Development of Care Model for Patients with Chronic Kidney Disease by Multidisciplinary Providers at Nang Rong Hospital

Abstract

Objective: To develop the care model for patients with stage 3-4 chronic kidney disease (CKD) by multidisciplinary team at CKD clinic in outpatient department. Method: This study was an action research by using focus group discussions in 9 members of multidisciplinary teams to develop the care model for patients with stage 3-4 chronic kidney disease. The study implemented the model in 29 patients in CKD clinics. The study evaluated the model by comparing the levels of knowledge, self-care behavior, satisfaction, and clinical outcomes results measured before and after model implementation for 7 months. Results: The most common drug related problems were inappropriate drug storage (17.65%), inaccurate drug use (14.71%), problem in taking pills out of blister due to weak hand muscles (14.71%) and lack of knowledge on disease, food, drugs and herbal medicines. After implementation of the care model with the participation of multidisciplinary, knowledge on the disease of the patients increased significantly (P <0.001) from 9.83 ± 2.14 to 12.52 ± 1.47. Scores of self-care behavior increased significantly (P=0.002) from 46.52 ±. 4.42 to 49.41 ± 4.98 The satisfaction score for patient services also increased, There were no statistically significant difference in systolic and diastolic blood pressure (P=0.288, P=0.768, respectively), fasting blood glucose levels (P=0.453), glomerular filtration rate (GFR) (P=0.092), while serum creatinine (P=0.037) was significantly different. However, after the implementation of the care model, there were 3 patients with an improved GFR, 18 with an unchanged GFR and 8 with a decreased GFR. Conclusion: The multidisciplinary care model for CKD improved patients’ knowledge on kidney disease and self-care behavior, which is likely to slow the deterioration of the kidneys and improve clinical outcomes.