The National Kidney Foundation of Michigan (NKFM) and the Michigan Center for Rural Health (MCRH) partnered to equip rural healthcare providers with the tools and education needed to effectively screen for and manage chronic kidney disease (CKD) through the Medicaid Impact and Expansion grant. The CKD Learning Collaborative focused on improving early detection and management of CKD among Medicaid-eligible populations, providing rural health clinics (RHCs) with clinical education, technology tools, and support to adopt evidence-based practices for high-risk patients.
CKD has long remained an overlooked chronic disease, despite the availability of diagnostic tests like estimated glomerular filtration (eGFR) and Albumin: Creatinine ratio (ACR), which can detect early signs of kidney damage. According to data from the U.S. Renal Data System (USRDS), fewer than half of individuals with diabetes and only 10% of those with hypertension received annual albuminuria screenings, even though both groups face heightened CKD risk (NKF, 2024).
The CKD Learning Collaborative brought together four rural health clinics: Cass City Family Practice, Cass City Medical Practice, St. Helen McLaren Primary Care, and Clare McLaren Central. Participating clinics were selected based on Medicaid data indicating high CKD prevalence or low kidney screening rates within their counties, underscoring the program’s focus on communities where enhanced CKD care was critically needed.
Through this collaboration, NKFM and MCRH aimed to identify gaps in CKD testing, diagnosis, and management and emphasize the need for enhanced care in underserved areas. The collaborative included six monthly, one-hour learning sessions, each covering a unique aspect of CKD management. Participating clinics designated a project team, which included a provider champion, project champion, quality lead, data lead, and patient educator lead. Key session topics included early detection, technology integration, lifestyle interventions, and pharmaceutical approaches to slow disease progression. NKFM and MCRH provided each RHC with personalized support through monthly one-on-one calls and several on-site visits.
Clinics provided baseline data on CKD screening rates and undiagnosed cases, allowing NKFM to deliver targeted, data-driven support and assess the program’s impact. All four clinics demonstrated significant improvements over different time frames, with active involvement from clinical leads and quality directors contributing to these gains. On average, CKD screening rates increased by 27.0% among diabetic patients (Figure 1) and by 17.1% among hypertensive patients (Figure 2) from baseline to final measurement. Several practices saw a substantial rise in CKD diagnoses, while other clinics experienced a smaller increase in diagnoses (Figure 3). Notably, some of the clinics also reported an overall reduction in the percentage of their population with diabetes and hypertension.
Figure 1
Figure 2
Figure 3
Building on these successes, a toolkit was developed to broaden the reach of the CKD Learning Collaborative’s impact and equip more rural health clinics with practical resources for screening and managing CKD. The Managing Chronic Kidney Disease (CKD): Resources for Rural Providers Toolkit provides a comprehensive suite of materials, including provider and patient education, tailored workflows, and screening tools. Developed from the feedback and lessons gained throughout the collaborative, this toolkit is designed to support clinics as they implement and maintain effective CKD management practices. Through this toolkit, NKFM and MCRH invite other rural health providers across Michigan to join the effort in enhancing CKD care. With these resources, clinics can take actionable steps to improve early detection, provide patient-centered management, and ultimately make a lasting impact on kidney health in their communities.
The MCRH has been proud to work alongside the NKFM to spread the word on early detection and management of CKD and look forward to continuing to share the invaluable resources provided by the NKFM.
Access the full toolkit here: Managing Chronic Kidney Disease (CKD): Resources for Rural Providers
Have additional questions? Contact Jill Oesterle at Oester35@msu.edu.
Resource:
National Kidney Foundation (2024). CKD Data Analysis Strategy. 10.17.2024 622-9794_2409 CKD_DataAnalysisProcessV5.pdf