Case Management of Patients with CKD

by Adeera Levin, MD

CKD is complex but co-exists with many other conditions, so develop optimal models of care that lead to good outcome for individuals, healthcare systems and and society

The Chronic Care Model developed by The MaxColl Institute (ACP-ASIM Journals and Books)

CKD is a chronic illness

-Define CKD in a consistent manner
-Consider development of care models specific to
a)Stage(s)
b)Unique conditions (transplant, GN, other)
-Recognize complexity, need for integration and specialization
-Philosophy: Longitudinal, regular, multidisciplinary, integration of services

Team + nephrologist better than nephrologist alone (Canadian and Italian data)
? Multidisciplinary Clinics (patient goes to DM clinic, CKD clinic, lipid clinic, Cardiology Clinic vs just go to one clinic that is multidisciplinary).