Bringing Care to Patients: A Patient-Centered Medical Home for Kidney Disease

Abstract

Patients with end-stage renal disease receive care from several different doctors at multiple locations. They often have other chronic diseases that require complex care and are at a higher risk for emergency room visits and hospitalizations. The patient-centered medical home model has been proposed as a solution to patients with complex needs such as those with ESRD. In this study, we will compare a patient-centered medical home model with the usual model of care for patients with end-stage renal disease and their caregivers.

For this new model of care, we will enhance the usual care team for these patients by providing a primary care doctor in the context of regularly scheduled dialysis sessions and by adding health promoters to help support patients and their caregivers. Patient and family stakeholders and care team members will assist in the design and refinement of this care model.

We will implement this model at the University of Illinois Hospital and Health Sciences System (UIHS) dialysis center and a local Fresenius Medical Care dialysis center. Patients receiving dialysis at participating centers will receive an initial comprehensive care visit followed by ongoing care from a multispecialty provider team during the patients’ regularly scheduled dialysis visits. Each patient’s care team will include a kidney doctor, a primary care doctor, an advanced practice nurse, a dialysis nurse, a dietician, a pharmacist, a social worker, and a health promoter. The primary care doctor will be available in the dialysis clinic to provide general and preventive care to the patient before or after dialysis sessions. This doctor would also coordinate care with other specialists/clinicians on the patient’s care team. The trained, bilingual (English/Spanish) health promoter will assist with making and rescheduling appointments, obtaining transportation, and reinforcing education components.

We expect that this approach will increase patient access to care for other conditions and will increase care coordination and communication among members of the patient’s care team. These improvements could potentially increase the likelihood of preventing complications or identifying problems earlier and allow for a more successful treatment. We expect that this will reduce emergency room visits and hospitalizations for dialysis patients. In addition, we anticipate that the addition of health promoters to the clinical team will help support and educate patients and their caregivers and, as a result, patient quality of life will improve and caregiver burden may be reduced.

Affiliated Center/Program

Principal investigator
Start date
11/01/2013
End date
07/31/2016
Total award
$2,096,521

Related publications


Cukor D, Cohen LM, Cope EL, Ghahramani N, Hedayati SS, Hynes DM, et al. Patient and Other Stakeholder Engagement in Patient-Centered Outcomes Research Institute Funded Studies of Patients with Kidney Diseases. Clin J Am Soc Nephrol. 2016 Sep 7;11(9):1703-12. [Access the full-text article.]