Community Health Center CKD Pilot Project Implementation

Why Community Health Centers?

More than 1,100 federally-qualified community health centers (CHCs) provide primary care services to almost 20 million Americans with limited health care access. CHCs supported by the Health Resources and Services Administration (HRSA) serve diverse patients: 66% of patients are racial/ethnic minorities, 70% live below poverty, and nearly 40% are uninsured.

CHCs are a critical primary care setting for people at risk for CKD. In 2010, more than 1.3 million CHC patients accounted for almost 3.7 million diabetes-focused patient visits. With a strong quality improvement (QI) culture, CHCs are dedicated to providing evidence-based care, open to change, and comfortable using a "rapid cycle" approach to test interventions.

Project Implementation

HRSA's Bureau of Primary Health Care helped NKDEP identify a project champion from the CHC community to help conceptualize the project and recruitment strategies. NKDEP invited centers that were active in HRSA's Health Disparities Collaboratives (HDCs) to learn about the project. Five centers joined in 2008 and a sixth in 2010 (see Table 1). Participation involved collecting and reporting data monthly, attending monthly conference calls, and sending representatives to in-person meetings. NKDEP provided technical assistance, free patient education materials, training, and small administrative/travel stipends. NKDEP also organized kick-off meetings at each center, including a presentation on CKD and primary care for continuing education credit.

Table 1. Pilot Center Characteristics

Center (Location)	Adult Patient Population with Diabetes for Project*	Notes
Community Health Center, Inc. (CT)	1,051	Used 20% of total adult patient population Included patients with diabetes, CKD, and elevated BP
Eric B. Chandler Health Center (NJ)	764	Used total adult patient population with diabetes
Fair Haven Community Health Center (CT)	1,043	Used total adult patient population with diabetes
Hudson River HealthCare (NY)	62	Started with 40% of adult patient population with diabetes Expanded population gradually over time
Manet Community Health Center (MA)	155	Used total adult patient population with diabetes Expanded to other sites in late 2009
Neponset Health Center (MA)	434	Used total adult patient population with diabetes

*In January 2009, except for Community Health Center, Inc. (2010).

Centers implemented a range of clinical interventions tailored to each center's needs, including establishing standing orders to implement CKD-related measures; conducting diabetes patient group visits; and conducting provider educational sessions on CKD, hypertension, patient self-management, and motivational interviewing.

Centers identified four primary objectives and collected data on 12 performance measures to assess progress in meeting these objectives (see Table 2). Data included race, ethnicity and gender. Centers determined their target populations for the project; some included their entire diabetes population (e.g., 1,000 patients) while others included diabetes patients from one or two providers (e.g., 30-50 patients), planning to increase over time. Data were submitted monthly to a common reporting site, allowing centers to see their own trends and combined data. NKDEP provided technical support from clinical information systems consultants to develop and maintain the reporting site.

Table 2. Performance objectives and associated measures

Objectives	Measures
Improve screening of patients with DM	Estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR)
Improve BP control in patients with DM	Estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR)
Improve screening for complications	Screening for anemia, malnutrition, metabolic bone disease, and lipid disorders
Improve basic CKD education	Documented discussion with provider on four key concepts (CKD/Risk, Testing, Treatment, ESRD)

NKDEP engaged the software developer that created HRSA's HDC patient registry to develop a CKD report and patch for PECSYS (Patient Electronic Care System). The developer helped centers update PECSYS and provided training.

For centers not using PECSYS, NKDEP provided additional financial/technical support for electronic data systems updates. Because the performance measures included a project-specific CKD education item, all centers needed to implement changes to their data systems. .

Five centers reported quantitative data from January through December 2009. Three continued reporting data though September 2010. The sixth center that joined in 2010 implemented a modified intervention based on its unique structure.

Qualitative data was collected at project start and end to inform direction and determine lessons learned. A baseline needs assessment included a survey about centers' processes and data-collection practices and in-depth interviews about needs and information-seeking behaviors. It confirmed centers didn't have existing practices or resources for CKD screening/management. Identified needs included guidelines and reminders for CKD screening/management, better nephrologist coordination, and CKD patient education materials. In mid-2010, centers completed follow-up in-depth interviews about the project experience.