Kidney Awareness Registry and Education

"Primary care providers (PCPs) will have access to a Chronic Kidney Disease (CKD) registry for patient care. The registry will:~* identify patients with CKD~* notify PCPs of a patients' CKD status~* provide PCP outreach with NKDEP guidelines and patient educational materials"

Patients with CKD will participate in an Automated Telephone Self Management (ATSM) program, which blends automated phone calls with live targeted call-backs from a health coach. Patients will receive bi-weekly automated calls for 52 weeks in their native language, consisting of pre-recorded queries pertaining to CKD management, preventive services, and lifestyle changes. Patients will interact with the system using a touch-tone keypad; Out-of-range values or invalid responses will prompt a live call-back within 24-48 hours by a health coach.

"Primary care providers will manage their patients with CKD per usual care.~Patients will receive usual care."