Chronic kidney disease (CKD) affects 15% of American adults and presents a significant clinical and financial burden, consuming approximately €127.4 billion ($137 billion) in Medicare funds annually. Yet, the gap between clinical guidelines and actual care practices remains wide, leading to delayed diagnoses, limited patient education and underutilisation of nephrology referrals. The University of Pittsburgh Medical Center (UPMC) is addressing these persistent disparities through comprehensive population health management (PHM) strategies that aim to improve patient outcomes, streamline care delivery and reduce costs. With an integrated care infrastructure and a robust electronic health record (EHR) system, UPMC offers valuable insights into how health systems can effectively manage CKD across diverse patient populations.
Building Infrastructure to Bridge Gaps in CKD Care
The UPMC approach begins with a foundation of data-driven infrastructure. A CKD registry within the EHR captures over 157,000 outpatients using clinical criteria and lab results, enabling precise identification and monitoring. This registry underpins a provider-facing dashboard that helps primary care physicians and nephrologists track and address care gaps in real time. These tools facilitate adherence to clinical guidelines, encouraging earlier intervention and consistent patient tracking. However, earlier attempts to use standalone EHR tools were unsuccessful, hindered by physician burnout and alert fatigue. In response, UPMC developed the K-CHAMP programme, a novel intervention aimed at enhancing collaboration between primary care and nephrology. Despite its inability to slow disease progression during a trial involving 1,596 high-risk patients, possibly impacted by the COVID-19 pandemic, K-CHAMP demonstrated improvements in quality-of-care indicators and served as a blueprint for further development.
Related Read: Building Trust in Population Health: Key to Effective Case Management
Integrated Models for Education, Palliative Care and Transplantation
Building on K-CHAMP, UPMC launched the Kidney-Care (K-Care) initiative as a systemwide model to embed PHM within routine clinical practice. This programme incorporates enhanced education for providers and patients, drawing from a learning health system approach. It leverages social workers, renal dietitians and palliative care specialists to support the holistic management of CKD. Social determinants of health are systematically screened and addressed during patient education sessions, with referrals triggered when needs such as food insecurity or medication affordability are identified. While the impact of the programme on outcomes has not yet been measured, it has already delivered thousands of consultations and education sessions.
PHM strategies have also been extended to advance care planning and dialysis decision-making. For patients with advanced CKD, UPMC implemented a palliative care referral model using age, disease stage and a prognostic “surprise question” to identify those needing additional support. This model aims to fill the care gaps experienced by patients with high symptom burdens and insufficient guidance in choosing treatment pathways. Additionally, recognising the importance of early transplantation, UPMC is developing automated transplant referrals through the CKD clinic for eligible patients. This ensures timely access and equity in referral processes, reducing disparities in kidney transplant opportunities.
Facilitating Optimal Transitions in CKD Treatment Pathways
Another core element of UPMC’s PHM strategy focuses on guiding patients through optimal transitions to kidney replacement therapy. This involves identifying candidates for preemptive transplants, home dialysis or outpatient centre dialysis before they reach end-stage kidney disease. The goal is to support informed, patient-centred decision-making and timely access to interventions. The multidisciplinary model includes care coordination, vascular access planning and management of social risk factors, all of which are facilitated through the EHR. By aligning clinical workflows and patient engagement, this strategy targets better health outcomes and cost savings.
However, implementing PHM in CKD care is not without its challenges. The fee-for-service healthcare environment remains a significant barrier to value-based models like PHM. Building the necessary infrastructure—including EHR enhancements, data analytics and integrated clinical teams—requires substantial upfront investment and leadership commitment. Financial instability across health systems adds to the complexity. Furthermore, without broader policy support and payer alignment to incentivise upstream CKD care, PHM’s potential may remain underrealised. Despite these constraints, combining data-driven methodologies, predictive modelling and social determinant integration within clinical pathways offers a promising route to transforming kidney care delivery.
UPMC’s population health management strategies demonstrate the potential for significant improvement in chronic kidney disease outcomes when supported by integrated systems, robust informatics and multidisciplinary collaboration. By addressing systemic gaps in early diagnosis, patient education, palliative care and access to transplantation, the health system is pioneering a shift toward value-based, patient-centred kidney care. While financial and policy barriers remain, the approaches trialled and implemented at UPMC offer a roadmap for other institutions aiming to close longstanding care gaps and improve outcomes for patients living with CKD.
Source: Managed Healthcare Executive
Image Credit: iStock
