This project collaborated with clinical teams across the Ontario health system to examine the experience of patients and their families managing chronic renal disease, and to identify opportunities for innovative models of care for this population that both strengthen health outcomes for patients and offer value for the health system. The research engaged clinical teams working with this population in specialized centres across the province to define opportunities for innovation in renal care. Clinical teams identified key priorities for renal care across the province and identified where there may be opportunities to strengthen services to improve patient outcomes and reduce the incidence of “crash starts” of dialysis care, a priority identified by experts in renal care.
Health system leaders defined key priorities for innovation in care approaches for this population, particularly given the significant impact of chronic renal failure on health services utilization across the province. Patients and their families identified the complex challenges of navigating the multiple care pathways associated with renal care, involving several specialists, primary care givers, health educators, and many others. Family caregivers described the significant challenge of coordinating services and managing prescribed treatments and interventions.
A key finding was the burden of care coordination that was described often as confusing, chaotic, and difficult to fully understand and manage. The perspective of patients, families and their caregivers, as well as the experiences of clinician experts informed the development of an innovative model of renal care. This innovative model is patient-family centric and partners with clinical teams by leveraging mobile digital technologies that connects patients and families to their clinical teams to support and strengthen self-management of their health, wellness and renal care more specifically. The proposed model engages a personalized approach to care for this highly complex patient population that achieves value for patients and families first and foremost, while at the same time achieving value for health providers and health systems more broadly. This project has resulted in an improved understanding of the systemic gaps in care for individuals with chronic kidney disease or those at risk in order to build a scalable, tactical plan to improve current practices.