A pilot study to support future interventions to optimize VA Medical Center nephrology-based care for Veterans with advanced chronic kidney disease.

About This Grant

Significance to VA: 110,000 VHA patients have advanced chronic kidney disease (CKD, Stage 4 or 5). These Veterans are mostly older, have multiple chronic conditions, and face a major health transition as they approach the need for chronic dialysis or a kidney transplant to live with kidney failure. Unmet needs include exceptionally high mortality, failure to delay dialysis as long as possible, insufficient preparation for dialysis, and barriers to home dialysis and kidney transplantation (preferred by many over in-center hemodialysis). Our longer-term goal is to improve these outcomes to maximize life participation for Veterans with advanced CKD. Most Veterans receive advanced CKD care at the 120+ VA Medical Centers (VAMCs) with nephrology services. Among Veterans reaching kidney failure, even though 80% transfer to Community Care dialysis, VA nephrology is responsible for assuring access to home dialysis, transplantation, and related services. Though VA/DoD and civilian nephrology practice guidelines recommend coordinated multidisciplinary care for advanced CKD patients, optimal approaches are unknown, and VA offers no national guidance. As such, approaches have evolved differently across VAMCs. Indeed, organized efforts to deliver equitable care within individual VAMCs may be uncommon. As such, strategic intervention to improve coordination of VAMC nephrology care may meaningfully improve the outlook for Veterans facing this life-altering health transition. Innovation & Impact: Our working hypothesis is that, in advanced CKD, a care coordination intervention can be developed that is feasible for VAMC nephrology services to implement, and that doing so will provide more effective care and ultimately improve Veteran-centered outcomes. We follow the Multiteam System (MTS) Framework to work toward a coordination ‘solution’ scoped around optimizing function of the nephrology team so that key services are offered effectively and equitably to highest-risk Veterans. VHA considers improving care coordination a top priority for Veterans with high-intensity, focused, specialty care service needs, such as advanced CKD, yet evidence, approach, and implementation are undeveloped. By addressing this gap, our work will make progress toward improving the outlook for Veterans facing this life-altering health transition. Specific Aims: This pilot project addresses foundational needs by building an evidence base for our hypothesis and gaining stakeholder support for the project’s next phase. Aim 1: Understand variation in VAMC care and outcomes for Veterans with advanced CKD. Obtain a comprehensive understanding of specialty kidney care at the VAMC level. Highlight promising approaches to effective care coordination. Aim 2: Co-Design a bundled care coordination intervention that is acceptable to diverse stakeholders. Methodology: Follows the MTS framework. Aim 1: Describe the current state of care by: (1) VAMC nephrology chief survey (pre-award) and (2) descriptive CDW data, providing an understanding of disparities in resources, care structure and care coordination, and outcomes across VAMCs nationally; (3) exploratory provider interviews, detailing care coordination and delivery at six VAMCs with varied resources and performance; (4) data integration, highlighting and contextualizing findings and inequities. Aim 2: Uses open-ended Co-Design, an evidence-based process that engages stakeholders to co-create solutions to an applied, complex problem. With Aim 1 findings as context, our Design Team (VAMC providers, content leaders, and Veterans) will: (1) identify challenges to providing coordinated care, (2) creative problem-solve to identify potential solutions, (2) assess impact and feasibility, and (4) operationalize into a bundled care coordination intervention for further development. Path to Translation/Implementation: Output will support and guide the next funding submission within 3 months after project end. The follow-on study (2nd phase) will complete pre-implementation activities including formulating a measurement plan, pilot testing at VISN 10 sites, and developing a draft protocol for the project’s 3rd phase, an effectiveness-implementation program incorporating adaptive design as part of a learning health system.