Closing Gaps and Improving Outcomes

Chronic kidney disease (CKD) does not affect all communities equally. In the United States, historically underserved populations, including Black, Hispanic/Latino, and Native American groups, are disproportionately affected by CKD. The same populations often face greater challenges in accessing treatment. According to the Centers for Medicare and Medicaid Services:

“Low-income and racial and ethnic minority patients are less likely to receive recommended care related to CKD risk factors and are less likely to reduce CKD risk through recommended treatment goals (blood pressure, diabetes, cholesterol control). Racial and ethnic minorities are also more likely to progress from CKD to end-stage renal disease (ESRD), also known as end-stage kidney disease (ESKD), and are less likely to have been under the care of a nephrologist before starting dialysis. These disparities are related to patient, clinician, clinical, and system factors.”

It is imperative for health plans and providers to understand and address the disparities among CKD patients in order to deliver quality, equitable care to all. By taking steps to advance health equity in kidney care, healthcare organizations can make a positive difference in their patients’ outcomes.

Where Disparities Arise

Diagnosis and staging

Because minority populations are at elevated risk for CKD, early detection is especially critical. Yet structural issues, such as the historic use of race-based eGFR calculations, have delayed recognition and nephrology referral for Black patients. This compounds the risk by postponing interventions that could slow disease progression.

Access to specialty care and home therapies

Communities with the highest rates of CKD are often the least likely to access timely nephrology care, home dialysis education, or specialty resources. This means patients who stand to benefit most from flexible and effective care options encounter the most obstacles in receiving them.

Kidney transplant eligibility and waitlisting

Minority patients experience higher rates of ESRD, but they are less likely to be referred for kidney transplant evaluation, placed on the waiting list, or ultimately receive a transplant. Even when patients meet medical criteria, systemic barriers such as financial burdens or lack of transportation often limit access to treatment. 

Actionable Solutions

There are many steps that healthcare providers and organizations can take to promote health equity and improve care for diverse populations.

Comprehensive care coordination: Connecting patients to the right care at the right time

Patients in underserved communities may experience fragmented care, such as delayed specialty referrals and missed follow-ups after hospital discharges. Improving care coordination across all providers on a patient’s care team (including primary care, specialists, dialysis providers, and other clinicians) can bridge these gaps and prevent adverse outcomes. 

Community outreach: Bringing education directly to patients

Community-based, culturally tailored education programs (in churches, barbershops, or community centers, for example) can help close knowledge gaps in high-risk communities. Meeting people where they are can make screening, education, and self-management more accessible.

Race-free diagnostics: Ensuring timely recognition for all

Adopting the CKD-EPI 2021 race-free equation, with cystatin-C confirmation testing when clinically indicated, helps ensure that minority patients at higher risk are not overlooked or delayed in diagnosis.

Primary care integration: Screening where patients already seek care

Embedding kidney risk calculators and urine albumin-creatinine ratio testing into primary care workflows brings early detection of kidney disease to those who might otherwise face barriers in accessing specialty services.

Home therapies and kidney transplant pathways: Expanding choices where options are limited

Providing education and resources in a patient’s preferred language and health literacy level, logistical support for evaluations (including home dialysis and transplant navigators) can reduce inequities in access to renal replacement therapy, particularly for patients who historically face systemic delays.

Health literacy and language access: Closing gaps in understanding

Tailoring educational materials to health literacy levels, bilingual educators, and teach-back methods ensure that patients from diverse backgrounds can fully engage with their care. Ensuring that patients have a comprehensive understanding of their treatment plans is essential for equitable kidney disease management.

Equity in metrics: Making progress visible

Stratifying quality metrics (such as screening rates, home dialysis utilization, and transplant referrals) by race, language, and neighborhood deprivation highlights inequities and keeps organizations accountable for improvement.

Bias awareness: Addressing hidden barriers to care

Regular team training on implicit bias and social drivers of health ensures that providers are better equipped to remove unseen barriers that prevent higher-risk populations from receiving equitable care.

How We Work for Equitable Kidney Care

Healthmap Solutions’ Kidney Population Health Management program supports health plans and providers with addressing health inequities related to kidney disease care. We do this through:

Risk stratification with an equity lens

Healthmap ingests various forms of data to create a population-level view of who is at high risk for an adverse medical event while taking into account any identified social drivers of health and barriers to care. Healthmap then presents intervention opportunities to providers and connect patients with community-based resources to help them overcome obstacles and get the care they need.  

Culturally tailored, multilingual engagement

Our Care Navigation team delivers education that is appropriate for patients based on their preferred language, culture, and health literacy level, helping patients understand their conditions, medications, nutrition, and more.

Renal replacement therapy readiness support

To combat inequities in renal replacement therapy, Healthmap ensures that all patients are aware of home dialysis and transplant options as clinically appropriate. Healthmap’s Care Navigation team works with providers to ensure members find treatment and screening centers and overcome barriers like transportation or time off work.

Quality improvement and reporting

We provide detailed quality reporting to health plans and providers to monitor patient progress and close gaps in care.

Conclusion

Achieving health equity in CKD is not an abstract ideal. It is a set of practical steps:

• Promoting standardization of race-free diagnostics
• Expanding localized, culturally tailored outreach
• Supporting home therapies and transplant navigation
• Making equity measurable 

Organizations that move on these levers can improve outcomes and reduce their total cost of care, while giving every patient the tools they need to improve or maintain their health and quality of life. With Healthmap Solutions as a partner, the tools, technology, processes, and people are already in place.