Background: Patients with end-stage renal disease (ESRD) receive care from several different doctors at multiple locations. They often have other chronic diseases that require complex care and are at a higher risk for emergency room visits and hospitalizations. The patient-centered medical home (PCMH) model has been proposed as a solution to patients with complex needs such as those with ESRD. We will compare a PCMH model with usual care on ESRD patients and their caregivers.
Purpose: 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.
Method: 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, an advanced practice nurse, 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.
Outcomes: 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 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.