Bringing Care to Patients: Patient-Centered Medical Home for Kidney Disease

Patients with end-stage renal disease (ESRD), have unique and complex care needs associated
with renal disease and common comorbidities (e.g., diabetes, hypertension), and under the
current care model, receive fragmented care from multiple providers at multiple locations.
ESRD patients typically spend three to five hours undergoing dialysis three days a week.
Scheduling and traveling to other appointments are difficult to manage, increase patient and
caregiver burden, and reduce patients' quality of life. These challenges keep many ESRD
patients from receiving care for other conditions outside of the dialysis setting, resulting
in higher rates of complications, and emergent healthcare use.

The patient-centered medical home (PCMH) model has been proposed as a solution to patients
with complex needs such as those with ESRD. The purpose of this project is to compare a PCMH
model of care with the usual care of ESRD patients and their caregivers. We propose to
enhance the usual care team for ESRD patients by providing a primary care doctor in the
context of regularly scheduled dialysis sessions and by adding health promoters to help
support patients and their caregivers. Patient and family stakeholders and care team members
will assist in the design and refinement of the PCMH model.

We plan to implement this model at the University of Illinois Hospital and Health Sciences
System (UIHS) dialysis center and a local Fresenius Medical Care dialysis center. Patients
receiving dialysis at participating centers will receive an initial comprehensive care visit
followed by ongoing care from a multispecialty provider team during the patients' regularly
scheduled dialysis visits. Each patient's care team will include a kidney doctor, a primary
care doctor, a nurse coordinator, a dialysis nurse, a dietician, a pharmacist, a social
worker, and a health promoter. The primary care doctor will be available in the dialysis
clinic to provide general and preventive care to the patient before or after dialysis
sessions. This doctor would also coordinate care with other specialists/clinicians on the
patient's care team. The trained, bilingual (English/Spanish) health promoter will assist
with making and rescheduling appointments, obtaining transportation, and reinforcing
education components.

We expect that this approach will increase patient access to care for other conditions and
will increase care coordination and communication among members of the patient's care team.
These improvements could potentially increase the likelihood of preventing complications or
identifying problems earlier and allow for a more successful treatment. We expect that this
enhanced care team will reduce emergency room visits and hospitalizations for dialysis
patients. In addition, we anticipate that the addition of health promoters to the clinical
team will help support and educate patients and their caregivers and as a result, patient
quality of life will improve and caregiver burden may be reduced.

Inclusion Criteria:

- Current patient receiving hemodialysis at two participating dialysis centers who are
able to provide informed consent

Exclusion Criteria:

- Not a patient at one of the two participating dialysis centers or not able to provide
informed consent