Ontario Renal Network | Reseau Renal de L'Ontario
 

Integrate Care


 
Jody B.
“We need to ensure that primary care doctors have the knowledge and experience to support CKD patients, otherwise patients become hot potatoes that no one takes responsibility for.”Jody's Story All Stories
Mother and daughter hugging

Three hospitals are developing strategies to ensure CKD patients have access to high-quality palliative care services. Read the Story

Goal

  • Integrate patient care throughout the kidney care journey


By 2019

  • Hospitals and primary care providers will have the tools they need to reduce the incidence of avoidable harm, including acute kidney injury, in people with, or at risk of, CKD.
  • Primary care providers will have timely access to the tools and support they require to identify and manage care for people with early CKD.
  • Patients transitioning from primary care to nephrology will have timely access to appropriate pre-dialysis care.
  • Patients will receive person-centred and well-coordinated palliative care.
  • Patients will experience an easy-to-navigate pre- and post-transplant care journey.

Strategic Objectives

  • Define care expectations, best practices and accountabilities to optimize the delivery of integrated and coordinated person-centred care.
  • Ensure partnerships with provider agencies are in place to facilitate seamless patient care transitions.
  • Support primary care providers in the early identification and management of people with CKD to reduce the risk of end-stage kidney disease.
  • Establish an integrated process for the early identification and management of people with CKD who would benefit from a palliative approach.
  • Enhance access to, and improve patients’ experiences of, transplantation.

Initiatives

  • Explore and develop safety initiatives and tools to prevent avoidable harm, including acute kidney injury, in primary care and hospital settings.
  • Develop and implement tools to assist with the early identification and management of people with CKD in primary care.
  • Establish provincial standards and accountabilities with Regional Renal Programs to streamline the transition between primary care and nephrology, for people with CKD at risk of progression to end-stage kidney disease.
  • Define and implement a model of care that supports comprehensive delivery of palliative care for patients.
  • Adopt and adapt provincial frameworks and standards for palliative care of people with CKD.
  • Identify and optimize the care pathway for patients navigating the transplant process, including pre- and post-transplant, in collaboration with Trillium Gift of Life Network.
  • Ensure the necessary infrastructure is in place across the provincial network for kidney care programs to support pre- and post-transplant care in collaboration with Trillium Gift of Life Network.