Change Packages and Interventions

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Improving Chronic Disease Self-Management Chronic Kidney Disease Change Package
The TMF Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services, designed this change package to provide strategies to address and prevent the progression of chronic kidney disease to end-stage renal disease.
Adobe PDF    Date Added: 09/28/2020    Date Last Modified: Sep 28 2020 7:18PM  
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  
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  
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  
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  
Take Care of Your Kidneys and They Will Take Care of You
This flier from the Centers for Disease Control and Prevention is easy to read and explains how kidney health is linked to cardiovascular health. It also discusses how to prevent kidney disease and kidney failure.
Adobe PDF    Date Added: 05/10/2022    Date Last Modified: May 10 2022 2:40PM  
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  
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  
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.
Web link    Date Added: 05/02/2022    Date Last Modified: May 2 2022 8:46AM  
Explaining Your Kidney Test Results: A Tool for Clinical Use, PDF
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 and can be downloaded as a PDF file.
Adobe PDF    Date Added: 05/02/2022    Date Last Modified: May 2 2022 8:50AM  
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