Medical Neighborhood Model for the Care of Chronic Kidney Disease Patients

Abstract

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.

Multidisciplinary proactive e-consults to improve guideline-directed medical therapies for patients with diabetes and chronic kidney disease: an implementation study

“…An alternative population health strategy that has been described is to proactively identify patients with T2D and CKD who would benefit Epidemiology/Health services research from an MPE while maintaining PCP autonomy would give PCPs an option to order the e-consult. 44 However, this approach requires an additional step which may limit feasibility and acceptability. To improve multidisciplinary collaboration, an adjunct strategy is for the specialists to pend orders for the medications and/or laboratory tests for the PCPs to review and sign if appropriate.…”

A System-Wide Population Health Value Approach to Reduce Hospitalization Among Chronic Kidney Disease Patients: an Observational Study

“…Previous population health approaches in primary and specialty care have demonstrated only modest, if any, reductions in inpatient utilization and expenses for patient populations requiring multispecialty care. 27 , 47 – 55 Limitations of previous programs include (1) leadership residing within siloed specialties that limit system-wide implementation, (2) patients not completing specialty clinic visits, 18 , 26 , 27 , 56 (3) local data constraints that limit responsiveness to patient needs, 21 , 50 , 55 – 60 (4) unclear identification of patients most likely to benefit from interventions, 61 (5) nebulous primary and specialty care clinical alignment, 18 , 26 , 53 , 62 – 65 and (6) narrowly resourced ambulatory care services. 66 …”

“… 18 , 26 Without a coordinated, team-based multispecialty approach, care teams risk delivering inconsistent, duplicative, and expensive care. 27 – 31 , 68 While previous care management programs have relied on PC-CCs, 33 , 69 , 70 leaders found that patients benefited from care coordination that could also span specialty and community practices. The PHV intervention, therefore, allowed system-wide care coordinators to proactively identify patients with clinical decline or need to prevent hospitalizations.…”

Screening for chronic kidney disease in a hypertensive primary care cohort

“…They found an increase in metabolic panel ordering and a slowed progression of CKD in patients with stage 3a CKD. Electronic nephrology consults have been found to increase comanagement of primary care patients with CKD and decrease the burden of traditional nephrology care visits (Mark et al, 2011; Smith et al, 2016). The other human resource needs identified by providers in the current study have also been addressed by other organizations.…”