title: Evaluating a novel health system intervention for chronic kidney disease care using the RE-AIM framework: Insights after two years.
abstract: Using a quasi-experimental design, we implemented the Patient-Centered Medical Home for Kidney Disease (PCMH-KD), a comprehensive, multidisciplinary care team to improve quality of life and healthcare coordination for adult chronic hemodialysis (CHD) patients. This paper highlights our experience in the first two years of the study. We focus on the process dimensions of Reach, Adoption, and Implementation within the context of the RE-AIM framework.
  
  
  
  We established a new PCMH-KD model at two outpatient dialysis centers. During the intervention phase, adult patients were recruited for participation and data collection. We monitored RE-AIM measures to identify areas for potential adaptation of the care model.
  
  
  
  During the start-up phase, we engaged patients and stakeholders in planning the intervention, established the new PCMH-KD team, and trained new and continuing clinicians and staff at two dialysis centers. In the intervention phase we recruited 155 patients to participate. Patients had individual visits with the PCP (40%) and the CHWs (92%) (Reach). Patient feedback informed procedures for appointment scheduling (Adoption). The new PCMH-KD team members were consistent in their roles. With staff changes, some responsibilities were adapted for cross coverage (Implementation).
  
  
  
  After one year of start-up and one year of intervention, active monitoring of Reach, Implementation and Adoption measures have facilitated necessary adaptions in the planned intervention to accommodate scheduling demands and patient feedback in the PCMH-KD model. Insights from this trial may inform care of CHD patients more broadly.
authors: Department of Medicine, Division of Academic Internal Medicine, University of Illinois at Chicago, Chicago, IL, United States; Center for Clinical and Translational Sciences, University of Illinois at Chicago, Chicago, IL, United States; Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL, United States; VA Information Resource Center, Edward Hines Jr. VA Hospital, Hines, IL, United States; Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, Hines, IL, United States. Electronic address: dhynes@uic.edu.
authors: Denise M
authors: DM
authors: Hynes
authors: Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, Hines, IL, United States; Department of Medicine, Division of Nephrology, University of Illinois at Chicago, Chicago, IL, United States; Jesse Brown VA Medical Center, Chicago, IL, United States.
authors: Michael J
authors: MJ
authors: Fischer
authors: Department of Medicine, Division of Academic Internal Medicine, University of Illinois at Chicago, Chicago, IL, United States.
authors: Linda A
authors: LA
authors: Schiffer
authors: Truven Health Analytics, Chicago, IL, United States.
authors: Rani
authors: R
authors: Gallardo
authors: Department of Medicine, Division of Academic Internal Medicine, University of Illinois at Chicago, Chicago, IL, United States; Center for Clinical and Translational Sciences, University of Illinois at Chicago, Chicago, IL, United States.
authors: Ifeanyi Beverly
authors: IB
authors: Chukwudozie
authors: Department of Medicine, Division of Nephrology, University of Illinois at Chicago, Chicago, IL, United States.
authors: Anna
authors: A
authors: Porter
authors: Center for Clinical and Translational Sciences, University of Illinois at Chicago, Chicago, IL, United States; Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL, United States.
authors: Michael
authors: M
authors: Berbaum
authors: Department of Medicine, Division of Academic Internal Medicine, University of Illinois at Chicago, Chicago, IL, United States.
authors: Jennifer
authors: J
authors: Earheart
authors: Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL, United States; Department of Pediatrics, University of Illinois at Chicago, Chicago, IL, United States.
authors: Marian L
authors: ML
authors: Fitzgibbon
mesh_terms: D000328:Adult; D000368:Aged; D000554:Ambulatory Care Facilities; D003150:Community Health Workers; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D065228:Non-Randomized Controlled Trials as Topic; D010348:Patient Care Team; D018802:Patient-Centered Care / Q000458:organization & administration*; D058007:Physicians, Primary Care; D006435:Renal Dialysis
keywords: Chronic kidney disease; Implementation science; Medical home; Patient centered medical home