From Chronic Kidney Disease Clinical Practice Guidelines to Primary Health Care: A Proposed Community Nurse Practitioner-led Care Model in the Digital Era

Abstract

Chronic kidney disease (CKD) is a major public health problem with a steadily increasing prevalence and is associated with serious complications, reduced quality of life, and rising healthcare costs. Although Thailand has established clinical practice guidelines for CKD screening, delaying disease progression, and referral management, significant challenges remain in implementing these recommendations in primary health care and community settings. This academic article aimed to synthesize key CKD clinical practice guidelines, analyze challenges in primary health care, and propose a community-based care model led by community nurse practitioners and supported by digital health technology. Evidence was synthesized from Thai CKD clinical practice guidelines, the kidney disease: Improving Global Outcomes (KDIGO) 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease, chronic care concepts, self-management support, and evidence on digital health interventions in nursing. The proposed care model consists of five key components: 1) proactive case finding, 2) risk classification, 3) coaching for self-management, 4) continuity of care through community and digital health technology, and 5) coordinated referral. The model has the potential to support guideline implementation and strengthen continuity of care. However, as the model remains conceptual, pilot studies are needed to evaluate its feasibility, clinical outcomes, and cost-effectiveness in real-world practice settings.