Bringing Care to Patients: A Patient-Centered Medical Home for Kidney Disease. The purpose of this project is to compare a Patient-Centered Medical Home (PCMH) model of care with the usual care of End Stage Renal Disease (ESRD) patients and their caregivers. The project proposes to enhance the usual care team for ESRD patients by providing a primary care doctor in the context of regularly scheduled dialysis sessions and by adding health promoters to help support patients and their caregivers. Patient and family stakeholders and care team members will assist in the design and refinement of the PCMH model.
It is expected that this approach will increase patient access to care for other conditions and will increase care coordination and communication among members of the patient’s care team. These improvements could potentially increase the likelihood of preventing complications or identifying problems earlier and allow for a more successful treatment. It is also expected that this project will reduce emergency room visits and hospitalizations for dialysis patients. In addition, it is anticipated that the addition of health promoters to the clinical team will help support and educate patients and their caregivers and, as a result, patient quality of life will improve and caregiver burden may be reduced.
