Fifth Free Tool in Kidney Toolkit Helps Fight Kidney Disease

March 22, 2023 · Andy Reynolds

Adding the Population Health Roadmap for Chronic Kidney Disease to our Kidney Health Toolkit means there’s a fifth free resource from NCQA to help manage chronic kidney disease (CKD) or end-stage renal disease (ESRD).

The Roadmap stands out because:

• It reflects real-world success. Based on extensive interviews with a variety of organizations, the Roadmap highlights established strategies for improving kidney care for CKD.
• It crosswalks to other NCQA programs. Diagrams in the Roadmap highlight how requirements in other NCQA programs—Patient-Centered Medical Home Recognition, Patient-Centered Specialty Practice Recognition and Population Health Accreditation—relate to improving care for CKD.

The bottom line: Organizations that want to get better at caring for patients with CKD will appreciate this updated comprehensive toolkit and learn which NCQA evaluation services can help them improve.

Four Roadmap Landmarks

The Roadmap is organized around four “landmarks”—key steps on the path to better CKD care.

1. Identify patients with CKD. As many as 90% of the estimated 37 million American adults with CKD don’t know they have it. Slowing or preventing disease progression is possible if the disease is treated early.
2. Center care on patients. People who receive a CKD diagnosis need patient-centered care, including targeted education to help them understand their condition and participate in their care.
3. Coordinate care across teams and settings. CKD patients often have more than one chronic condition and are seen by multiple providers. Risk stratification can help determine which patients need a specific intervention. This helps care teams collaborate to ensure patients’ needs are met.
4. Measure outcomes. Continuous improvement is the larger goal of quality measurement. Kidney damage is permanent, and CKD can be a significant detriment to quality of life.

Sources and Inspiration

We developed the Roadmap in partnership with Bayer Healthcare Pharmaceuticals, Inc.

The Roadmap highlights recommendations from seven diverse organizations that generously gave time to our interviewers:

• Accordant Health Services.
• DaVita Integrated Kidney Care.
• Fresenius Health Partners—InterWell Health.
• Healthmap Solutions.
• Renalogic.
• Luke’s University Health Network.
• Somatus, Inc.

“In-the-Field Example” sections comprise roughly one-third of the Roadmap’s 28 pages. These detail specific strategies and advice from each participating organization.

Initial Toolkit Resources

The original Roadmap contained these resources:

• PROVIDER GUIDE: “Let’s Talk About Diabetes and Kidney Health: Ready – Set – Test”
  • Informs clinicians about new developments in kidney care and the importance of assessing the kidney health of patients with diabetes.
  • Aligns with the Kidney Health Evaluation for Patients With Diabetes (KED) HEDIS measure .
• INFOGRAPHIC FOR PATIENTS: “Are Your Kidneys at Risk?”
  • Raises patient awareness of CKD risk factors like diabetes and hypertension.
  • Highlights recommended tests.
• PAMPHLET FOR PATIENTS: “You’ve Been Diagnosed with CKD. Now What?”
  • Sparks questions and facilitates conversations between patients and clinicians.
  • Gives patients practical advice to review once they leave their doctor’s office.
• POSTER FOR PATIENTS & PROVIDERS: “Chronic Kidney Disease: Talk, Listen, and Learn”
  • Highlights barriers to—and effective solutions for—talking about CKD.
  • Directs readers to additional information and resources.

As part of our drive to improve health equity, most toolkit resources are available in Spanish.

Have you used the toolkit? Let us know how it’s going! We welcome your feedback.

Other NCQA Kidney Health Projects

The Kidney Health Toolkit builds on other NCQA quality improvement efforts related to kidney health; for example, these HEDIS measures:

• Kidney Health Evaluation for Patients With Diabetes assesses adherence to clinical guidelines for CKD testing among adults with diabetes.
• Medication Management in Older Adults checks for patients with CKD who are prescribed Cox-2 selective non-steroidal anti-inflammatory drugs (NSAID) or non-aspirin NSAIDs, which are not recommended.

To help primary care teams identify, treat and monitor CKD in vulnerable populations, we partnered with the CMS Office of Minority Health to raise awareness of kidney disease and its risk factors, and published Chronic Kidney Disease Disparities: Educational Guide for Primary Care.

We also joined forces with the CMS Innovation Center to support development and implementation of the Comprehensive ESRD Care Model, which offers payment incentives to accountable care organizations—networks of providers including dialysis facilities, nephrologists and other specialists working together to coordinate patient care—that deliver more efficient, higher-quality care.