Background: The patient-centered medical home is a popular model of care, but the patient-centered medical neighborhood (PCMN) is rarely described. We developed a PCMN in an academic practice to improve care for patients with chronic kidney disease (CKD). The purpose of this study is to identify the prevalence of CKD in this practice and describe baseline characteristics, develop an interdisciplinary team-based approach to care and determine cost associated with CKD patients. Methods: Patients with CKD stage 3a with comorbidities through stage 5 were identified. Data collected include demographics, comorbidities and whether patients had a nephrologist. Using a screening tool based on the 2012 Kidney Disease Improving Global Outcomes guidelines, a nurse care manager (NCM) made recommendations about management including indications for referral. A pharmacist reviewed patients' charts and made medication-related recommendations. Blue Cross Blue Shield (BCBS) insurance provided cost data for a subset of patients. Results: A total of 1,255 patients were identified. Half did not have a formal diagnosis of CKD and three-quarters had never seen a nephrologist. Based on the results of the screening tool, the NCM recommended nephrology E-consult or full consult for 85 patients. The subset of BCBS patients had a mean healthcare cost of $1,528.69 per member per month. Conclusions: We implemented a PCMN that allowed for easy identification of a high-risk, high-cost population of CKD patients and optimized their care to reflect guideline-based standards.

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