Coordinating care means that each health care provider serving a patient shares information with one another in a timely manner about the patient’s health, treatments prescribed and care delivered to him or her. Research has shown that coordinated care is helpful in improving the health of people with chronic conditions and in lowering their health care costs. Care coordination is most effective when patients are empowered to be active participants in managing their disease along with their care providers.

Current proposed models that focus on improving the coordination and integration of care to improve quality include Accountable Care Organizations (ACO) and Medical Homes. An ACO may be defined as a network of doctors, hospitals and other health care providers that share responsibility for delivering care to patients, and a Medical Home is an approach where one physician may lead coordination efforts with patients’ health care providers.

Improving coordination among health care providers is necessary to improve the quality of care received by patients with chronic kidney disease (CKD) stages three through five. Most people with CKD also suffer from other chronic conditions like diabetes, high blood pressure and cardiovascular disease, making their care more complicated. CKD patients often need to see multiple health care providers and take many medications, particularly in the later stages of the disease. Care coordination reduces duplicative services, allows for the whole patient to be cared for and treated rather than just the specific disease and can improve patients’ overall health and quality of life.

Regardless of the payment model chosen to facilitate improved care coordination, DPC believes reimbursement should be aligned to provide incentives for all of a CKD patient’s health care providers to better coordinate with one another. This includes coordination among, but not limited to: primary care physicians and practitioners, nephrologists, dialysis facilities, hospitals, cardiologists, endocrinologists and mental health professionals. For patients with CKD stages three through five, a primary care physician should work closely with a nephrologist, who is a specialist in kidney disease. In the case where CKD has progressed to stage five (also known as end stage renal disease) and patients need to rely on dialysis to continue living, dialysis facilities need to be included in the care coordination model.

No matter how doctors and providers organize to provide care to CKD patients, patients should always retain the right to seek care from the health care providers of their choosing without the risk of losing the benefits of coordinated care. Additionally, patients should be informed, active participants in the coordinated care model used.