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The Role of Care Coordination in Managing Kidney Disease

Aug 10, 2023

Chronic kidney disease (CKD) is a significant health problem that affects more than 37 million adults in the United States. The growing burden of CKD continues to increase its associated financial costs and contribute to total mortality

Fragmented healthcare systems fail to adequately identify at-risk populations timely, resulting in many CKD patients only being diagnosed in the later stages of disease progression. Due to the progressive nature of CKD, advanced-stage patients’ needs are more complex and expensive.

Key Points

  • Patient care in chronic diseases such as CKD and ESRD is often fragmented, with opportunities available to reduce costs and improve population health.
  • Care coordination is crucial for CKD and ESRD patients that have two or more chronic medical conditions.
  • Care coordination for CKD patients has been shown to effectively reduce costs and improve outcomes.

The Principles of Care Coordination 

Care coordination is broadly defined as the synchronization of delivery of a patient’s health care from multiple specialists and providers. Care coordination aims to improve outcomes by ensuring that care from different providers is not delivered in silos.

Coordinated care is implemented across the continuum of care, from primary and acute care to long-term care. The people involved in a patient’s care include physicians, pharmacists, family caregivers, the patient, social workers, nurses, and other support and medical professionals.

As the complexity of a patient’s care needs increases, so does the number of people involved in the care team. Thus the increased importance of seamless communication between patients, providers, and specialists.

Why Care Coordination? 

Care coordination has been implemented to address the obstacles identified in the U.S. healthcare system. Care coordination is essential because current healthcare systems are often fragmented, and there are no standard processes between specialty and primary care sites. In addition, patients are often uneducated or unclear about why they have been referred to a specialist from primary care.

Coordinated care has been identified as a key strategy in the American Healthcare system that can improve efficiency, effectiveness, and safety. Care coordination also identifies the full range of medical, social, emotional, and functional problems that chronically ill patients experience.

Principles of care coordination may include:

  • Creating a proactive treatment plan
  • Good communication/sharing knowledge
  • Helping with the transitions of care
  • Responding to changes in patients’ needs through monitoring and follow-ups
  • Aligning resources with population and patient needs
  • Defining accountability and agreeing on responsibility
  • Clear and straightforward information that the patient can understand

When designed and implemented effectively, care coordination ensures that patients receive the proper care at the right time, which can improve outcomes for patients, providers, and payers and reduce costs.

Coordinated Kidney Care 

CKD and ESRD patients’ needs are highly complex, as they receive care from multiple providers and organizations. Any fragmentation in the healthcare system leaves providers misinformed and misaligned on each other’s treatment plans or history.

The reason CKD and ESRD patients require care from multiple professionals across different clinical settings is two-fold.

  1. The characteristics of CKD are complex and involve primary care, nephrology care, dialysis, transplantation, and palliative care. Transitions of care in this continuum are often fragmented.
  2. The presence of two or more chronic diseases in CKD patients occurs frequently.

Inadequate consideration of the management of coexisting conditions and the transitions along the continuum of CKD care can contribute to poor clinical outcomes, high healthcare costs, and a high treatment burden for patients and their families.

How Does Coordinated Kidney Care Help in the Management of CKD? 

Coordinated kidney care addresses this fragmentation by delivering the appropriate healthcare services in the right setting at the right time. Care coordination for CKD patients has been shown to slow disease progression, reduce and lower morbidity and mortality.

A care coordination model for managing kidney disease may include the following principles:

  • Support the smooth integration of renal care across the care continuum
  • Deliver evidence-based care coordination interventions
  • Ensure that all care team members are accountable for outcomes
  • Increase the primary care practice presence of care team members
  • Design and implement a framework for structure coordination between care team members and providers
  • Deliver care that is patient-centric and cost-effective

The Impact of Coordinated Kidney Care

A well-structured care coordination model/plan can provide a committed, focused care management approach that treats CKD patients as individuals with current clinical needs and safeguards patient choice. Thus coordinated kidney care streamlines patient care, improves patient outcomes, and reduces healthcare costs for providers and patients.

Post Kidney Transplant Care Coordination Plan 

For patients with ESRD, the first choice of treatment still remains a kidney transplant, as it provides a better quality of life and lower mortality rates compared to dialysis. However, often opportunities for early and pre-emptive transplantation are missed. Implementing an effective care coordination plan can reduce missed at-home dialysis and transplant opportunities.

In recent years, short-term kidney allograft survival has significantly improved due to the improvement of the introduction and maintenance of immunosuppression and viral and immunological screenings.

The outcomes of long-term kidney allografts remain stable due to different reasons. As the leading causes of mortality for kidney transplant patients are infectious diseases, heart diseases, and cancer, there is an increased need for careful follow-up and identification and treatment of complications in a timely manner.

Ideal post-kidney transplant care should include close collaboration between the transplant center and the nephrologist, ensuring improved allograft outcomes are increased independently of the caregiver.

Post-kidney transplant management for patients is complex. Recommendations for the management of medical conditions in kidney transplant recipients may include:

  • Kidney function. CKD-related complications are prevalent in transplants and are often overlooked. A management plan for kidney function monitoring, urinary protein excretion, blood pressure control, anemia, acidosis, calcium, phosphorus and lipid abnormalities, and hypoalbuminemia should be implemented.
  • Therapeutic drug monitoring. Immunosuppression systematic plans and protocols should constantly evolve due to monitoring schedules and goals, past and current patient side effects, and any prior immunosuppression changes.
  • Heart disease. Cardiovascular disease management is essential in kidney transplant recipients as it is the leading cause of graft loss and mortality. Because of this, the Kidney Disease Outcomes Quality Initiative (KDOQI) has provided clinical practice guidelines for transplant recipients in the highest-risk category.
  • Infectious disease. Due to the atypical symptoms and signs of infection in kidney transplant recipients, transplant centers have implemented routine surveillance strategies. Screening protocols and infectious disease issues should be specific to the patient and should be communicated clearly between the care team members.
  • Cancer. Kidney transplant recipients need to be screened for organ cancer in a suitable manner, adhering to the guidelines of the American Cancer Society.

Good collaboration and communication between primary providers and transplant centers can ensure that post-kidney transplant patients are diagnosed and treated early for comorbidities.

Panoramic Health 

Panoramic Health is a physician-led value-based care platform uniquely positioned to understand the complex needs of patients and providers. We are successfully able to sustain value-based kidney care through our innovative solutions.

As part of the value-based care platform, we have created a comprehensive care model that includes:

  • Data platform and predictive analysis
  • Patient education, access, and engagement
  • Holistic care management
  • Provider decision and engagement support tools