This best practice developed by three HCPs (a pharmacist, a nurse practitioner, and an endocrinologist) who work at Baptist Health Deaconess Madisonville, Kentucky, USA, demonstrates how an effective small MDT collaboration can help to overcome barriers to effective care of patients with CKD in the community they serve.

Introducing Baptist Health Deaconess Madisonville

Baptist Health Deaconess Madisonville (hereafter referred to as BHDM) is a 410-bed acute and skilled care facility located in Madisonville, Kentucky. The facility places special emphasis on community outreach and training students to provide medical care in rural areas.

Patient Demographics

BHDM serves patients from a wide geographical area. Most patients who visit the practice come from low-income communities, have poor health literacy, and do not have a PCP. Each month the practice sees around 30–40 patients who have CKD (mostly stages 3a or 3b). Around 30–40% of patients who visit the practice have evidence of kidney damage (proteinuria) but have a normal eGFR. The practice includes an endocrinology department, so most of the patients who visit also have T2DM; on this basis, a frequent reason for repeat visits is glycemic control.

The MDT at BHDM

Figure 2 gives an overview of the small MDT team collaboration.

Fig. 2

Baptist Health Deaconess Madisonville multidisciplinary team (MDT) member role flow diagram. *Nephrologist services will only occasionally be used (not active members of the MDT for each patient with advanced-stage chronic kidney disease [CKD]). T2DM type 2 diabetes mellitus

Cross-Team Collaboration: Ambulatory Care PharmacistExtends Consultation Time

Physicians have limited time with their patient during a consultation, so to address this time constraint, the pharmacist also meets with the patient, which effectively extends the consultation time. This extra time helps to reduce the time from report to action (e.g., the response time from a patient reporting a concern to the physician taking action), thereby reducing delays in care for their patients (Fig. 3).

Fig. 3

Closer view of the pharmacist’s role within the multidisciplinary team at Baptist Health Deaconess Madisonville. NP nurse practitioner

Medical Chart Review

The pharmacist reviews the patient’s medical chart with the patient. Two important aspects of this chart review are to check the patient’s kidney function test results/kidney function test needs and to review the patient’s list of current drug treatments. The benefit of having a pharmacist in the MDT in this capacity was demonstrated in a study that found that serum creatinine and eGFR testing (methods that test kidney function) ordered or reviewed by pharmacists led to identification of 40% of patients who had previously unrecognized CKD [36]. The intention of the collaborative approach at BHDM is that patients are directed to an appropriate treatment plan sooner.

Patients with CKD will probably have comorbidities that require additional drug treatments. The pharmacist reviews the drug list to check for drug contraindications as well as to check for recent drug discontinuations. Early identification of missed contraindications may prevent significant health consequences for patients. Indeed, medical chart review by pharmacists can result in the identification of dosing errors and, as a result, lead to improved drug optimization for patients [37]. Furthermore, unchecked discontinuations may lead to inappropriate withdrawal of treatment, e.g., discontinuation of potassium supplements in patients taking angiotensin-converting enzyme inhibitors (ACEis) or angiotensin receptor blockers (ARBs) or discontinuation of the newer CKD drug finerenone because of fear of the patient later developing hyperkalemia (manageable for most patients without needing to discontinue the drug). Drug dosage and frequency are also checked by the pharmacist for possible prescription errors. Indeed, one study found that appropriate drug dosing and activities in CKD overseen by pharmacists led to less drug use and lower costs associated with managing patients with end-stage renal disease undergoing hemodialysis [38]. Also, decisions made by pharmacists regarding drug–drug interactions are trusted; a recent prospective study found that a great proportion (92%) of pharmacist recommendations on how to manage detected negative drug–drug interactions were accepted and fully implemented by prescribers [39].

During the consultation, the pharmacist requests feedback from the patient on whether they are experiencing drug adverse effects, and if any adverse effects are reported, the pharmacist will suggest possible alternatives or consider reducing the dose of the drug but will also check the patient’s level of treatment adherence. Drug adjustments/discontinuations may also be made for cost reasons if the patient’s health insurance only covers a short period of treatment or certain treatments, or if the patient cannot afford to pay for certain drugs. Such an extensive review of a patient’s current and recent drug treatments by the pharmacist may not occur during a physician-only visit/approach.

Patient Education

Patients do better when they are empowered to be active participants in their own care, so effective patient education is an important aspect of patient care. The pharmacist’s role in patient education is to support the efforts made by the endocrinologist and nurse practitioner; a patient should understand what their T2DM or CKD diagnosis means for them, the treatments available, their risks of T2DM/CKD worsening and what they can to reduce that risk, and ongoing care. Although this is the desired outcome of patient education, it is important to remember that the cost of treatment does limit the number of options available to some patients. The pharmacist has an important role in this regard in communicating clearly to the patient what their health insurance plan covers in relation to the practice’s services and how much various treatments will cost, to avoid confusion and wasting time when an alternative could have been sought.

The pharmacist uses a holistic approach to patient education, and this means focusing on the whole patient and not just their CKD or their diabetes. It starts with checking the patient’s current level of health literacy to identify areas where the patient’s knowledge about their various conditions is limited; the pharmacist helps to fill those knowledge gaps (referring to a physician specialist as needed). Lifestyle changes can have a major beneficial impact on a patient’s risk of developing associated comorbidities (e.g., T2DM and hypertension leading to CKD) or worsening of chronic conditions [40, 41]. The pharmacist encourages self-care, which includes questions about adherence, their diet, the amount of exercise they get, and the amount of alcohol consumed over a certain period of time; from this, the pharmacist provides recommendations on changes that can be made to improve the patient’s health status. Other potential patient education tools that could be used during a consultation include anticipating questions a patient may ask during a consultation and having answers ready and talking through easy-to-follow clinical pathway diagrams [13].

Cross-Team Collaboration: Endocrinologist and Nurse Practitioner

The endocrinologist and the nurse practitioner work closely with the pharmacist at BHDM. Both have their own patients who they see regularly, and their other responsibilities include ordering and reviewing laboratory test results and making decisions on drug-dose changes as needed. The endocrinologist and the nurse practitioner will also seek support from the pharmacist regarding potential new drug treatment initiations for a patient or, if a patient is experiencing adverse effects, about alternative treatments. They will also refer a patient to the pharmacist if the patient would benefit from disease education support, adherence concerns (including refills), and/or filling of knowledge gaps. As noted, the main advantages of this MDT collaborative approach are fewer delays to action (drug treatment start or drug-dose reduction/discontinuation) and ensuring patients are onboard in terms of knowing what their T2DM associated with CKD means for them and the treatment options available in their circumstances.

Supporting Team Members

Nephrology services may occasionally be consulted to confirm a CKD diagnosis and, where appropriate, provide CKD treatment advice for patients who have T2DM and CKD. Nephrologists are thus consulted on an as-needed basis and are not active members of the MDT at BHDM. Pharmacy care coordinators (PCCs) work closely with the endocrinologist, nurse practitioner, and pharmacist to offer administrative support to them and their patients. For example, PCCs will contact patients to remind them about prescription refills and serve as an additional point of contact for patients who want to let the care team know about adverse effects they are experiencing with a particular drug and any associated risk of non-adherence. PCCs also coordinate with the outpatient pharmacy team to ensure that medication is mailed or picked up by patients as needed.