Expanding the Use of an End-of-Life Care Planning Program for Patients with Kidney Disease

This PCORI-funded implementation project is expanding the use of an advance care planning program to support end-of-life care discussions for patients with kidney disease at dialysis clinics across the United States.

Stakeholders Involved in This Project

• DaVita
• Fresenius Kidney Care
• American Renal Associates
• ESRD Network 15
• National Forum of ESRD Networks
• National Kidney Foundation (NKF)
• Coalition for Supportive Care of Kidney Patients
• American Association of Kidney Patients
• American Society of Nephrology
• Renal Physicians Association
• NKF Council of Nephrology Social Workers
• American Nephrology Nurses Association
• Social Work Hospice and Palliative Care Network

Implementation Strategies

• Use a clinical decision support tool
• Adapt the program to work for all patients with kidney disease, to be delivered remotely for patients on home dialysis, and to work across different platforms, including iPads, tablets.
• Adapt the program to work for sites’ existing resources and workflows.
• Adapt electronic health record systems to make program materials more accessible and usable.
• Adapt in-person training by transferring existing content to an online format and adding guidance to support use of the program in a telehealth environment.
• Provide sites with tools to support implementation, including checklists and documentation templates.
• Integrate the online training and protocols into organization-wide policies, procedures, and training programs.
• Create and support implementation teams at sites, including a social worker, nephrologist, and nurse.
• Develop and use online training, including modules specific to different types of providers.
• Train dialysis unit staff, including nephrologists, nurse practitioners, nurses, physician assistants, dieticians, and patient care technicians, to introduce and support end-of-life care planning discussions with patients and coordinate care with social workers, through written materials and videos.
• Train clinic social workers to lead end-of-life care discussions and hospice care coordination, in coordination with the patient’s other care team members through written materials and videos.
• Use a phased implementation approach, launching the program in three waves.
• Identify and prepare nephrologist champions at sites.
• Provide technical assistance for sites, including monthly small-group consultation and one-on-one coaching for social workers.
• Partner with national stakeholder organizations to promote implementation.
• Offer continuing education credits for social workers.

Evaluation Outcomes

To document implementation:

• Number of patients who have an ACP discussion
• Number of clinic staff who receive training
• Program fidelity (end-of-life care process checklist)
• Intent to sustain the use of the intervention

To assess healthcare and health outcomes:

• End-of-life planning documentation
• Completion of Goals of Care Conversation Checklist
• Completion of Advance directive/surrogate decision maker
• Completion of Medical Orders for Life Sustaining Treatment (MOLST)/Physician Orders for Life Sustaining Treatment (POLST)
• Quality and comprehensiveness of Goals of Care conversation
• Goal-concordant care
• Time and resource costs to deliver the SDM program