A practical approach to integrated care for chronic kidney disease

Between 10 and 20 per cent of north west London’s population is affected by chronic kidney disease (CKD). Even mild CKD increases a person’s risk of heart attack and stroke, but most patients can have their condition managed effectively in the community with the right support. CKD education nurse Lynn Dahri and clinical lecturer Dr James Tomlinson explain how a new model of integrated care builds a bridge between hospital specialists at Imperial College Healthcare NHS Trust and community practitioners to improve the management of this condition as well as our patients’ experience.

In its early stages, CKD rarely shows symptoms – most people don't even feel it. In advanced kidney disease, many patients experience non-specific symptoms and tend to put it down to getting older or generally feeling tired or unwell. Fortunately, the disease’s progression is often a long, gradual process and most people will never require specific treatment for kidney failure. However, even with mild loss of kidney function, the risk of heart attack and stroke increases, which together represent some of the leading causes of death worldwide.

When it comes to CKD, there can be a disconnect between the services provided by hospitals and those provided by local GPs and other primary care professionals. This presents a vexing problem for our local community. That's why it is so important to identify the disease early and for hospital clinicians, GPs and patients to work together to manage and stabilise it.

For many years, Imperial College Healthcare NHS Trust nephrology consultant Dr Andrew Frankel has been helping to develop a local network of primary and secondary care professionals to support people with stable CKD. It’s been quite difficult to set up any kind of infrastructure to support this until more recently, when national health policy is moving much more towards genuinely integrated care.

As part of a wider multidisciplinary team led by Dr Frankel, we have now developed a programme called the Shared Care CKD Pathway. This has been designed with GPs and patients and is based upon National Institute of Health and Care Excellence (NICE) guidelines on CKD management. A growing number of practices and primary care leads across north west London are embracing this, and working together to create an infrastructure to better manage CKD across the region.

When a patient is referred to our CKD service, we set up an appointment to assess their condition. Some require on-going care within our hospitals but most people with stable CKD can have their condition better managed in the community. In those cases, patients leave our clinic armed with a pack of information about living with and managing CKD, lifestyle recommendations and notes on medications.

We send additional information to the patient’s GP and provide the GP with access to our consultant-led CKD e-advice service. Each week, this service is monitored by a named consultant nephrologist. GPs can email that service at any time with questions about referrals and potential drug interactions. A named consultant will reply within 36 hours, Monday through Friday. We are currently receiving 10 to 15 emails per month with about half of these queries preventing unnecessary referrals.

Education is a key theme that underpins the Shared Care CKD Pathway. Led by our experienced CKD education nurse Lynn Dahri, we provide a number of regular teaching and education sessions for GPs, allied healthcare professionals and patients in the community. These have been well received and are under continual review and development. We are currently designing an education package for patients and their relatives.

Working more closely with GPs has helped us gain a better understanding of the challenges facing our community, which has helped us find more effective ways of working. It has also empowered GPs to take on a greater role in managing this condition.

Above all, this delivers a better experience for patients. Building an infrastructure to manage this condition in the community means that patients can get to appointments more easily and on their own schedule, rather than having to wait for slots at hospital clinics. Many people already have wonderful relationships with their local GP and would much prefer to be supported closer to home. In the hospital setting, this programme has already reduced waiting times in clinics, giving people with severe kidney disease faster access to consultant-level care.

Looking ahead, we are exploring creating patient focus groups to help us better understand our patients’ needs. We’re also working to better integrate our IT systems with GP systems to improve our ability to track a patient’s condition over time, so we can try to anticipate when patients will need more support or interventions. In addition, we’re working with nurses who support people with multiple conditions, including diabetes, so we can help manage their overall health more effectively. Finally, we’re looking to additional professionals including community pharmacists, who can help us improve every aspect of a patient’s care.

Even at this early stage in the programme, we’ve found that a series of small changes can, cumulatively, make a very big difference. Through integrated working with patients and colleagues in primary and secondary care, we can all manage this disease and its complications more effectively and create an overall healthier community.