Rural Primary Care CKD Workflow Integration Aligned with National Standards
Rural Primary Care CKD Workflow Integration Aligned with National Standards" focuses on incorporating evidence-based workflows into rural primary care settings to enhance the detection, management, and treatment of Chronic Kidney Disease (CKD). This approach ensures alignment with national clinical guidelines and best practices, streamlining processes for early diagnosis, patient education, care coordination, and ongoing monitoring, ultimately improving patient outcomes in underserved rural communities.
Chronic Kidney Disease (CKD) Screening and Management Policy
The Chronic Kidney Disease (CKD) Screening and Management Policy" outlines standardized procedures for identifying, monitoring, and managing CKD in patients. This policy emphasizes early detection through routine screenings, particularly for high-risk populations, and provides guidelines for diagnosis.
Micro Learnings for Medical Teams:
- Pre-Vist Phase
- Rooming Phase
- Sample Order set for CKD Testing
- Healthy Huddles Happen
- Video Huddle Example
Sample Huddle provides a practical example of a daily huddle format used in clinical settings, aimed at improving team communication and patient care coordination. The huddle includes discussions on high-risk patients, follow-up care, chronic disease management, workflow optimization, and resource allocation.
PDSA (Plan-Do-Study-Act) | Chronic Kidney Disease PDSA (Plan-Do-Study-Act) Cycle is a systematic, data-driven approach to quality improvement aimed at enhancing CKD care within healthcare settings. It helps clinics and healthcare teams improve processes for early detection, management, and long-term outcomes for patients with CKD.
Sample Chronic Kidney Disease Registry | Michigan Primary Care Association (MPCA) Example: Identify and manage CKD progression in diabetic and hypertensive patients using the Chronic Kidney Disease registry, which tracks vital test results and risk factors for comprehensive care.
Email Template for Patient Outreach | Patient letter templates encouraging kidney health screening for individuals with diabetes and/or high blood pressure through recommended eGFR and uACR testing.
Questions? Contact
Jill Oesterle
Director of Provider Solutions
Michigan Center for Rural Health
Oester35@msu.edu
For Technical Assistance
Mary Wozniak
Program Manager
National Kidney Foundation of Michigan
mwozniak@nkfm.org
This toolkit was developed in partnership with the National Kidney Foundation of Michigan (NKFM)
