Comprehensive Kidney Disease Management: Multidisciplinary Approaches and the Transition to Dialysis and Transplant

Chronic kidney disease (CKD) causes multisystem complications. This complexity, which includes both mental and physical manifestations, makes it challenging for one practitioner to take care of all of a patient's needs, especially given increasing constraints on time and stagnant reimbursement. One answer to this challenge is a multidisciplinary care (MDC) approach. MDC clinics are increasingly being implemented by health systems, payers, and nephrology practices participating in value-based payment models, such as the Centers for Medicare & Medicaid Services’ Kidney Care Choices Model.

Several programs that incorporate MDC approaches to CKD have been implemented and report positive outcomes. One such program, the Healthy Transitions Program in Late Stage Kidney Disease at Northwell Health in New York, used nurses who partner with nephrologists and an informatics system for tracking. They reported fewer hospitalizations, increased peritoneal dialysis and pre-emptive transplantation, and improved optimal starts (1). Another MDC program is the Program for Education in Advanced Kidney Disease (PEAK) at the Rogosin Institute in New York City, which includes nurse practitioners, a nurse educator, a dietitian, a social worker, a psychologist, and peer mentors to assist the primary nephrologist in caring for patients with CKD stages 4 and 5. Initial PEAK appointments are made with a nurse practitioner and a social worker, and appointments with the other disciplines are scheduled on an individualized basis (Figure). When compared with national averages, both Healthy Transitions and PEAK consistently outperform in several patient outcomes (Table) (2). Given the importance of optimal dialysis starts, pre-emptive transplantation, and preventing hospitalizations, an MDC approach seems to be our best chance to improve the well-being and lives of a vulnerable patient population.

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PEAK program process

Citation: Kidney News 16, 9

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Table

Clinical outcomes in two New York-based MDC clinics for CKD

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One question that has repeatedly come up is how to best compose an MDC team. A previous systematic review examined the staffing compositions of MDC clinics for CKD care. Among 38 MDC clinics reviewed, the average team size was 4.6 members, and 97.4% incorporated nephrologists, 86.8% nurses, 84.2% dietitians, 57.9% social workers, and 42.1% pharmacists (3). In some cases, different MDC teams have distinct staffing models but yield similar positive results. Part of the reason for this may be the complexity of the care rendered and/or the subtle, even unknown, contributions that are difficult to measure. For example, a nurse who checks in with a patient in between visits and before important appointments and a social worker who arranges transportation and delivery from a pharmacy are critical to care for patients with multimorbidity.

Although the optimal MDC model is unclear, it is also likely to vary for different patient populations and health care settings. Future studies could leverage pragmatic trial designs within large health care systems to understand which MDC staffing models may have the greatest improvement in clinical outcomes and which are cost-effective. MDC clinics have traditionally focused on patients with CKD stages 4 and 5, but modeling studies suggest that MDC may be cost-effective even in earlier stages of CKD (4). MDC clinics that engage with patients through multiple health care professionals may ultimately encourage patient engagement and lead to optimal outcomes and well-being.