At a glance
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Kidney Coordinated Health Management Partnership
In Brief
A clinical study evaluating EHR-based PHM and Usual Care for Chronic Kidney Diseases. Completed, enrolled 1,596 participants across 1 site.
Detailed Summary
As part of a 42-month pragmatic, cluster randomized trial in 1,650 primary care patients with high-risk Chronic Kidney Disease (CKD), the investigators will test the effectiveness of a multifaceted Electronic Health Record (EHR)-based Population Health Management (PHM) intervention that targets improvements in the delivery of evidence-based CKD care.
Study Details
Timeline
Interventions
An EHR in-basket message will be sent to the patient's PCP which identifies the patient's high-risk CKD status and indicates that the patient will receive: 1. Nephrologist led electronic consultation: review of the patient's EHR with recommendations sent to the PCP every \~6 months, 2. Medication therapy management: PharmD led telephonic medication therapy management with the patient every \~6 months, 3. and Nurse led CKD patient education, every \~6-12 months unless the PCP opts the patient out of the interventions (by responding to the EHR in-basket message and providing an opt-out reason or requesting an office consultation with nephrology).
Patients in the usual care arm will continue to receive CKD care guided by their PCPs as per usual care practices (i.e., specialty consultation, pharmacotherapy, nurse education, etc. may be ordered by the PCP according to their usual practice).