Major Health Partners Kidney Care Options (KCO) Program

Description

Major Health Partners in Shelbyville, Indiana, created a nurse-led quality improvement initiative to improve care for patients with advanced chronic kidney disease. Kidney Care Options provides patient education early in the treatment process, and program coordinators revised clinical workflows for a more proactive, patient-centered approach to kidney care.

The program shifts kidney care from a reactive model, where patients often first learn about treatment options during a medical crisis, to a proactive model that gives patients time to understand their disease, consider all treatment options, involve family members, and make informed decisions. To support this approach, the care team redesigned clinical workflows and began kidney disease education earlier in the disease process. This approach allows patients to prepare for future treatment before it becomes urgent.

Major Health Partners primarily serves Shelby County but also sees patients from surrounding counties in central and southeastern Indiana.

In 2026, the program received the American Nephrology Nurses Association (ANNA) Clinical Practice Grant.

Services offered

The program provides:

• Assistance with addressing social determinants of health
• Assistance with transportation and telehealth for patients who can't travel to Major Health Partners
• Care coordination with primary care, dialysis facilities, transplant centers, and hospice
• Community education
• Coordinated transition planning from dialysis to transplant
• Counseling and helping patients make informed treatment decisions
• Discussions about advance care planning
• Education about home dialysis, transplants, and conservative (non-dialysis) care
• Lab work monitoring
• Patient support and advocacy
• Transplant referral coordination

Results

From 2023 to 2025:

• At least 80% of patients received kidney disease education before starting therapy.
• Optimal start rates (dialysis without an emergency catheter) are three times the national average (43-69% of patients versus 20-25% nationally).
• Almost 30% of patients used home dialysis.
• Patients were more likely to avoid using catheters or hospitalizations during home dialysis after receiving education.
• Patients were referred earlier if they needed a kidney transplant.

Together, these changes helped patients prepare for treatment and improved coordination among nephrology, primary care, dialysis facilities, and transplant centers.

Community fundraising efforts helped patients overcome barriers related to housing, transportation, medications, and other basic needs that affected their health. Patients have received gas cards, furniture, bed bug treatment, and assistance with affording medications.

Challenges

Challenges include:

• Changing clinical workflows
• Gaining provider buy-in on starting patient education earlier
• Making sure providers consistently document and track this work

Program coordinators addressed these challenges by engaging clinical team members, standardizing workflows, and reminding providers of their shared goals.

Replication

Celebrate the small victories.

Develop consistent workflows that allow nurses and providers to begin education early and continue those conversations over time. Starting patient education early gives patients time to understand their options, involve their support system, and make informed decisions before treatment becomes urgent. Small changes implemented consistently can improve patient preparedness.

Focus on understanding the barriers that keep patients from receiving care. Rather than assuming a patient is unwilling to participate in treatment, explore challenges such as transportation, financial concerns, health literacy, and other social needs that may affect access to care.

Contact Information