Active

Chronic Kidney Disease Pharmacist Model in Primary Care

to improve chronic kidney disease care an innovative partnership model between nephrology, primary care, and clinical pharmacy

County-wide initiative in Sonoma County to preserve access to specialty care for Medicaid members. Working collaboratively across health plans, Federally Qualified Health Centers (FQHCs), and hospitals to ensure the use of e-consult first, with referral to in-person specialty only if determined by e-consult. Pilot works collaboratively with plans, FQHCs, and hospitals to leverage the best practicesof health centers and networks that have already developed promising practices. This initiative explores the ability of health center coalitions or networks to act collectively to change health system outcomes at a regional level.

Background

Patients with chronic kidney disease (CKD) suffer from some of the poorest clinical outcomes and highest healthcare costs in the
US. For three decades, limited treatment options for slowing kidney disease progression, low adherence rates to standards of care, and a national shortage of nephrologists (kidney medicine specialists) have led to high rates of CKD-related cardiovascular co-morbidities, disproportionate healthcare costs, and a high per capita prevalence of end-stage kidney disease (ESKD) – second

internationally only to Taiwan. Several new therapies for treating patients with CKD have emerged over the last decade, but uptake of these therapies in the indicated patient population is dismally low, ranging between 10-20%. This implementation problem is made worse by a national shortage of kidney disease specialists, known as nephrologists. Access to nephrology care is most limited in rural communities among safety-net patient populations.

To tackle these issues of guideline-concordant care implementation and limited specialist access, a team of multidisciplinary providers at Stanford Medicine took a population health approach to early-stage CKD care. Led by a nephrologist and primary care physician, the team has leveraged the top-of-license expertise of clinical pharmacists to extend CKD expertise to a larger population of patients within the primary care empaneled patient population who may not normally receive care from a nephrologist. The clinical pharmacy team utilizes evidence-based clinical workflows to ensure that enrolled patients are on all indicated kidney-preserving medications. A collaborative practice agreement with nephrology enables access to nephrology expertise without the need for a formal nephrology visit, greatly expanding patients’ access to nephrology specialty care.

Patients are identified through a triage algorithm consisting of common lab values and diagnostic codes, with the sickest patients being scheduled with the clinical pharmacy team first. The clinical pharmacist meets with each patient and works through an evidence-based treatment protocol to identify opportunities to optimize medication management to improve CKD care delivery. Working under a collaborative practice agreement (CPA) with nephrology and primary care, clinical pharmacists prescribe, titrate, and discontinue disease-slowing medications as well as order the labs required to monitor the medications’ effects. Over the two years the program has been supporting patients, documented outcomes include:

Higher rates of guideline-concordant care among the intervention group,
Clinically meaningful reductions in albuminuria (the specialty surrogate for CVD risk)
Fewer inpatient admissions for the intervention group
Higher rates of patient engagement
Primary care physicians have felt more supported in caring for these complex patients (increased provider satisfaction)

The upstream CKD care provided by this PharmD-led team not only slows patients’ progression towards ESKD but also focuses
patients on improving control of their concurrent diabetes, hypertension, and reducing cardiometabolic risk.

Proposal

We propose a collaboration between Stanford Medicine (CERC Impact Accelerator Lab) and Northern California Federally Qualified
Health Centers to design a similar model of care focused on improving CKD care delivery for the safety net population. The
partnership offers an innovative opportunity to scale early learnings: (1) leverage an underutilized and financially sustainable
resource in our clinical pharmacists, (2) support primary care providers treating patients with CKD, (3) improve access to
nephrology specialty care, and (4) improve clinical outcomes for patients with kidney disease This proposal aims to bring
standardized, evidence-based practice to patients in their own communities

Patients identified via CKD registry (triage process, PCP’s can opt out) → patient care coordinator outreaches and schedules
patients with PharmD for CKD-focused visit → PharmD sees patients and prescribes/adjusts etc. according to clinical algorithm under CPA with primary care, determines follow up → PharmD communicates with primary care team about medication changes/follow up → weekly meetings between PharmD and nephrologist to review cases, clinical decision making, and questions.

Phase I (months 1-6): Stakeholder collaboration to develop workflows, build appropriate clinical teams, engage primary care providers, and establish a contractual arrangement for nephrology work effort.

Phase II (months 7-12): Enroll 50 patients in the pilot program to demonstrate proof of concept, evaluate patient and provider
satisfaction, establish sustainable billing practices, and develop longitudinal scaling plans.

Phase III: (months 13-24): Scale to 300 patients; evaluation of clinical, utilization, and experience metrics; finalize scale plan.

The CKD population is highly comorbid and disproportionately costly. With limited access to nephrology care in the safety net
population, new approaches to upstream CKD care are required to improve care delivery, reduce healthcare costs, and achieve
more equitable health outcomes. A partnership between nephrology and primary care to build a telemedicine-based
multidisciplinary team, maximizing team members’ clinical licensure and leveraging an underutilized clinical pharmacy resource,
offers an innovative opportunity primed for further implementation and evaluation.

This pilot represents a potential template for other chronic diseases where evidence-based practice is widely underutilized.
Stanford Medicine is interested in pursuing similar pilots for Congestive Heart Failure or other relevant diseases.