Kidney care is a team sport
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When patients receive a diagnosis of chronic kidney disease from their primary care physician, they are typically sent to a nephrologist for further care.
A care plan is then designed that is unique to each patient’s needs, based on the stage of CKD. Dialysis is arranged if it is determined to be the best therapy.
As nephrologists, we will often see patients once a week — at a minimum, once a month. In all likelihood, no other physician will see this patient more frequently than we do. We become the primary caregiver by default.
Teamwork
For patients with CKD, slowing or halting progression cannot be achieved without the help of a variety of teams that support them in a clinical setting, as well as outside the walls of the hospital or practice.
These teams range from physicians to nurses to patient health advocates and even members of the patient’s community — and all have an important role if optimal results are to be achieved.
Primary care physicians have always been referred to as the “quarterback of the care team,” and this must remain true in kidney care. As the quarterback, the primary care physician ensures the patient’s care plan and prescriptions are coordinated and that necessary preventive care, such as cancer screenings, immunizations and annual check-ups, do not fall by the wayside.
The interdisciplinary care team — the nurses, dietitians and social workers — also provide invaluable support, and when lab tests and symptoms indicate a patient is heading toward dialysis, these valuable care partners or team members become crucial.
Ideally, a nephrologist will initiate a discussion with the patient on starting dialysis at least 6 months before it is needed, but preferably at least a year ahead of the anticipated need for dialysis. This gives the patient time to prepare and have an access placed before beginning home dialysis.
Making the transition to dialysis in a planned, preemptive way is critically important, and an interdisciplinary care team can help both nephrologists and primary care physicians be more proactive by offering their services and support to patients as soon as their kidney disease is identified.
Community support
If a nephrologist has an arrangement with a value-based care company, patients will find their care team extends well beyond a nurse, dietitian and social worker. It includes the critical role of the patient health advocate, sometimes called a community health worker. The patient health advocate can connect patients with local organizations and resources that can help address any unmet socioeconomic or inequity issues or barriers tied to a lack of financial means or resources.
As pillars in their community, patient health advocates ensure barriers are addressed in an effective and compassionate way. Often, they connect patients with rideshare drivers, food banks, libraries, nonprofits, volunteer organizations, churches, home care aides and many other resources. Something as simple as securing a ride to dialysis for patients who do not have a reliable mode of transportation can drastically reduce the likelihood that they will miss their appointment.
Nephrologists are an important part in helping patients achieve their goals, as are the many additional clinical and nonclinical workers who have key roles. With so many key players, coordination and communication are essential. With primary care physicians as quarterbacks and interdisciplinary care teams and community support teams in critical connective roles, patients are given a fighting chance to take back control of their kidney health and change the course of their disease.
- For more information:
- Shree Mulay, MD, is a co-founder of The Kidney Experts, a nephrology practice based in Jackson, Tennessee. He can be reached at info@kidneyexperts.com.
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