Change Ideas

  1. Focus on data discipline to support to support primary care providers to screen populations to identify patients at risk of CKD with the intent to test eGR and urine ACR
    • EMR use for capturing identification of eligible patients
    • EMR use for capturing screening rates
    • EMR use for capturing patients who refuse or are not ready for screening
    • Implement an evidence-informed CKD screening flow sheet for standardized, consistent assessment and documentation in the EMR
    • Map the CKD patient journey from diagnosis including modification of vascular risk factors including lipid management & referral to nephrology/CKD regional program where relevant
  2. Complete outreach to patients
    • Letters
    • Email
    • Phone calls
    • Focus groups
  3. Collaborate with the Regional CKD Program
    • Work with the early CKD team in Nephrology on a referral process to assist in preventing risk of CKD progression
  4. Decision support aids for Patients
  5. Decision support aids for Health Care Providers (HCP)
    • HCP and staff training/education
    • Use of a CKD screening medical directive (e.g., Vascular Health Medical Directives when available) to enhance capacity for interprofessional team collaboration in screening
CorHealth Ontario

Vascular Health Primary Care Work Group
Last Updated: April 30, 2017