Nursing Intervention Aimed at Improving
Self-Management for Persons with
Chronic Kidney Disease in North Carolina
Medicaid: A Pilot Project
Julie C. Jacobson Vann
Jenny Hawley
Steven Wegner
hronic kidney disease (CKD)
C
is a health condition character-
ized by kidney damage that
persists and generally worsens
over time (National Kidney Founda-
tion [NKF], 2002). Kidney damage
can range from a decline in kidney
function to kidney failure (NKF,
2002). The disease has been classified
into five stages based on glomerular
filtration rates (GFR), ranging from
Stage 1, which can be described as
having kidney damage with normal
or elevated GFR (90 mL/min/1.73m2
or higher), to Stage 5, described as
kidney failure or end stage renal dis-
ease (ESRD) (GFR less than 15 mL/
min/1.73m2 (Kidney Disease Im-
proving Global Outcomes [KDIGO],
2013; NKF, 2002). The disease can
also be classified by cause or albumin-
uria category (KDIGO, 2013).
More than 10% of adults in the
United States (U.S.), or more than 20
million people, are estimated to have
CKD (Centers for Disease Control
and Prevention [CDC], 2014). The
prevalence of CKD is increasing most
rapidly among persons 60 years of
age and over; and incidence among
those 65 years of age and older more
than doubled between 2000 and 2008
(National Kidney and Urologic Dis-
eases Information Clearinghouse
[NKUDIC], 2012). At year-end 2012,
Publishers Note: Author biographical state-
ments and acknowledgments can be found on the
following page.
Statements of Disclosure: Abhijit V. Kshirsagar
is on the Fresenius Medical Care Advisory Board.
All other authors reported no actual or potential
conflict of interest in relation to this continuing
nursing education activity.
Note: Additional statements of disclosure and
instructions for CNE evaluation can be found on
page 256.
Nephrology Nursing Journal May-June 2015
Continuing Nursing
Education
Ronald J. Falk
Donna H. Harward
Abhijit V. Kshirsagar
Copyright 2015 American Nephrology Nurses Association.
Jacobson Vann, J.C., Hawley, J., Wegner, S., Falk, R.J., Harward, D.H., & Kshiragar, A.V.
(2015). Nursing intervention aimed at improving self-management for persons with
chronic kidney disease in North Carolina Medicaid: A pilot project. Nephrology
Nursing Journal, 42(3), 239-255.
This pilot project aimed to improve knowledge and self-management among Medicaid
beneficiaries with Stage 3b and 4 chronic kidney disease who were identified using a
population-based approach. Participants received up to six in-person educational ses-
sions delivered by a nurse practitioner. Increases in knowledge and self-reported behav-
ior changes were generally observed among participants.
Key Words: Chronic kidney disease, self-management, nurse intervention, educa-
tion, and population-based approach.
Goal
To provide an overview of a pilot project designed to improve knowledge and self-manage-
ment among Medicaid beneficiaries with chronic kidney disease 9CKD) Stages 3b and 4.
Objectives
1. Discuss the use of a population-based approach to identify individuals with CKD
Stages 3b and 4..
2. Describe the results of a nurse-led education intervention pilot study to improve
knowledge and self-management individuals with CKD Stages 3b and 4.
approximately 636,905 persons were (USRDS, 2014). In North Carolina,
reported to have ESRD in the U.S. the estimated prevalence of ESRD
(NKUDIC, 2012), up from an estimat- was 21,140 persons as of December 31,
ed 391,321 in 2000 (United States 2012; with an incident count of
Renal Data System [USRDS], 2014). approximately 3,618 new cases during
The incidence rates of ESRD were 2012 (USRDS, 2014). Approximately
3.25 times higher among African 15,389 persons in North Carolina
Americans (908.0 per million popula- were receiving hemodialysis or peri-
tion) in the U.S. than for whites (279.2 toneal dialysis at year-end 2013; and
per million population) during 2012 an estimated 5,092 had previously re-
This offering for 1.5 contact hours is provided by the American Nephrology Nurses
Association (ANNA).
American Nephrology Nurses Association is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center Commission on Accreditation.
ANNA is a provider approved by the California Board of Registered Nursing, provider number
CEP 00910.
This CNE article meets the Nephrology Nursing Certification Commissions (NNCCs) continu-
ing nursing education requirements for certification and recertification.
Vol. 42, No. 3 239
Nursing Intervention Aimed at Improving Self-Management for Persons with Chronic
Kidney Disease in North Carolina Medicaid: A Pilot Project

