Kidney Coordinated Health Management Partnership

"An EHR in-basket message will be sent to the patient's PCP which identifies the patient's high-risk CKD status and indicates that the patient will receive:~1. Nephrologist led electronic consultation: review of the patient's EHR with recommendations sent to the PCP every \~6 months,~2. Medication therapy management: PharmD led telephonic medication therapy management with the patient every \~6 months,~3. and Nurse led CKD patient education, every \~6-12 months~unless the PCP opts the patient out of the interventions (by responding to the EHR in-basket message and providing an opt-out reason or requesting an office consultation with nephrology)."

Patients in the usual care arm will continue to receive CKD care guided by their PCPs as per usual care practices (i.e., specialty consultation, pharmacotherapy, nurse education, etc. may be ordered by the PCP according to their usual practice).