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In pursuing the goals of value-based care, providers and healthcare organizations are making an effort to move away from one-size-fits-all treatment regimens and toward individualized, whole-patient care plans. This is especially important in managing critical conditions like chronic kidney disease (CKD) and end-stage renal disease (ESRD).
For insight into the details of developing personalized treatment plans for CKD and ESRD patients, we turned to Kristy Wilson, RN, a highly experienced Quality Practice Advisor at Healthmap Solutions. Healthmap’s Quality Practice Advisors support collaborative patient car through regular interactions with providers and clinical teams to review patient risks, identify, present, and close care gaps, plan care transitions, and eliminate unnecessary treatments. Through these discussions, the Healthmap team is able to develop holistic, personalized care plans for patients and work with their providers to implement this patient-level care plan.
Why is it important for kidney disease patients to have personalized treatment plans?
KRISTY: Many people living with kidney disease have multiple morbidities, and not everyone has the same health history and the same diagnoses. Each condition needs to be treated individually, while considering how other conditions may be affected. You can’t use a one-size-fits-all approach.
That’s why it’s important for providers to get to know their patients and understand what matters to them. Culture often has a huge impact on a patient’s health outcome. Providers must learn about the patient’s beliefs, customs, and values and consider how these may impact their treatment plan.
They may eat different foods or have a different outlook on medical care compared to other people and cultures. By knowing this, a provider will be better able to educate the patient about their different treatment options.
Overall, a personalized approach to care will help patients feel more in control and empower them to take an active role in their health management, which makes a big difference in outcomes.
What assessment tools should be used to evaluate patients and make sure their treatment plan works for them?
KRISTY: It’s important to utilize knowledge assessment tools to gauge a patient's understanding of their condition and treatment plan. At Healthmap, we conduct these kinds of knowledge assessments with eligible members, particularly to see how well they understand their renal replacement options. If a patient doesn’t understand their treatment plan, they’re less likely to be able to adhere to it. These assessments help us promote better adherence and fill in knowledge gaps with additional patient education. During this process, Healthmap is a trusted source for providers and members, always working to reduce the workload for the physicians and supporting the patients to complete the assessments.
In addition to conducting the knowledge assessments, providers should also be constantly assessing lab values for patients to see how well their existing treatment plans are working. Healthmap can help with this, too; for example, if our data shows that a patient’s CKD is progressing, we can work with their providers to recommend interventions and treatment adjustments that can slow that progression.
When the Healthmap team identifies an adherence issue, we communicate directly with the patient and their providers to address it. If the patient isn’t grasping why their treatments are important, our nurses can educate them about why the medications or treatments are necessary and what they do. If the patient has a barrier to care, such as a lack of transportation or financial struggles, we can connect them with a social worker or community resource that ca help overcome these barriers.
How should providers discuss treatment options with patients, including renal replacement therapy options?
KRISTY: Ideally, any discussion of renal replacement therapy options should start while the patient is still in Stage 4 or 5, well before progressing to ESRD. Many times, patients who are not prepared will crash into dialysis at the emergency room, which can be scary and may give them a negative overall outlook on treatment. At that point, it’s very difficult to educate them on the benefits of home dialysis as they, in most cases, have been forced to initiate in-center dialysis.
The best way to present this is to have an open and honest discussion to make sure the patient understands their diagnosis and is ready to be educated about their renal replacement therapy options, to make a decision. Not every treatment option will work well for every patient, so again, a personalized approach that considers the patient's individual goals is critical. Healthmap’s Care Navigation team addresses this by providing resources and education to our CKD Stage 4 and 5 program members and using a shared decision-making model to help them work with their physicians to determine the best option. Once they make a decision, we also help them get connected to the appropriate specialists and clinics, so they’ll be ready to start their treatments if and when they progress to ESRD.
How engaged should patients be in the decision-making process regarding their treatment? What can they do to get the information they need to make informed choices?
KRISTY: Patients must take an active role in their care and decision-making process. They need to make sure they understand their conditions and treatment options and know what would work best for them, based on their lifestyle and goals. Healthmap’s team is here to advocate for patients and support them throughout this process, but ultimately, we want to empower patients to feel like they are in control of their own healthcare journey.
Engagement should start soon after their diagnosis. Patients need to understand the diagnosis and what the numbers mean like their estimated glomerular filtration rate, for example, so that when they see a change, it will prompt them to ask questions.
I recommend that patients get to know their healthcare providers and ask lots of questions. Healthmap’s Care Navigators can support patients with this by talking through their concerns and helping them figure out what conversations they need to have with their providers. On the provider side, the Healthmap team then works directly with the patient’s providers to make sure they are aware of the patient’s questions or concerns ahead of time.
Outside of their appointments, patients should also be trying to educate themselves on their condition. In Healthmap’s program, they can reach out to a Care Navigator for helpful educational materials and resources. There is also a lot of great content available from the National Kidney Foundation and other online resources for patients looking to learn more about their kidney health.
What should a patient do if they are struggling to adhere to their treatment plan?
KRISTY: Patients need to discuss their concerns with their providers so that they can work on an action plan together. If the patient is in Healthmap’s Kidney Population Health Management program and is struggling with their treatment, of course we recommend that they reach out to their dedicated Care Navigator for support. Our clinical team bridges the gap between patients and their various providers and helps to facilitate these conversations and reach a resolution.
How should treatment challenges be addressed?
KRISTY: It’s important to have guided discussions that get to the root of any struggles or barriers to care. For example, if a patient isn’t attending their scheduled dialysis appointments or getting their prescriptions filled, ask them to tell you more about the situation. Use open-ended questions, such as, “Can you tell me more about that? What’s preventing you from getting your medicines?”
How does Healthmap Solutions support providers in delivering personalized, whole-patient care?
KRISTY: We partner with providers to ensure that their patients don’t have gaps in care. We take a holistic approach to make sure that all comorbidities are being managed effectively and that a patient’s treatment plan will work with their values and lifestyle. We also provide education to patients to help them understand their condition and make decisions about their treatments. Not only does this help patients feel more in control, but it also helps to ensure that they are getting the most out of their care plan, which can improve their outcomes and overall health.
Summary
Personalizing renal care treatment plans is essential for achieving better outcomes for CKD and ESRD patients. By tailoring treatments to individual needs, understanding each patient’s values and lifestyle, and engaging them in their care, providers and Healthmap can enhance patient engagement and realize significantly improved clinical outcomes.
Through our Kidney Population Health Management program, Healthmap Solutions supports personalized care by working closely with providers to develop coordinated, patient-specific treatment plans and engaging with patients to provide the education and assistant they need to take an active role in their treatment.
Kristy Wilson, RN
A registered nurse for over 20 years, Kristy previously worked in intensive care and the emergency department. In the 10 years prior to joining Healthmap, she worked with a heart failure specialist and managed in-center and in-home therapies. She is passionate about working with providers and facilities to improve quality of care and enable patients to lead longer, healthier lives.