Authors (including presenting author) :
(1)Angela Yee-Moon WANG, (2) Belinda MH CHEUNG, (2) Alfred SK KWONG, (1) Shuk-King PANG, (1) Cindy Bo-Ying CHOY, (2) Welchie WK KO, (1) Daniel Tak-Mao CHAN
Affiliation :
(1) Department of Medicine, Queen Mary Hospital, University of Hong Kong (2) Department of Family Medicine and Primary Healthcare, Queen Mary Hospital, University of Hong Kong.
Introduction :
The current global prevalence of CKD is estimated to be around 9 – 14%. The global burden of CKD is expected to increase further with increase in the global burden of diabetes and an aging population.
Objectives :
The primary objective of this program is to develop a CKD shared-care model involving Renal Specialist Clinical Service and Family Medicine and Primary Healthcare Clinic Service in the Hong Kong West Cluster to streamline the care of CKD patients.
Methodology :
The CKD shared-care model involves a close partnership between the Renal Specialty of Queen Mary Hospital (QMH) and Sai Ying Pun Family Medicine Specialist Clinic (FMSC) for the management of patients with mild to moderate CKD. In essence, patients currently followed up in QMH Renal Specialty Outpatient Clinic (SOPC) with stable mild to moderate CKD, defined as estimated glomerular filtration rate (eGFR >=30ml/min per 1.73m2) and annual decline in eGFR < 20%, not requiring any immune therapy are considered eligible for the shared-care programme. Patients also need to have controlled blood pressure and diabetes as well as received maximal proteinuria reduction therapy. FMSC colleagues follow a protocol co-developed with QMH Renal Specialty for managing patients in this shared-care pathway. An urgent back referral mechanism is in place for patients that develop acute renal deterioration.
Result & Outcome :
The shared CKD care model has just started in November 2018. On the average around 2-3 cases were referred to FMSC for shared CKD care weekly. These patients will attend QMH SOPC on an annual basis for monitoring. To date, no patient required urgent back referral. The CKD shared-care model not only allows streamlining of CKD management but also enables Family Physicians to involve early in CKD care, raising awareness among family physicians of the importance in instituting a protocol-driven management for mild to moderate CKD early in order to retard CKD progression. It also aims to strengthen engagement and empowerment of patients early in their CKD management. Given the growing burden of CKD and the increasing service load of CKD patients, the shared-care model in the HKWC engages Family Physicians and Nephrologists to work together early in enhancing a streamlined service delivery to CKD patients.
Co-location with:
