Pathways Project Pragmatic Lessons Learned: Integrating Supportive Care Best Practices into Real-World Kidney Care

Abstract

Key Points A multisite quality improvement project using the Institute for Healthcare Improvement learning collaborative structure helped kidney care teams identify seriously ill patients and implement supportive care best practices.Helpful approaches included needs assessment, Quality Assurance and Performance Improvement tools, peer exchange, clinician role modeling, data feedback, and technical assistance.Dialysis center teams tailored implementation of best practices into routine dialysis workflows with nephrologist prerogative to delegate goals of care conversations to nurse practitioners and social workers. Background Despite two decades of national and international guidelines urging greater availability of kidney supportive care (KSC), uptake in the United States has been slow. We conducted a multisite quality improvement project with ten US dialysis centers to foster implementation of three KSC best practices. This article shares pragmatic lessons learned by the project organizers. Methods The project team engaged in reflection to distill key lessons about what did or did not work in implementing KSC. Results The seven key lessons are (1) systematically assess KSC needs; (2) prioritize both the initial practices to be implemented and the patients who have the most urgent needs; (3) use a multifaceted approach to bolster communication skills, including in-person role modeling and mentoring; (4) empower nurse practitioners and social workers to conduct advance care planning through teamwork and warm handoffs; (5) provide tailored technical assistance to help sites improve documentation and electronic health record processes for storing advance care planning information; (6) coach dialysis centers in how to use required Quality Assurance and Performance Improvement processes to improve KSC; and (7) implement systematic approaches to support patients who choose active medical management without dialysis. Conclusions Treatment of patients with kidney disease is provided in a complex system, especially when considered across the continuum, from CKD to kidney failure on dialysis, and at the end of life. Even among enthusiastic early adopters of KSC, 18 months was insufficient time to implement the three prioritized KSC best practices. Concentrating on a few key practices helped teams focus and see progress in targeted areas. However, effect for patients was attenuated because federal policy and financial incentives are not aligned with KSC best practices and goals. Clinical Trial registry name and registration number Pathways Project: KSC, NCT04125537.