Change Packages and Interventions

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Chronic Kidney Disease Toolkit
Share this toolkit from the TMF Quality Innovation Network to help patients better manage chronic kidney disease (CKD).
Adobe PDF    Date Added: 08/29/2024    Date Last Modified: Aug 29 2024 8:16AM  
5 things you can do to protect your kidneys
This flyer from the American Kidney Fund recommends five actions people can take to prevent or deley kidney failure.
Adobe PDF    Date Added: 05/24/2024    Date Last Modified: May 24 2024 2:47PM  
Decision aid helps older adults choose treatment for chronic kidney disease
A survey of adults with chronic kidney disease, but not on dialysis, found that providing patients with a decision aid improved their knowledge about the condition and helped build confidence in treatement preferences.
Web link    Date Added: 05/24/2024    Date Last Modified: May 24 2024 2:50PM  
Casual Conversation 3, Call to Action: Empowering care providers by implementing Target:BP to address hypertension
Listen to this recorded webinar to get an overview of the Target:BP program, including what to expect when enrolling in the program and how Target:BP can be used to improve your patient outcomes.
WebEx    Date Added: 03/29/2024    Date Last Modified: Mar 29 2024 8:28AM  
What to eat and how often
The Mediterranean Diet is the doctor-approved eating plan for all people. The diet suggests people eat more fresh fruits and vegetables and limit how much chicken and meat they eat. Health care providers can give this flyer to patients who should adopt an eating plan to help them manage chronic illnesses, such as heart disease and type 2 diabetes.
Adobe PDF    Date Added: 03/18/2024    Date Last Modified: Mar 18 2024 8:11AM  
Taking an Early Approach to Improve Outcomes in Chronic Kidney Care
In this recorded webinar, participants reviewed tools to help them develop processes for diagnosing and treating chronic kidney disease. This program is intended for providers, nursing staff, medical assistants and office staff with scheduling protocols.
Video    Date Added: 11/09/2023    Date Last Modified: Nov 9 2023 2:27PM  
Know Your Kidney Number
This website is maintained by the University of Arkansas for Medical Science (UAMS). Here you'll find resources for an educational campaign that focuses on chronic kidney disease (CKD) and the estimated Glomerular Filtration (eGFR) rate. Included is a presentation that can be downloaded, along with "Know Your Kidney Number..." eGFR posters.
Web link    Date Added: 08/23/2023    Date Last Modified: Aug 23 2023 7:54AM  
Hospital Admissions, Readmissions and ER Visits
Patients who miss dialysis treatments, a primary driver of hospitalizations, can be addressed with strategies and interventions. This change package supports dialysis facilities and End Stage Renal Disease Networks in reducing hospitalizations, re-hospitalizations and emergency department visits for patients receiving dialysis care.
Adobe PDF    Date Added: 06/26/2023    Date Last Modified: Jun 26 2023 2:36PM  
Webinar: Battling Health Disparities in Treating Chronic Kidney Disease
LaVarne Burton, president and chief executive officer of the American Kidney Fund, was part of an expert panel that discussed efforts to ensure that all people have access to the most effective kidney care. The webinar was hosted by the U.S. News and World Report.
Web link    Date Added: 06/16/2023    Date Last Modified: Jun 16 2023 1:03PM  
Your CKD Toolkit
If you or someone you know has chronic kidney disease (CKD), this toolkit from the American Kidney Fund provides information that people can help you manage the disease.
Adobe PDF    Date Added: 06/16/2023    Date Last Modified: Jun 16 2023 1:05PM  
Empowering Patient Kidney Health Self-Management
This April 27, 2023, recorded webinar features Dr. Richard Gibney, who has been in the kidney care industry for more than four decades. Dr. Gibney spoke to members of the Partnership for Community Health, North and South Antonio and Central Texas community members. If you have questions or want a copy of the handout, please contact us at communityhealth@tmf.org.
Video    Date Added: 05/25/2023    Date Last Modified: May 25 2023 8:26AM  
Chronic Kidney Disease e-Learning Series
Managing chronic kidney disease is a job for many. This 10-course e-learning series shares best practices and practical experience from a diverse group of patient subject matter experts. The series is designed to be used with the Chronic Kidney Disease Disparities: Educational Guide for Primary Care from the Centers for Medicare & Medicaid Services @ https://www.cms.gov/files/document/chronic-kidney-disease-disparities-educational-guide-primary-care.pdf.
Web link    Date Added: 04/14/2023    Date Last Modified: Apr 14 2023 8:09AM  
Food Security: Key Dimensions of the Social Determinant of Health
This article examines how food access and security affects health and well-being. It states that many illnesses, such as heart disease and diabetes, may be diet-related. However, through community health partnerships, health care organizations are trying to connect patients in need with nutritious food.
