Rationale and design of a patient-centered medical home intervention for patients with end-stage renal disease on hemodialysis

Abstract

In the U.S., more than 400,000 individuals with end-stage renal disease (ESRD) require hemodialysis (HD) for renal replacement therapy. ESRD patients experience a high burden of morbidity, mortality, resource utilization, and poor quality of life (QOL). Under current care models ESRD patients receive fragmented care from multiple providers at multiple locations. The Patient-Centered Medical Home (PCMH) is a team approach, providing coordinated care across the healthcare continuum. While this model has shown some early benefits for complex chronic diseases such as diabetes, it has not been applied to HD patients. This study is a non-randomized quasi-experimental intervention trial implementing a Patient-Centered Medical Home for Kidney Disease (PCMH-KD). The PCMH-KD extends the existing dialysis care team (comprised of a nephrologist, dialysis nurse, dialysis technician, social worker, and dietitian) by adding a general internist, pharmacist, nurse coordinator, and a community health worker, all of whom will see the patients together, and separately, as needed. The primary goal is to implement a comprehensive, multidisciplinary care team to improve care coordination, quality of life, and healthcare use for HD patients. Approximately 240 patients will be recruited from two sites; a non-profit university-affiliated dialysis center and an independent for-profit dialysis center. Outcomes include: i) patient-reported outcomes, including QOL and satisfaction; ii) clinical outcomes, including blood pressure and diet; iii) healthcare use, including emergency room visits and hospitalizations; and iv) staff perceptions. Given the significant burden that patients with ESRD on HD experience, enhanced care coordination provides an opportunity to reduce this burden and improve QOL.

Integrating a Medical Home in an Outpatient Dialysis Setting: Effects on Health-Related Quality of Life

“…The study has been described previously 26 . Briefly, we used a before-after design to evaluate a PCMH-KD model of care at two dialysis centers with rolling enrollment.…”

“…Briefly, demographics, medical history, social characteristics, and HRQOL were part of the initial intake 26 . Interviews were conducted by trained interviewers at baseline, 6, 12, and 18 months.…”

“…Described previously [26][27][28][29][30] , our study is the first systematic design, implementation, and evaluation of an adaptation of a PCMH model for chronic hemodialysis patients. We sought to integrate PCMH with the current dialysis-mandated team by adding a general internist serving as the primary care physician (PCP), nurse coordinator, pharmacist, and community health worker (CHW).…”

Learning culture in nephrology / Cultura de aprendizagem em nefrologia / La cultura del aprendizaje en nefrología

“…Considerado problema de saúde pública de impacto mundial, a doença obriga o doente a uma forma de tratamento dolorosa e de longa duração. Uma das formas de tratamento, a hemodiálise consiste no método de depuração extracorpóreo pelo qual o sangue obtido por acesso vascular é filtrado (2) . Sua duração e frequência são estabelecidas, em geral, com base na necessidade de depuração de cada paciente, mas comumente duram em média quatro horas.…”

Increasing the Relevance of Clinical Research for Patients With Kidney Disease

“…In recent years, patient engagement has been a growing area of interest in nephrology, in both clinical and research settings, and the existing literature supports its benefits at various steps in the research process, from identifying and setting research priorities 7-10 to research implementation and policy making. 11 A fundamental premise of the SONG-HD, which was also highlighted during the workshop, is the need for patients' involvement in establishing health care delivery practices and policy, 12 as well as in developing and conducting research. 13 For example, in a recent expert consensus meeting, representatives of renal registries across Europe described optimal practices for the collection of patient-reported outcomes or experiences measurements in routine clinical practice.…”