Disease management

Advanced Care Planning in Nephrology Patients

Davies Award of Excellence
man getting dialysis

This case study from St. Luke's University Health Network highlights the challenges faced by patients with end stage kidney disease and chronic kidney disease, particularly in terms of high mortality, hospitalization rates, and poor addressment of advanced care planning. The study aimed to improve patient outcomes by implementing a comprehensive approach, including a dedicated office encounter for advanced care planning, utilizing Epic (EHR system), and establishing clear protocols for patient criteria, visit workflow, and treatment algorithms based on patient goals. The results of the project were positive, with a significant reduction in ER utilization (17.2%), admissions (24%), and readmissions (50%) for patients who attended the advanced care planning visit. Additionally, the number of advance directives increased substantially (750%) after implementing this initiative.