Web link    Date Added: 04/07/2023    Date Last Modified: Apr 7 2023 12:18PM  
Measuring And Addressing Nutrition Security To Achieve Health And Health Equity
This article explores food insecurity and the impact nutrition-related diseases have on health inequity and health care costs in the US and globally. The article also offers potential interventions to address nutrition security in different populations.
Web link    Date Added: 04/07/2023    Date Last Modified: Apr 7 2023 12:48PM  
Executive summary of the KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease: an update based on rapidly emerging new evidence
The Kidney Disease: Improving Global Outcomes (KDIGO) 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease (CKD) is an update on the KDIGO 2020 guidelines. The KDIGO 2022 guideline outlines the latest in treatment approaches for people with diabetes and CKD.
Adobe PDF    Date Added: 03/09/2023    Date Last Modified: Mar 9 2023 12:35PM  
Top 10 Takeaways for Clinicians from the KDIGO 2022 Clinical Practice Guideline for Diabetes Management in CKD
This one-page fact sheet includes practice guidelines and infographics about the latest in treatment approaches for people with diabetes and CKD.
Adobe PDF    Date Added: 03/09/2023    Date Last Modified: Mar 9 2023 12:37PM  
2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease
This article, published as a supplement supported by Kidney Disease: Improving Global Outcomes (KDIGO), is an update to the original KDIGO 2020 Clinical Practice Guideline. It focuses providing evidence-based answers to clinical management questions. This full report includes numerous infographics that address the latest in treatment approaches for people with diabetes and chronic kidney disease.
Adobe PDF    Date Added: 03/09/2023    Date Last Modified: Mar 9 2023 12:39PM  
ADA-KDIGO Consensus Report on Diabetes Management in CKD
People with diabetes and chronic kidney disease (CKD) are at high risk for other serious illnesses, such as kidney failure, cardiovascular disease and heart failure. This consensus report supports new approaches to treat diabetes and CKD.
Adobe PDF    Date Added: 03/09/2023    Date Last Modified: Mar 9 2023 12:42PM  
Top 10 Takeaways for Patients from the KDIGO 2022 Clinical Practice Guideline for Diabetes Management in CKD
Providers can give this fact sheet to their patients who want to know that latest treatment approaches for diabetes and chronic kidney disease.
Adobe PDF    Date Added: 03/09/2023    Date Last Modified: Mar 9 2023 12:41PM  
Hot Topics in Kidney Health: Working with your clinician to make shared decisions for your care
Shared decision making can play a vital role in the treatment of kidney disease. When physicians involve patients in their care, they may be able to help slow progression and improve outcomes. In this episode, we discussed how patients and their physicians can achieve this and hear stories from patients who have been there.
Web link    Date Added: 03/03/2023    Date Last Modified: Mar 3 2023 8:09AM  
Your Healthcare Team
Good health care is always a team effort - especially for people with chronic kidney disease (CKD). Since each member of the health care staff contributes to a patient's care, it is important to build a good working relationship with them. This National Kidney Foundation webpage introduces people with CKD to the providers and specialists who will likely be on the team.
Web link    Date Added: 03/03/2023    Date Last Modified: Mar 3 2023 7:55AM  
Social Determinants of Kidney Disease (SDoH)
The National Kidney Foundation (NKF) has identified some of the SDoH that have been found to contribute to people developing kidney disease. There are many environmental, medical, and social factors that contribute to an increased risk of developing kidney disease, also known as chronic kidney disease or CKD.
Web link    Date Added: 02/10/2023    Date Last Modified: Feb 10 2023 2:17PM  
Resources for Living with CKD
This two-page handout lists resources for CKD patients, including: associations and foundations, educational sites, kidney transplant, financial resources and support for family and caregivers.
Adobe PDF    Date Added: 02/10/2023    Date Last Modified: Feb 10 2023 2:22PM  
The Basics of CKD - English
Healthcare providers are encouraged to give this two-page handout to CKD patients to help explain the five stages of kidney disease.
Adobe PDF    Date Added: 02/10/2023    Date Last Modified: Feb 10 2023 2:25PM  
The American Kidney Fund launches Kidney Health for All
This new website from the American Kidney Fund is intended to improve health equity, especially among patients from underrepresented groups. The site houses tools and resources that can be shared with patients to help them have conversations with their doctors and make informed health care decisions.
