The suboptimal outcomes experienced by patients with chronic kidney disease (CKD) are a direct result of flaws in the design of the health care delivery model. This is evidenced by lack of pre-existing nephrology care, high rates of dialysis initiation using a central venous catheter, increased morbidity and mortality, and low rates of preemptive transplantation (1). Improvement on the associated outcomes can be facilitated by the creation and deployment of supportive interdisciplinary care delivery models.
Under the Advancing American Kidney Health initiative, ambitious targets have been identified to improve on the care delivery model for patients with kidney diseases, including the aim to increase the use of home dialysis therapies and transplantation. Little progress can be made on these initiatives without the identification of gaps in the existing care delivery model. This requires foundational knowledge of the disease trajectory, direct experience with the population, stakeholder management, organizational awareness, and expertise in population and community health initiatives. The direct patient access, advanced education and training, knowledge of evidence-based practice, and expanded clinical skills (2) of nurse practitioners (NPs) make these professionals ideal candidates to lead the co-creation of care delivery models.
Launched in 2012, Northwell Health's Healthy Transitions program is evidence that the integrated use of NPs and nephrologists has positively affected health care delivery. Under this model, NP-driven care delivery design coupled with nephrologist collaboration, partnership, and medical direction results in positive patient outcomes. In affiliation with a medical director and under the clinical supervision and daily operational direction of an NP, the Healthy Transitions program was created to deliver evidence-based treatment interventions that improve coordination of care and education to decrease cost and proactively prepare for treatment therapies (3).
In 2017, a formalized, randomized controlled study of the program (4) provided evidence for the value of coordinated care management. This study randomized 130 patients with late-stage kidney diseases (stages 4 and 5) to an intervention and control group for a period of 18 months. Patients assigned to the intervention group received education, monitoring, and follow-up care with an assigned nurse care manager. Study results revealed a significant reduction in hospitalization when the intervention group was compared with the control group.
Hospitalizations were measured per patient per year with 0.61 per year in the intervention group and 0.92 per year in the control group (incident rate ratio, 0.66%; 95% CI, 0.43–0.99; p = 0.04); 37% of patients initiated peritoneal dialysis, and 58% of program participants-initiated dialysis therapies without hospitalization. In addition, at the start of hemodialysis therapy, a catheter was present in 37% of the intervention group compared with 69% of the control group; 53% of those in the intervention group initiated dialysis with a functioning arteriovenous access compared with 27% in the control group.
Insight into the patient journey affords teams the opportunity to develop patient-centered care solutions and engage in design thinking (5) (Figure 1). This is particularly true in CKD care. In nephrology, experienced nephrology NPs offer a distinct, competitive advantage because they understand the health care delivery system from a patient and provider perspective as well as possess working knowledge of the internal and external patient journey. In addition, they are afforded the opportunity and time to educate and monitor patients throughout the trajectory of their disease. In nephrology settings, NPs are often called on to deliver care in one primary setting (i.e., dialysis, transplant, or clinic). When compared with the competing demands placed on the nephrologist to deliver care in multiple settings, NPs are more accessible and may have more bandwidth to provide personalized educational sessions and follow-up. This allows for additional insight into psychosocial factors and social determinants of health. Understanding patient-, organizational-, and nephrologist-related obstacles (Figure 2) in the context of patient care delivery allows for consideration of fundamental questions (6) (Figure 3) to enable the collaborative creation and adoption of policies, procedures, and protocols that drive positive patient outcomes.
Design thinking in the creation of kidney-related care delivery models
Citation: Kidney News 14, 9
Design thinking in the creation of kidney-related care delivery models
Citation: Kidney News 14, 9
Design thinking in the creation of kidney-related care delivery models
Citation: Kidney News 14, 9
Obstacles in nephrology care delivery
Citation: Kidney News 14, 9
Obstacles in nephrology care delivery
Citation: Kidney News 14, 9
Obstacles in nephrology care delivery
Citation: Kidney News 14, 9
Fundamental questions for health care delivery design
Citation: Kidney News 14, 9
Fundamental questions for health care delivery design
Citation: Kidney News 14, 9
Fundamental questions for health care delivery design
Citation: Kidney News 14, 9
NPs can integrate science into practice to design programs that improve clinical outcomes.
The process of health care delivery redesign is facilitated when there is comprehensive understanding of the disease trajectory and the lived experience of the patient. With foundational training in leadership, communication, and holistic care; knowledge of disease management; and advanced clinical assessment skill, NPs can integrate science into practice to design programs that improve clinical outcomes. Their experience as clinical team leaders and patient advocates is essential to the co-creation, development, and sustainability of health care delivery design. As the nephrology landscape continues to evolve, it is likely that there will be a rising demand for NPs to serve as collaborators and leaders in health care delivery design.
References
- 1.↑
United States Renal Data System (USRDS). 2021 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. 2021. https://adr.usrds.org/2021/introduction
- 2.↑
Heinen M, et al. An integrative review of leadership competencies and attributes in advanced nursing practice. J Adv Nurs 2019; 75: 2378–2392. doi: 10.1111/jan.14092
- 3.↑
Halinski C, et al. Improving outcomes in late-stage kidney disease: The Healthy Transitions program. Nephrol News Issues, September 18, 2014; 28: 18–20; 22–25. PMID: 25306845. https://www.healio.com/news/nephrology/20180226/improving-outcomes-in-latestage-kidney-disease-the
- 4.↑
Fishbane S, et al. Augmented nurse care management in CKD stages 4 to 5: A randomized trial. Am J Kidney Dis 2017; 70: 498–505. doi: 10.1053/j.ajkd.2017.02.366
- 5.↑
Roberts JP, et al. A design thinking framework for healthcare management and innovation. Healthc (Amst) 2016; 4: 11–14. doi: 10.1016/j.hjdsi.2015
- 6.↑
Agency for Healthcare Research and Quality (AHRQ). Designing and implementing Medicaid disease and care management programs. Created March 2008; last reviewed October 2014. https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm1.html
