Dialysis Clinic, Inc., has been providing care coordination to patients with chronic kidney disease (CKD) since 2010. This program was started in Spartanburg, South Carolina, and has since grown to care for more than 4000 patients in more than 15 locations in 12 states. In one location we have enrolled more than 400 patients under a program in a partnership with a local health plan. For all other programs, we provide this service free of charge to patients as a community benefit.
Four years ago we officially named our program REACH Kidney Care. REACH stands for Real Engagement Allowing Complete Health. As a nonprofit provider, we believe that when possible we should fully inform people with kidney diseases about their choices in care, and work with them to determine the course that best meets their culture, values, and life goals. More information about the REACH program is provided at http://www.reachkidneycare.org/. Below is a summary of our program.
Patient population
We serve patients with GFR below 30 mL/min per 1.73 m2 and patients with GFR 30 to 59 mL/min per 1.73 m2, with albuminuria detectable on dipstick, exceeding 300 mg/g creatinine.
Primary goal
Our primary goal is to treat a patient with late-stage CKD, focusing care on meeting that patient’s current clinical needs instead of treating the patient as someone who may need dialysis.
Secondary goals
For patients whose kidney disease has progressed to the point where GFR is below 20 mL/min per 1.73 m2, we provide education on choices of care for renal replacement therapy (RRT), including transplantation, home dialysis, in-center dialysis with a permanent access, and medical management without dialysis. For a patient choosing a modality for RRT, we help the patient navigate the healthcare system to implement this choice.
We recognize that not all patients desiring transplantation will receive a transplant before they start dialysis. If a patient chooses transplantation, we also work with the patient to choose a dialysis modality to prepare the patient in case the patient does not receive a preemptive transplant. For a patient choosing medical management without dialysis, we follow and support the patient closely through this journey, let the patient and his or her family know that we will not abandon them, and add additional services as needed and requested, including palliative and hospice care.
Tertiary goal
For a patient who has chosen a modality for RRT, we follow the patient closely, in partnership with the patient’s nephrologist, to allow a safe start of dialysis later in the progression of the patient’s CKD. Nationwide, 11.7% of patients start with a GFR at or above 15 mL/min per 1.73 m2. In Spartanburg, only 3% of patients since January 1, 2014, have started with a GFR above 15 mL/min per 1.73 m2, and 71% start with a GFR 5 to 10 mL/min per 1.73 m2.
Frequency of visits
The frequency of visits depends on the clinical needs of the patient. At a minimum, the nurse care coordinator sees the patient at the same frequency as the patient’s nephrologist, with these visits alternated so that the patient is seen twice as often. In some instances, the patient is seen by the nurse care coordinator on a weekly basis. The nurse care coordinator sends a progress note for each visit to the patient’s nephrologist and other physicians.
Staff
➤ Nurse care coordinator: role described above.
➤ Dietitian: helps the patient learn what she/he can eat, instead of providing a list of foods to be avoided. Specific attention is paid to include foods important to the patient’s culture of origin.
➤ Social worker: educates the patient on available resources; provides supportive counseling.
Very advanced CKD
For patients with very advanced CKD who plan eventual dialysis, and who otherwise would have been referred to start dialysis but do not have a clinical need to start, we provide a framework of support and services for the patient to allow a safe transition to dialysis later in the progression of CKD, delaying the burden of thrice-weekly dialysis. A patient could visit the care coordinator once a week to allow for close evaluation. We provide consistent support, close follow-up, and clear communication with the nephrology team. The level of care of a patient with late-stage CKD should be comparable with the care given to patients receiving dialysis, without the requirement for dialysis or thrice-weekly clinic visits.
