A Community-Based Nephrology and Palliative Care Partnership to Improve Advanced Chronic Kidney Disease Care.

1. Describe how to develop an integrated palliative care approach to advanced CKD care through a community-based partnership. 2. Describe the implementation of a community-based collaboration for advanced CKD as a model to apply with other advanced chronic diseases. This quality improvement, pilot program demonstrates the value of community practices collaborating to improve the care for patients with advanced CKD. We will share how a private, nephrology practice integrated palliative care support in their own private clinic setting to improve the care for their patients with advanced CKD. Many older patients with advanced kidney disease have multimorbidity and high symptom burden1. In addition, patients with advanced CKD and caregivers must face numerous treatment-related decisions, including whether to opt for kidney replacement therapy or conservative medical management, choosing among dialysis modalities, establishing goals of care, and completing advance directives1. Integrating a palliative care provider in a nephrology practice may help patients to actively participate in shared decision making for their care to promote later and better starts on dialysis, or to avoid dialysis entirely2. We implemented an integrated palliative care approach to advanced CKD care management through a community-based partnership. A palliative care provider provided tandem consultation visits in a community-based nephrology clinic to serve selected patients. These visits included patients with their caregivers or family to provide anticipatory guidance regarding advanced kidney disease and progression, documentation of advanced care planning, goals of care, and social determinants of health (SDH). A total of 55 patients were seen in the Nephrology-PC clinic with a diagnosis of CKD 4-5. This pilot clinic with a PC provider integrated within a nephrology clinic demonstrated: an increase in % of patients with a surrogate decision-maker documented in the EHR; an increase in % of patients with goals of care conversations documented in the EHR; and an increase in % of patients with SDH documented in the EHR. Fatigue was the most common symptom burden among these patients. This pilot also demonstrated a cost-savings benefit for this approach to advanced CKD care. This partnership should be considered a model-of-care in a value-based arrangement at risk for total cost of care in managing patients with advanced CKD. This model-of-care can be designed to incentivize better management of advanced chronic kidney disease while improving quality of care. Models of Palliative Care DeliveryShared Decision Making / Advance Care Planning [ABSTRACT FROM AUTHOR]