Remote CKD Monitoring as a part of Disease Management Program

Setting/Patient Group: Sheffield Kidney Institute

Issue to be addressed:

Discharge rates from secondary care is limited by concerns about whether patients can be reliably locked into a disease management programme in primary care.

Intervention:

• Development of renal database (Proton) in collaboration with primary care, at the Sheffield Kidney Institute (SKI) to allow remote monitoring of patients with CKD. Enabling:
  • implementation of a Clinician-led CKD-DMP specifying frequency of laboratory and blood pressure testing with individualised targets for care
  • patients on CKD-DMP to have bloods taking in primary care and self-monitor blood pressure
  • CKD nurse specialists tele-consultations with patient and primary care physicians.

Outcome:

Social

• By involving patients in self-monitoring, the model could potentially enhance patient empowerment in the management of their care, while reducing the need for travel as services are provided closer to home.

Environmental

• Reduced travel to and from hospital due to clinic visits replaced with teleconsultation, hence carbon emission reduction.

Economic

• Financial savings from avoided unnecessary travel for clinical visits and consultations replace clinic visits with a teleconsultation.

Key learning point 

The introduction of remote monitoring with teleconsultation has the potential to improve the targeting of specialist care resources (financial and environmental) to deliver the maximum value to patients.