An Updated Care Pathway for Nephrology Chronic Care Management

There is good news for patients with Chronic Kidney Disease (CKD) this week. A study published in the American Journal of Physiology reports that closely monitored exercise for patients, who do not require dialysis, does not impair kidney function. This is an important finding, as previous treatment recommendations for people with CKD discouraged exercise. The former recommendation is based upon the belief that the release of creatinine into the bloodstream caused by exercise would stress kidney function.(1) On the contrary, moderate exercise reduces glomerular filtration rate (GFR), the best indicator of kidney function. This finding will change the guidelines for Nephrology Chronic Care Management and CareHarmony is positioned to quickly implement improved patient education.

Care Pathways and Nephrology Chronic Care Management

The National Kidney Foundation recommends Chronic Care Management to CKD patients for two main reasons. First, it assists patients with building and maintaining a health routine that ought to include diet and regular doctors’ visits.(2) With CareHarmony’s Care Pathways, the needs of individual patients are met through expert evaluation and personal, monthly assessments. Second, and just as critical, is patient education. Although there are numerous medical websites that provide education to CKD patients,(3) there is no substitute for human interaction. Good Care Coordinators, like those at CareHarmony, can evaluate gaps in knowledge. Also, they can provide answers to specific questions that are directly applicable to the individual CKD patient’s life.(2) Through case oversight and patient education, Nephrology Chronic Care Management can slow disease progression and help CKD patients live healthier lives.

Updating Treatment Recommendations through Care Pathways

When patients are proactive in their care and use multiple sources, new methods of treatment and recommendation implementation is faster. However, incorporating new guidelines into patient education can often lag when patients only have one source of information. Unfortunately, Medicare patients face barriers to accessing these sources. This is where a Care Pathway is essential. As part of their individualized Care Pathway, all CareHarmony patients are routinely assessed by Care Coordinators. Therefore, changes in health recommendations can reach them faster. This will assist in slowing the progression of CKD through frequent monitoring and increased education.

CDC graphic of risks for CKD
Approximately 1 of 3 adults with diabetes (and 1 of 5 adults with high blood pressure) has chronic kidney disease. –

The best role a Care Coordinator can play in the fight against CKD is that of prevention. The risk factors for developing CKD include a long list of chronic conditions that would qualify a patient for Chronic Care Management (CCM). The most common being diabetes and hypertension.(5) In fact, many these patients could already have CKD and be unaware of it.(6) Care Coordinators can reduce risk and slow progression by educating existing patients on the need to modify their diet, exercise regularly, take medications consistently, smoking cessation, and the increased risk for minorities.(4) Because Care Coordinators contact their patients monthly, they can deliver on-going patient education. Care Coordinators develop rapport with their patients and help them see the benefits of changing their habits and lifestyle.

Versatility Provides a Safeguard to Patients

Changing guidelines for Nephrology Chronic Care Management highlights the effectiveness and utility of Care Coordinators in managing Chronic Kidney Disease. CCM is more responsive than physician oversight because of the greater frequency of patient interaction and the flexibility inherent in Care Pathways. As such, experienced management of Care Pathways allow for the skillful oversight of patient health. Through responsiveness, flexibility, and frequent contact, Care Coordinators at CareHarmony can provide patients with another line of defense in their efforts to improve health outcomes.


  1. APS Communications Office, “Aerobic Exercise Found Safe for Non-Dialysis Kidney Disease Patients,” The American Physiological Society Press Release, 2017, July 12. [Online: July 13, 2017] and University of Delaware, “Combating Chronic Kidney Disease with Exercise: Study Finds that Specially Designed Program Improves Blood Vessel Health,” ScienceDaily, 2017, June 28. [Online: July 13, 2017]
  2. MACC Task Force, Chronic Kidney Disease and Care Coordination: Working Together to Improve Outcomes, 2016, March. [Online: July 13, 2017]
  3. National Kidney Foundation, “About Chronic Kidney Disease,” A to Z Health Guide, 2017, February 15. [Online: July 13, 2017]
  4. National Kidney Foundation, “Letter to Andrew Slavitt, Acting Administrator, Centers for Medicare and Medicaid Services,” dated September 8, 2015. {Online: July 13, 2017]
  5. NN&I Staff, “CDC Estimates 1 in 7 American Adults Have Chronic Kidney Disease,” Nephrology News & Issues, 2017, June 12. [Online: July 13, 2017]
  6. Centers for Disease Control and Prevention, “Know Your Chronic Kidney Disease Risk,” Our Health: With Joan Lunden and CDC, 2016, December 30.
  7. Centers for Disease Control and Prevention, “Chronic Kidney Disease,” Chronic Kidney Disease Initiative, 2017, June 2. [Online: July 13, 2017]

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