Overview 

Patients with chronic kidney disease (CKD) face not only a challenging diagnosis, but also an often circuitous and unpredictable treatment path. In partnership with Mass General Brigham’s Population Health Management team, we sought out insights and opportunities to make the CKD care pathway more empathetic and efficient.

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Discovery

Patient Treatment Journey

︎Gathered from patient interviews, these perspectives add color to the broad strokes journey from diagnosis through treatment. 

Patient Emotional Journey Map

︎Emotional well-being is as important as physical well-being in this diagnosis and decision-making process. Treatment delays and decisions were a core pain point to address in our interventions.


︎From the clinical side, we gathered the many delays, inefficiencies, and obstacles across the process. In combination with a patient’s own experience and acceptance about their diagnosis, we needed an intervention that was efficient and emotionally supportive.  

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Co-Design & Prototyping 

Working within the resources we had with Population Health Management, we identified a need for better support of patients through incorporating a care coordinator role into their treatment model as well as making the dialysis procedure process more efficient.
Role: visualize workflows based on clinician feedback
︎Draft of the initial intervention for supporting CKD patients through care coordination. This non-clinical role acts as a liaison for patients, helping them with the supplementary care and decision-making that may support them between appointments and as they approach renal replacement therapy decisions. 

︎Draft access workflow at both MGH and BWH highlight a portion of this intervention focused on improving the process for patients to receive an ‘access procedure,’ a procedure used to create the necessary port to initiate dialysis. This is a critical point in a patient’s CKD journey as it officially begins their renal replacement therapy journey. From the care team side, it requires significant coordination between surgeons, and other providers and staff. 

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Testing & Next Steps  

Changes have been implemented across the Mass General Brigham system and continue to be monitored and adjusted. This work launched a new way to approach chronic kidney disease care within the health system.