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Kidney Week

Abstract: TH-PO544

Primary Care-Nephrology Multidisciplinary Partnership Improves CKD Care

Session Information

Category: Chronic Kidney Disease (Non-Dialysis)

  • 307 CKD: Health Services, Disparities, Prevention


  • Haberman, Paula, Family Practice, Park City, Utah, United States
  • Edgel, Denney, Intermountain Medical Center, Murray, Utah, United States
  • Hamilton, Sharon, Intermountain Medical Center, Murray, Utah, United States
  • Gopinath, Arasu, Nephrology Associates, Salt Lake City, Utah, United States
  • Morales, Ray, Intermountain Healthcare, Murray, Utah, United States
  • Greenwood, Mark R, Intermountain Medical Center, Murray, Utah, United States
  • Srinivas, Titte, Intermountain Medical Center, Murray, Utah, United States

Resources for CKD care are often clustered around late stage CKD with poor medical care in early stages leading to increased costs of care. Patients with realy stage stage CKD may overburden alaredy stretched nephrology resources and are cared for by primary care providers (PCPs) who may not be fully empowered to render appropriate CKD Care. Structured partnerships between PCPs, health systems, payers and nephrologist could be used to improve early stage CKD care. We report on a process improvement and care delivery redesign in a large integrated health system serving 5 states in the Intermountain West that demonstrates initial success of a PCP centered multidisciplinary approach to CKD care.


As a first step, we aimed to increase the numbers of urine albumin creatinine ratios (ACR) obtained on patients in CKD stage 3a/ 3b from 15% to 25% over a year. Engagement of frontline staff in primary care practices was identified as a key driver to ensure success. EMR advisories werefollowed by academic detailing through care process modules to Drive change. Key Process Drivers and Change Implementation methods are shown in Figure 1, a, b.


A robust and sustained increase in rates of ordering albumin creatinine ratios is shown in Figure 1, c. Marked improvement in adherence to ACR ordering followed academic detailing.


A multidisciplinary primary care-nephrology-health system partnership in care redesign can produce robust sustained improvements in Early Stage CKD evaluation. This approach will be extended to CKD treatment

Figure 1 Process Drivers, Leverage Points, Results; a) Key Drivers, b) Leverage for change c) Change in Behaviour