Kidney Disease Population Health Management in the Era of Accountable Care: A Conceptual Framework for Optimizing Care Across the CKD Spectrum.

Since its passage in 2010, the Affordable Care Act has led to the creation of numerous accountable care organizations that face the challenge of transforming the traditional care delivery model to provide more patient-centered, high-quality, and low-cost care. Complex patients, including those with chronic kidney disease (CKD), present the most challenges and opportunities. CKD is a condition with significant morbidity, mortality, and cost and thought to be partly secondary to known gaps in care delivery. Successful population management for CKD requires consideration of the needs of patients at all phases of the disease. In this article, we offer a comprehensive framework for a population-based approach to CKD and examples of programs we are implementing in each area. These initiatives include the development and implementation of an electronic nephrology consult (e-consult) platform, CKD quality metrics, CKD registry, CKD collaborative care agreement, multidisciplinary care clinic for advanced CKD, end-stage renal disease care coordinator program, shared decision-making tools for renal replacement, CKD education videos, and a tablet-based CKD patient-reported outcome measures tool.