Aim
A new model of care to improve access to tertiary level management of chronic kidney disease in the Western Cape.
Outcomes
The primary outcome to be measured is the number of moderate to severe CKD patients accessing the service. Secondary outcomes are biomedical targets including reducing urine ACRs and blood pressure, improved patient and primary care staff knowledge of chronic kidney disease, and patient and primary care satisfaction with the model.
The project has successfully navigated healthcare system challenges to deliver change, improvement and innovation in the health service and was presented at the Clinical Excellence Queensland Showcase 2019.
Background
Chronic disease, including Chronic Kidney Disease, is a major health burden in the Aboriginal and Torres Strait Islander (ATSI) population. Many ATSI people face difficulties attending specialist clinics secondary to concerns such as the distance required to travel for appointments and transportation, cultural and community expectations, and possible dislocated trust in the health care system. Limited engagement with the system can lead to delayed presentation with some patients historically having first contact with a renal service when they were at end stage renal disease.
The rate of chronic kidney disease is up to eight times that of the national average, with up to 76 per cent of those with moderate to severe kidney disease currently not accessing tertiary level Nephrology services either in person or via Telehealth.
