Analysis of Multidisciplinary Care Models and Interface With Primary Care in Management of Chronic Kidney Disease
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.
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Care is accessible, patient-centered, holistic, interdisciplinary, and cost effective;
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Care is proactive and planned, and may be provided by telephone, group education, or individual visits (in-person or telehealth);
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Care facilitates and supports the principles of patient self-management;
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Services include assessment, management, and secondary prevention;
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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.
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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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Cited by (33)
The Role of Primary Health Care Professionals
2017, Chronic Kidney Disease in Disadvantaged PopulationsThe need for collaboration to improve cardiovascular outcomes in patients with CKD
2014, Advances in Chronic Kidney DiseaseMultidisciplinary strategies in the management of early chronic kidney disease
2013, Archives of Medical ResearchCitation Excerpt :In the case of progression of CKD, the multidisciplinary intervention will also help to provide a timely preparation for renal replacement therapy (dialysis or transplantation) (30). Complexity of the factors involved in the management of CKD makes necessary the multidisciplinary approach to optimize renal care (14–17,30–35). Several models with comprehensive approaches have been proposed (14–16,30,36,37).
Internet-Based Tools to Assess Diet and Provide Feedback in Chronic Kidney Disease Stage IV: A Pilot Study
2013, Journal of Renal NutritionCitation Excerpt :As we refine this tool, we will have the opportunity to incorporate updates to K/DOQI35,36 as well as CKD nutritional guidelines from a broader range of care provider organizations.37-39 In addition, the expansion of patient education opportunities offered by the Medicare Improvement for Patients and Providers Act, the growing evidence of benefit from multidisciplinary care teams,40-42 and the potential for expanded financial support for care coordination in the Affordable Care Act highlight the need for tools to efficiently assess and disseminate patient's knowledge and adherence to nutritional guidelines to a broad array of providers. Although a lack of educational resources for CKD patients plays a role in poor dietary adherence, several studies have shown that nutritional food knowledge alone is unrelated to dietary adherence.23,43-47
Quality of patient-physician discussions about CKD in primary care: A cross-sectional study
2011, American Journal of Kidney Diseases