Web link    Date Added: 02/07/2023    Date Last Modified: Apr 7 2023 12:15PM  
Diabetic Kidney Disease (a patient teaching tool)
Providers can refer patients to this site so they can learn more about the connection between diabetes and kidney disease. Patients with diabetes can also get tips on how to keep their kidneys healthy and avoid developing diabetic kidney disease.
Web link    Date Added: 05/10/2022    Date Last Modified: May 10 2022 2:28PM  
Identify & Evaluate Patients with Chronic Kidney Disease
Kidney damage is generally irreversible, so it is important to know how to detect and monitor kidney disease as early as possible. This site can help providers with disease management and treatment.
Web link    Date Added: 05/10/2022    Date Last Modified: May 10 2022 2:36PM  
Kidney Basics
This patient education tool from the National Kidney Foundation links to information collected under four major categories: Understanding kidney health, rick factors & causes, kidney health testing and kidney stones.
Web link    Date Added: 05/10/2022    Date Last Modified: May 10 2022 2:38PM  
Know Diabetes by Heart, Diabetes INSIDE® Shared Learning
This site includes links to recorded Shared Learning sessions held in 2021. The subject: A quality improvement initiative focused on improving population health outcomes for people with diabetes or at risk for cardiovascular disease.
Web link    Date Added: 05/10/2022    Date Last Modified: May 10 2022 2:23PM  
Advanced Health Information Search, Kidney Disease for Health Professionals
This website, from the National Institute of Diabetes and Digestive and Kidney Diseases, includes patient education and outreach materials about chronic kidney disease, along with practice tools for diagnosis and treatment of diseases and conditions.
Web link    Date Added: 05/10/2022    Date Last Modified: May 10 2022 2:45PM  
Chronic Kidney Disease (CKD) Surveillance System
This website features the work of the chronic kidney disease (CKD) surveillance project, established by the Centers for Disease Control and Prevention. The surveillance system documents the burden of CKD and its risk factors in the U.S. and tracks the progress of efforts to prevent, detect, and manage CKD and its complications.
Web link    Date Added: 05/10/2022    Date Last Modified: May 10 2022 2:25PM  
Making Sense of CKD, A Concise Guide for Managing Chronic Kidney Disease in the Primary Care Setting
Developed by the National Kidney Disease Education Program (NKDEP), this guide is intended to help health care professionals manage adult patients with chronic kidney disease in the primary care setting.
Adobe PDF    Date Added: 05/10/2022    Date Last Modified: May 10 2022 2:27PM  
DiabetesPro, Standards of Care App
This site links providers to information they need to get the Standards of Care App for their mobile devices. There is also a link to a web app.
Web link    Date Added: 05/10/2022    Date Last Modified: May 10 2022 2:18PM  
Advancing American Kidney Health
In this report, the Department of Health and Human Services outlines how it will reach its goal to reduce the number of Americans developing end-stage renal disease by 25 percent by 2030.
Adobe PDF    Date Added: 05/10/2022    Date Last Modified: May 10 2022 2:14PM  
Assess Urine Albumin
Albuminuria, a condition caused by too much albumin (protein) in a patient's urine, is a sign of kidney disease. This site provides information for providers who want to asses and monitor their patients' urine albumin.
Web link    Date Added: 05/10/2022    Date Last Modified: May 10 2022 2:44PM  
Chronic Kidney Disease and Risk Management: Standards of Medical Care in Diabetes—2022
The Standards of Medical Care in Diabetes (the Standards) from the American Diabetes Association (ADA) summarizes evidence-based clinical practice recommendations for patients with diabetes and chronic kidney disease. Included in the Standards are several recommended interventions.
Web link    Date Added: 05/10/2022    Date Last Modified: May 10 2022 1:58PM  
Standards of Medical Care in Diabetes—2022 Abridged for Primary Care Providers
While primary care providers can effectively care for patients with chronic kidney disease, there may be times when conferring with a nephrologist is in the patient's best interests. This resource outlines when providers should consult with a nephrologist to improve patient outcomes.
Web link    Date Added: 05/10/2022    Date Last Modified: May 10 2022 2:00PM  
Find a Diabetes Education Program in Your Area
Having diabetes can lead to kidney disease. Providers can send patients to this site to find resources that will explain what causes diabetic kidney disease and what they can do to prevent it.
Web link    Date Added: 05/10/2022    Date Last Modified: May 10 2022 2:15PM  
Collaborate with a Nephrologist
While primary care providers can effectively care for patients with chronic kidney disease, there may be times when conferring with a nephrologist is in the patient's best interests. This resource outlines when providers should consult with a nephrologist to improve patient outcomes.
