Elsevier

Seminars in Nephrology

Volume 29, Issue 5, September 2009, Pages 467-474
Seminars in Nephrology

Analysis of Multidisciplinary Care Models and Interface With Primary Care in Management of Chronic Kidney Disease

https://doi.org/10.1016/j.semnephrol.2009.06.003Get rights and content

Summary

Public policy efforts and education have led to an increased appreciation of the prevalence of chronic kidney disease (CKD) in general outpatient populations. The complexity of the care of individuals with established CKD has led to the development of multidisciplinary care models, which have been shown to improve the clinical outcomes of those with CKD. The interface between specialty and primary care in various systems remains necessary and desired, albeit a continuing challenge. This overview reviews various models of specialty care for CKD patients, including those that emphasize multidisciplinary team approaches, and highlight the essential role(s) of primary care physicians. Importantly, there is a need for improved definition of CKD populations and individuals, review and refinement of proposed care pathways, and the need to define essential elements of care for the patient. Models of care often are not subject to the same rigor that other interventions applied to this population are; nonetheless, we offer here a framework for establishing and evaluating care models for the CKD populations at various stages of disease and with various comorbidities.

Section snippets

Models of Care in CKD

Central to the development of any model of care is defining the focus of that model. The focus of the model of care in CKD must be the patient with kidney disease and all of the complexity that entails. Although apparently obvious when so stated, many of the current paradigms have compromised patient focus for system functioning. Too often, the model of care addresses health care system or physician needs. The goal of this overview is to re-establish the appropriate framework in which to

Principles of Integrated Care

The following is a list of the principles of integrated care.

  • Care is accessible, patient-centered, holistic, interdisciplinary, and cost effective;

  • Care is proactive and planned, and may be provided by telephone, group education, or individual visits (in-person or telehealth);

  • Care facilitates and supports the principles of patient self-management;

  • Services include assessment, management, and secondary prevention;

  • Services may be consultative (ie, family physician maintains responsibility with

Staffing Requirements

At a minimum, we recommend that a clinical care coordinator (usually a registered nurse) specializing in the disease cluster must be assigned to the patients, and that access to an interdisciplinary team that specializes in the disease cluster is available. The team may include one or more of a dietitian, pharmacist, social worker, psychologist, physiotherapist, occupational therapist, exercise specialist, and clerk.

Service Delivery Components and Tools

The following aids in the implementation and follow-up evaluation of patients.

Patient Needs in CKD

The identification of patient needs and the modification of protocols based on patient stability or change in clinical condition is important in the development of models of care for chronic conditions. Rigid models or protocols that categorize patients by level of kidney function, without considering level of education, socioeconomic status, progression of CKD, or other comorbidities, are less likely to be effective. In particular, the adult learning principles of education, which include

PCPs as Part of the MDC Team

To date, most publications have not regularly, or overtly, identified the PCP as part of the MDC team for CKD care. However, this is an increasing recognition of the need to do so. There is no question that the PCP remains the key provider of much of the care early on in the course of CKD, however, the unique components of shared care for CKD have not been well examined. There are currently many initiatives worldwide focused on redefining the way patients with chronic conditions are managed.

Defining Care Plans for Patients With Complex Disease

The development of overt care plans retains the focus on the patient again. An appropriate care plan would acknowledge changes in patient status, both in the context of a transient or permanent change in status. This will ensure that the appropriate team members are involved at the appropriate time for specific patients. Furthermore, given the increasing complexity of CKD patients, and the health care system that they must navigate, overt care plans help the patient and their family understand

Summary

Optimal care of patients requires a scientific understanding of the disease, identification of patients at risk and with early disease, evidence-based treatment strategies, and a supportive health care environment.41 A supportive health care environment is one that includes a system framework and resources, as well as education and ongoing research. The care of patients with CKD remains challenging for primary care physicians, specialists, nephrologists, and health care systems and for people

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