Kidney Coordinated Health Management Partnership (Kidney-CHAMP)
Chronic Kidney Diseases
About this trial
This is an interventional treatment trial for Chronic Kidney Diseases focused on measuring electronic health record, population health management, patient education, medication therapy management, electronic consultation, randomized controlled trial, pragmatic trial
Eligibility Criteria
Inclusion criteria for PCPs: presence of an ambulatory continuity clinic in the University of Pittsburgh Medical Center (UPMC) community medicine practice.
Inclusion criteria for patients:
- age greater than or equal to 18, and less than or equal to 85
- most recent eGFR less than 60 ml/min/yr
- established care with UPMC PCP
- high risk CKD based on validated external and internal risk prediction models or severe reduction in eGFR, or substantial loss in eGFR in prior 18 months.
Exclusion Criteria for PCPs: none
Exclusion Criteria for patients:
- history of kidney transplant
- receiving maintenance dialysis
- recent (within 12 months) outpatient nephrology visit
- baseline eGFR less than 15ml/min
- expected survival less than 6 months or hospice enrollee (e.g., stage IV heart failure, metastatic cancer, oxygen dependent Chronic Obstructive Pulmonary Disease)
- active substance dependence or severe/uncontrolled psychiatric condition
Sites / Locations
- UPMC Presbyterian
Arms of the Study
Arm 1
Arm 2
Active Comparator
Experimental
Usual care
Intervention Arm
Patients in the usual care arm will continue to receive CKD care guided by their PCPs as per usual care practices (i.e., specialty consultation, pharmacotherapy, nurse education, etc. may be ordered by the PCP according to their usual practice).
Patients will receive a care bundle