Web link    Date Added: 05/10/2022    Date Last Modified: May 10 2022 2:02PM  
Collaborate with a Nephrologist: Referral Form
Providers can use this form to provide pertinent information when asking a nephrologist to consult on care for patients with chronic kidney disease.
Adobe PDF    Date Added: 05/10/2022    Date Last Modified: May 10 2022 2:04PM  
Collaborate with a Registered Dietitian
Patients with chronic kidney disease may benefit by making changes to their diets. Registered dietitians can asses and conduct individualized medical nutrition therapy. This resource describes the referral process.
Web link    Date Added: 05/10/2022    Date Last Modified: May 10 2022 2:06PM  
Collaborate with a Registered Dietitian: Referral Form
Providers can use this form to provide pertinent information when asking a registered dietitian to consult on care for patients with chronic kidney disease.
Adobe PDF    Date Added: 05/10/2022    Date Last Modified: May 10 2022 2:08PM  
About the Chronic Kidney Disease Initiative
The Centers for Disease Control and Prevention established the Chronic Kidney Disease (CKD) Initiative to provide public health strategies for promoting kidney health. This site lists the CKD Initiative's current activities.
Web link    Date Added: 05/10/2022    Date Last Modified: May 10 2022 2:12PM  
Using Electronic Health Records to Identify Patients with Chronic Kidney Disease
Diagnosis codes in electronic health records (EHRs), cannot correctly identify people with CKD when used alone. To address this, a working group at the National Institutes of Health developed an e-phenotype—a validated a set of laboratory tests and values drawn from data available in EHRs—to help identify patients likely to have CKD.
Web link    Date Added: 05/02/2022    Date Last Modified: May 2 2022 8:28AM  
Chronic Kidney Disease Change Package
This quality improvement tool, created by the National Kidney Foundation, offers process improvement suggestions for health care professionals in outpatient health care settings. The change package can help clinical teams implement a chronic kidney disease (CKD) program that supports CKD recognition in its earliest stage. The change package also includes strategies for increasing patient engagement and education about CKD.
Web link    Date Added: 05/02/2022    Date Last Modified: May 2 2022 8:37AM  
Chronic Kidney Disease Change Package, PDF
This quality improvement tool, created by the National Kidney Foundation, offers process improvement suggestions for health care professionals in outpatient health care settings. The change package can help clinical teams implement a chronic kidney disease (CKD) program that supports CKD recognition in its earliest stage. The change package also includes strategies for increasing patient engagement and education about CKD.
Adobe PDF    Date Added: 05/02/2022    Date Last Modified: May 2 2022 8:43AM  
Explaining Your Kidney Test Results: A Tool for Clinical Use
Developed by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), this short, easy-to-follow document can help providers better explain CKD and discuss treatments with their patients. This guide is available in several languages. Included is a link to a PDF version of this document, along with PDFs on other kidney health-related topics.
Web link    Date Added: 05/02/2022    Date Last Modified: Apr 24 2024 9:16AM  
Your Kidney Test Results
NIDDK created this two-page worksheet that providers can fill out using patients’ kidney test results to help patients better understand the severity of their CKD. (Note: After clicking on the link above, please check your file downloads to find the PDF document.)
Adobe PDF    Date Added: 05/02/2022    Date Last Modified: May 2 2022 8:52AM  
Kidney Disease Intervention List
Download this two-page handout the TMF Quality Innovation Network created to help health care providers and practitioners learn how to identify patients who are at risk for developing kidney disease, and how to educate patients with kidney disease about the condition and how to care for themselves.
Adobe PDF    Date Added: 04/29/2022    Date Last Modified: Apr 29 2022 9:23AM  
Paquete para facilitar el cambio: Mejoramiento del automanejo de enfermedades crónicas – Insuficiencia renal, para Puerto Rico
TMF Quality Innovation Network, según el contrato con los Centros de Servicios de Medicare y Medicaid, diseñó este paquete para facilitar el cambio a fin de proporcionar estrategias para abordar y prevenir la progresión de la insuficiencia renal a insuficiencia renal terminal.
Adobe PDF    Date Added: 11/30/2020    Date Last Modified: Nov 30 2020 5:28PM  
Resources for Living with CKD - Spanish
This two-page handout lists resources for CKD patients, including: associations and foundations, educational sites, kidney transplant, financial resources and support for family and caregivers.
Adobe PDF    Date Added: 02/10/2023    Date Last Modified: Feb 10 2023 2:19PM  
The Basics of CKD - Spanish
Healthcare providers are encouraged to give this two-page handout to CKD patients to help explain the five stages of kidney disease. In Spanish.
Adobe PDF    Date Added: 02/10/2023    Date Last Modified: Feb 10 2023 2:24PM