Personalized Health Planning in Shared Medical Appointments for Chronic Kidney Disease Patients

In collaboration with the Duke Population Health Management Office (PHMO), the Duke Center for Personalized Health Care implemented an evidence based Personalized Health Planning - Shared Medical Appointment (PHP-SMA) program for Duke Accountable Care Organization (ACO) patients with diabetic kidney disease at Duke Nephrology and Endocrinology at Brier Creek. Due to COVID-19 disruption, the in-person PHP-SMA program was adapted to telehealth. This clinical quality improvement initiative filled a direct need within the Duke ACO to advance value based care for high-risk CKD patients.

Project Aims

Aim 1. Implement a PHP-SMA program for patients with diabetic kidney disease (stage 3b CKD and diabetic nephropathy) to be delivered in-person and via HIPAA compliant telehealth and video conferencing software.

Aim 2. Collect evidence on the clinical efficacy and cost effectiveness of the CKD PHP-SMA program.

Aim 3. Identify implementation strategies needed to facilitate dissemination of the CKD PHP-SMA model (through both in-person and telemedicine modalities) into diverse clinical settings.

A manuscript reporting results of this quality initiative is in preparation for publication.