Providing More Holistic CKD Care

This blog post was made by Beth Witten, MSW, ACSW, LSCSW on March 3, 2016.
Providing More Holistic CKD Care

March is National Kidney Month. Much has been written to increase awareness of risk factors for kidney disease to avoid or delay kidney failure. Since reducing or eliminating kidney failure is a goal of the kidney community, why don’t we provide services in physician’s offices that can improve nutritional, physical functioning, emotional well-being, and rehabilitation— instead of waiting until patients’ kidneys fail and they become malnourished, depressed, and unemployed?

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) established Medicare coverage for six sessions in a lifetime of Kidney Disease Education (KDE) for those with Medicare who have Part B and a diagnosis of Stage 4 CKD1. To be reimbursed:

  • Patients must be referred by the physician treating the patient’s CKD
  • KDE must address certain topics
  • KDI can only be provided by “qualified providers” (physician, physician’s assistant, nurse practitioner or clinical nurse specialist, and certain institutional providers).

CMS assigned the G-codes G0420 for one-on-one sessions and G0421 for sessions with 2-20 participants, not all of whom have to have Stage 4 CKD (G0421).2 The KDE benefit is subject to the Medicare Part B deductible and 20% coinsurance that may be paid by other coverage.

Offering this service could help so many more who have CKD 4, but it has only been used by a small number of Medicare beneficiaries. Could the small numbers of patients using the kidney education benefit be related to patient factors? Or, could the narrow definition of who qualifies to provide and to receive the education, no requirement to measure outcomes, payment amount, or could something else be contributing? More research is needed to determine why.

Some companies and organizations provide free CKD education to people with any stage of kidney disease, including but not limited to:

CKD education is associated with better outcomes. Studies have shown that those who receive CKD education have higher knowledge scores, are more interested in choosing a home treatment especially PD,3 have slower CKD progression4, increased fistula placement and use, and are hospitalized less.5 Referral for CKD education can help patients learn what they need to know about managing their kidney disease and choosing a treatment option.

Medicare pays for a number of other preventive services that could help people with CKD as well, including but not limited to:

  • Diabetes screening and self-management education
  • Medical nutrition therapy
  • Medication therapy management
  • Obesity screening and counseling
  • Tobacco use cessation counseling
  • Alcohol misuse screening and counseling
  • Cardiovascular disease screening

Encouraging CKD patients to use these benefits could reduce the number of those requiring dialysis or transplantation.

However, it takes an interdisciplinary staff to better address some problems. For example, physicians, physician assistants, and nurses may not:

  • Have the broad knowledge that pharmacists do of options for medications to use to treat different conditions, their contraindications, side effects, food/drug interactions, and cost comparisons.6
  • Know as much as experienced renal dietitians on ways to meet CKD patient’s nutritional needs when patients are living with multiple diagnoses.
  • Know as much as experienced renal social workers about screening and addressing depression and other mental health and lifestyle behaviors, financial barriers, and work-related concerns.

Is it time to look at expanding busy nephrologists’ practices to include other disciplines who have expertise that could help people with CKD? Providing more services in a one-stop nephrologist’s office may allow nephrologists, PAs, and nurses to address patients’ medical needs, and may offer those with CKD the chance to live longer, happier, and more productive lives with a treatment that fits better with those things they value—in their homes, workplaces, and communities.

  1. Medicare & Kidney Disease Education
  2. Medicare Claims Processing Manual, Chapter 32 Special Services
  3. King K, Witten B, Brown JM, Whitlock RW, Waterman AD. (2008). The Missouri Kidney Program's Patient Education Program: a 12-year retrospective analysis. Nephrol News Issues 22(12):44-5, 48-52, 54.
  4. Enworom CD, Tabi M. (2005). Evaluation of Kidney Disease Education on Clinical Outcomes and Knowledge of Self-Management Behaviors of Patients with Chronic Kidney Disease. Nephrol Nurs J. 42(4):363-72.
  5. Dixon J, Borden P, Kaneko TM, Schoolwerth AC. (2011). Multidisciplinary CKD care enhances outcomes at dialysis initiation. Nephrol Nurs J. 38(2):165-71.
  6. Medicare Learning Network, Centers for Medicare & Medicaid Services Preventive Services


  • Beth Witten

    Mar 04, 2016 4:01 PM

    In addition to consulting with MEI, my small consulting business consults with the Missouri Kidney Program (MoKP). My daughter and I coordinate CKD education classes in Kansas City. You're absolutely right that one of the most important things that CKD education can provide is the perspective of someone living with kidney disease and undergoing the treatment. We regularly use people on all types of dialysis and recipients of living donor and deceased donor kidneys. When we can find one, we have a kidney donor. We also use renal professionals of all disciplines in the area and provide slides for them to use. MoKP PEP classes are 1-hour each (6 hours total) and include topics like Intro to Kidney Disease, Diet & Kidney Disease, Coping & Financing, Transplant, PD, and HD. Those who attend get a take-home binder with all slide copies and extra materials and we have a table of even more printed materials, plus we give them information on helpful websites. MoKP has been doing its FREE classes in MO since 1984 and people in other states are welcome to attend. We're very proud of our classes. Knowledge assessment (pre/post) and evaluations show improved knowledge and high ratings by attendees. Our only barrier to educating more CKD and ESRD patients is getting referrals. If anyone reading this is from MO or near enough to come to our classes, read about them and register at
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  • Henning Sondergaard

    Mar 04, 2016 10:57 AM

    Thanks for a great post, Beth.

    Once again I am appalled at how dialysis is run in the US.

    Failure to see that proper education of patients by those who know the most about CKD will have an effect on the entire dialysis process boggles my mind.

    In my country virtually all hospitals have some form of CKD education once people reach Stage 4. Some of it is worthless, IMHO, but it does exist after all. The most worthless programs are done only (or primarily) by doctors and nurses, failing to include dietitians and/or mental health workers.

    But an even more important issue is the failure to use experienced patients. Nobody knows more about the questions that people have before they move into Stage 5 than people who have had CKD for years and have been on dialysis for a while and maybe even received a transplant. Failure to acknowledge these experts is a sign of the inherent stupidity that exists in the healthcare system. Yes, I said STUPIDITY. I could have used stronger wording but I will restrain myself.

    People whose kidneys are failing want to know about the everyday aspects of their disease. Virtually ALL the information they can glean from professionals scores extremely low on their list of questions. Many are not ready to process medical knowledge (some might never be) but what they want to know is how they will be able to continue their life in a proper manner. And on this issue, other patients are the only experts.

    I am not suggesting that anybody can or should perform this kind of teaching. However, there are plenty of experienced users out there who would be able to take on such a task. Particularly among the home patient population - yes, I think they should all be taken from that population, but there might be a few in-center patients here and there that would be up to it as well. It might require some education into different issues of these expert patients. But no matter how much formal education one has in nephrology it will never come close to the hands on experience of a fellow patient.

    By this I am not out to exclude professionals from the CKD education process. I think we need both doctors, nurses, dietitians and social workers to do their bit as well. But I am certain, that if peer-to-peer education was the backbone of the CDK education of patients, we would see the best outcomes of any educational program.

    And as opposed to so many other factors that are extremely difficult to research - but still are tried - this would be an easy thing to arrange all kinds of comparative studies for someone who is interested in such.
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