Care Plan

It may be helpful for healthcare professionals to document and track patient care and the various components of Conservative Kidney Management. An example Care Planning Tool is provided for your use. Similar to a Kardex, it would be written in pencil and updated as necessary.

Regular communication between healthcare teams is encouraged.

Patients often have multiple healthcare professionals involved in their care. When nephrology is involved, the roles and responsibilities of the nephrologist and the primary care provider should be clearly defined for each patient. If a transition in care is taking place (such as a patient deciding to no longer attend the kidney clinic), this needs to be communicated.

If they are involved, nephrology will generally manage the patient’s kidney disease. As part of a negotiated plan of care, nephrology can help with advance care planning, symptom management, and crisis management.

To ensure that all healthcare professionals are aware of a patient’s decision about conservative kidney management, this information should be communicated widely. This is an example letter to primary care when a patient chooses CKM. It should also be sent to other teams involved in the patient’s care (eg. home care).

If they are involved in a patient’s care, it is recommend that the nephrology team sends regular updates to the patient’s GP or NP as appropriate (suggested every 3-6 months). If a patient has support from Continuing Care (eg. homecare, supportive living, or facility living), they should receive these updates as well.

Case Conferences between care providers via telehealth or telephone are possible and should be encouraged if they can help with care coordination. The nephrology team can assist with coordinating these case conferences. Possible attendees may include: patient and family, nephrologist and/or nephrology case manager, family physician or NP, homecare case manager, palliative care consultant, and possibly others.

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