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Chronic Kidney Disease Initiatives

Three years ago, the CE LHIN had a vision for the three Regional Renal programs in the Central East region to improve renal care and outcomes for clients by working collaboratively and individually on three unique Initiatives. The over arching goal was for all three Regional Renal program partners to come together and jointly develop and implement a sustainable CKD Chronic Disease Prevention Management (CDPM) model for the CE LHIN, a model that could also be replicated as a whole or in parts across other LHINS (including other chronic disease specific models). The model is intended to meet the needs of the renal health care providers, current CKD Patients and those at risk for CKD. The outcomes would be a consistent approach to create an effective, comprehensive management and treatment plan across the care continuum for the client identified with CKD to End Stage Renal Disease (ESRD).

The vision has come to life.

Below is a report on the three Chronic Kidney Disease (CKD) Initiatives: The Scarborough Hospital/Carefirst, the Lakeridge Health(LH)/Baxter Canada, and the Peterborough Regional Health Centre (PRHC)/First Nations. The report covers the actual scope, deliverables and benefits for the three Initiatives, and positions some promising practices as both scalable within the Central East Local Health Integration Network (CE LHIN) and to other LHINs, with the potential to be adopted for other chronic disease models.

There are two components to this document, namely a Summary Report  entitled "Promising Practice Report" and a Practitioners’ Manual.

The Summary Report is high level and intended as an overview of the intent and accomplishments of the three CKD Initiatives. The Practitioners’ Manual is a deep dive on lessons learned, the emerging promising practices and tools developed by the Initiatives.

The Initiatives have proven that early detection is possible, and indeed for those high risk groups imperative, since people can be asymptomatic and their condition only ‘discovered’ through early detection efforts such as screening. The collaboration and integration of the three Initiatives’ efforts, and the broader partnerships with Baxter Canada, and with innumerable community agencies has greatly benefitted our professionals and complemented the drive to improve the Patients’ experience.

A great number of healthcare professionals participated in process improvement groups to improve internal and Patient-facing processes. The results have been to improve the coordination of information and transfer of accountability between the processes and at the transition points between the processes. The roles of the healthcare professionals and the Patient are more clearly identified to support a seamless flow and to enhance the opportunities for Patient self-management. We have focused on developing and delivering information and educational events and materials that support Patients’ knowledge and capability to make the appropriate modality decisions, and sustain their decision to move to home dialysis. We have built a much better view of indicators for health and effective use of resources across the Continuum of Care, validated existing indicators, and developed new metrics and cost benchmarks to support more effective planning and funding decisions on future Initiatives.

We invite you to review these reports and offer your feedback by contacting Jay Wilson at jwilson@tsh.to.

Through this project, the CE LHIN Renal Network will:

  • Continue to incorporate Patient self-management principles and clinical best practices from these three Initiatives throughout the CE LHIN.
  • Communicate these results and ‘Promising Practices’ more broadly to increase Practitioners’ awareness that these practices are available, and provide insight on how they might be applied.
  • Continue advocacy with the Ontario Renal Network to position these three CKD Initiatives as magnets for other renal programs/ LHINS across the province.

Chronic Kidney Disease Initiatives - Promising Practices Report

Please click HERE to download a PDF of the Promising Practices Report.

Links to video presentations:

Jack Pine, Aboriginal elder and healer, First Nations

Dr. Hanson, Nephrologist

Bill Crowe, Alderville First Nation

Pam Stevenson, community health nurse, Alderville First Nation

Gail Chan, Project Co-ordinator, Carefirst/TSH

Pat Howell, patient and volunteer

Emily Harrison, Project Co-ordinator, Lakeridge Health/Baxter Canada Initiative 

Chronic Kidney Disease Initiatives - Practitioners Manual

Please click HERE to download a PDF of the Practitioners Manual.

Links to embedded files:

Early Surveillance and Risk Stratification

Early Referral tools and templates

CKD Management

Patient Self Management

Training and Education

Data Management 

Modality Decision and Dialysis Access Creation

Maintain on Dialysis

Internal Supporting Practices

Measures, Tracking and Reporting

Progam Management