are designed to incentivize coordinated care for CKD and ESRD patients, promote renal transplantation, and remove disparity and obstacles to patient choice in dialysis options. These integrated kidney care models also encourage CKD patient education, the promotion of medical management, advanced care planning, and patient quality of life.

These care approaches reduce costs, improve ESRD outcomes, and coordinate CKD care. However, none of these integrated care approaches currently contain measures to delay the start of kidney replacement therapy or slow the progression of CKD.

The future of integrated kidney care models sees the nephrologist maintaining or assuming a leadership role with both input and oversight into the design and implementation of any integrated nephrology care models. For the long-term success of an integrated kidney care model, the nephrologist must have a leadership role. Their clinical expertise ensures that the model design reduces costs and improves overall patient care.

Implementing Integrated Kidney Care Approaches


While integrated care is complex, containing many different frameworks, research recommends that the goal of an integrated kidney care platform should include the following:

  • Respond to patient preferences
  • Improve care
  • Decrease cost
  • Limit initial enrolment to contain unintended consequences and,
  • Allow all dialysis care providers, regardless of size, to participate independently.

Suggested strategies for developing an integrated kidney care program:

  • Understanding the burden of kidney disease and kidney failure at local and national levels.
  • Standardization for integrated kidney care.
  • Implementation of integrated kidney care.
  • Sustainability and quality improvement.
  • Outcome measures.

The Benefits of Integrated Kidney Care 

The benefits of integrated kidney care include lower rates of unplanned dialysis starts, reduced avoidable hospitalizations, all patients receiving education about CKD and ESRD, coordinated care delays, or avoiding renal replacement therapy. This platform or care model approach also optimizes patients’ chances of receiving kidney transplants.

Integrated kidney care models also provide physicians, patients, providers, and payers with relevant resources and tools, such as accessible patient education, actionable data, and personalized care, improving outcomes for CKD and ESRD patients.

The future of integrated kidney care

To address the huge gap between the number of CKD patients globally requiring adequate care versus those patients who actually receive sustainable, safe, and equitable care for CKD and ESRD, the International Society of Nephrology has coordinated the development of a Strategic Plan for the Integrated Care of Patients with Kidney Failure. For this plan to be implemented, the whole nephrology community will need to participate over the next 5-10 years.

Panoramic Health Integrated Kidney Care


Panoramic Health is one of the nation’s largest integrated kidney care platforms, with over 800+ providers. This care model option offers a significant improvement compared to the previous ‘fee-for-service’ model.

Our integrated value-based care model is led by physicians and uses the largest, real-time CKD databases with episodic and longitudinal data from over 630,000 patients, enabling superior analytics and risk stratification. This robust database powers our data-driven care interventions for CKD and ESRD patients, ensuring they get the proper care at the right time.

Critical aspects of Panoramic Health’s integrated kidney care platform:

  • Holistic care management. The frequency of services and services offered are tailored to the individual patient’s risk profile and disease stage. These services include nutrition, pharmacy, PCP coordination, and Social Determinants of Health (SDOH).
  • Patient education, engagement, and access. Both patients and providers have a seamless experience due to smooth operational integration. Patient engagement is increased with enhanced patient interaction in the clinic, at home, and virtually.
  • Data platform and predictive analytics. The platform utilizes automated reporting to enrich payers’ understanding of the attributed population, as well as being the largest real-time CKD database.
  • Provider decision and engagement support tools. Panoramic Health proudly has 14 years of experience driving improved patient outcomes. Operationally integrated practices can expect frictionless and seamless experiences and unmatched workflow automation.

The impact of Panoramic Health’s integrated kidney care platform:

  • $872 average pmpm savings
  • 56% reduction in hospital readmissions
  • 65% patient engagement
  • 54% improvement in planned dialysis starts
  • 30% of at-home dialysis starts
  • 77% optimal dialysis rates (compared to the national average of 54%)
  • 30% decrease in hospitalizations
  • 35% pre-emptive transplant rate (compared to the national average of 17%)


Panoramic Health’s integrated kidney care platform improves the outcomes of CKD and ESRD patients while reducing both patient and provider costs.