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.