ceived a kidney transplant (South- It is important to intervene with initiated after being admitted emer-
eastern Kidney Council, 2013). The patients about their CKD at the earli- gently to the hospital. Such patients
prevalence of ESRD per 1,000,000 est possible point in the disease pro- subsequently found, for the first time,
population adjusted for age, race and gression to have the greatest effect on that they had ESRD and would not
sex in North Carolina increased from health status and/or treatment deci- have received the prior education
approximately 864 as of December sions. Yet persons in the early stages of about options, such as peritoneal dial-
31, 1990, to 1,870 as of December 31, CKD may not be aware of common ysis. Peritoneal dialysis would only be
2012 (USRDS, 2014). but subtle symptoms (CDC, 2014; an option at a later time, after dis-
The progression of CKD to kid- Flessner et al., 2009; Moyer, 2012). charge from the hospital.
ney failure can be prevented or Early intervention for patients with To address the concerns that
delayed with appropriate interven- CKD may also be challenged by Medicaid beneficiaries with CKD
tions (CDC, 2014). For example, tight inconsistent identification, manage- may not be receiving information
glucose control for persons with type ment, and referral of patients by pri- about self-care and treatment options
1 diabetes mellitus, adequate blood mary care providers (Allen et al., 2010; prior to being diagnosed with ESRD,
pressure control for persons with Bouleware, Troll, Jaar, Myers, & Powe, our team developed a population-
hypertension, and reducing elevated 2006). Problems with access to care based intervention aimed at identify-
urine albumin levels are three strate- may also contribute to delays in receiv- ing and educating persons with CKD
gies shown to reduce the progression ing treatments and educational inter- about kidney disease and self-care.
of CKD (Formica, 2003). These goals ventions (North Carolina Institute of Previously published studies have
may be achieved with medications Medicine [NCIOM], 2007). shown mixed results in the effective-
that are appropriately taken, dietary Within the CKD Clinic at the ness of educational interventions on
changes, and other lifestyle changes, University of North Carolina (UNC), improving knowledge and self-man-
such as physical activity and quitting there were concerns that some agement for persons with CKD
smoking (National Kidney Disease patients with kidney failure may not (Bonner et al., 2014) or other chronic
Education Program [NKDEP], 2013). have been aware of CKD in earlier conditions.
Several dietary approaches include stages, may not have received care for However, several previously
limiting dietary sodium to 1,500 mg kidney disease by a health profession- published interventions provided evi-
per day, avoiding some salt substi- al prior to being seen in the emer- dence to support the development
tutes if rich in potassium, consuming gency department with acute kidney and implementation of our interven-
adequate but not excessive protein, episodes, and may not have been tion. One study evaluated the effec-
limiting dietary phosphorous and given information about treatment tiveness of a brief intervention on
potassium, and eating foods that are options. From July 2008 through June knowledge of dietary phosphorus
heart healthy (NKDEP, 2013). 2009, approximately 64% of patients control among patients receiving
Patient-centered education and man- seen for CKD education were in Stage hemodialysis (Brogdon, 2013). The
agement in the early stages of CKD 4 and 22% in Stage 5 at the time of intervention consisted of an educa-
may provide the greatest potential to referral to the CKD clinic. For some tional brochure that was reviewed
slow disease progression. patients, hemodialysis therapy was individually with patients by the
investigator. The intervention was
reinforced by reviewing the pre-test
Julie C. Jacobson Vann, PhD, MS, RN, is a Senior Researcher, American Institutes for Research, Chapel Hill, results and related educational con-
NC; an Evaluation Consultant, AccessCare, Morrisville, ND; and an Adjunct Assistant Professor, University of tent with patients and by sending the
North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC. She may be contacted directly via email at
jjacobsonvann@air.org
brochure home with the patients to
use as a source for review prior to
Jenny Hawley, MSN, RN, FNP-BC, is a Family Nurse Practitioner, University of North Carolina at Chapel completing the post-test. One month
Hill, UNC Kidney Center, Chapel Hill, NC, and a member of ANNAs Cardinal Chapter.
later, the average level of participant
Steven Wegner, MD, JD, is President, AccessCare, Morrisville, NC; a Professor, University of North Carolina knowledge, as assessed by a 20 multi-
at Chapel Hill, Department of Pediatrics, Chapel Hill, NC; and Senior Vice President & Chief Innovations ple-choice question pre- and post-test,
Officer, Community Care of North Carolina, Raleigh, NC.
increased from 40.0% to 72.5%
Ronald J. Falk, MD, is a Doc J. Thurston Professor of Medicine; Chief, Division of Nephrology & Hypertension; (Brogdon, 2013).
and Director, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, NC. A second study was conducted in
Donna H. Harward, is Director of Education and Outreach, University of North Carolina at Chapel Hill, a group of 30 patients in Japan with
UNC Kidney Center, Chapel Hill, NC. type 2 diabetic neuropathy and
Abhijit V. Kshirsagar, MD, MPH, is an Assistant Professor of Medicine, University of North Carolina at eGFR levels of 15 to 59 mL/min/
Chapel Hill, UNC Kidney Center, Chapel Hill, NC. 1.73m2 (Kazawa & Moriyama, 2013).
The nurse-led intervention consisted
Acknowledgments: This pilot project was conducted as a collaboration between the North Carolina Kidney
Center and AccessCare. The authors wish to acknowledge the support of NC Tracs, the North Carolina of six educational visits; the first four
Community Care Network (CCNC), and the CCNC care coordinators. were face-to-face in the home or clin-

240 Nephrology Nursing Journal May-June 2015 Vol. 42, No. 3

ic, and the remaining two occurred
by telephone or email. Improvements
in participant self-efficacy, self-man-
agement, and hemoglobin A1c levels
were observed among participants.
Another study utilized a combination
of peer and professional instructors in
a group intervention called the
Chronic Disease Self Management
Program (Lorig, Sobel, Ritter, Laurent,
& Hobbs, 2001). This intervention
was delivered as a 17-hour course
over seven weeks in groups of 8 to 20
participants with various diagnoses.
In this initiative, there was an empha-
sis on helping participants learn to
problem solve, make decisions, and
build confidence in self-care. Family
members were also invited to partici-
pate in the program. Participants in
this study, with a range of chronic ill-
nesses, were observed to have
improved health behaviors, such as
exercise, self-efficacy, and health sta-
tus, and had fewer visits to the emer-
gency department.
The intensity of the interventions
in previously published studies has
varied; therefore, our team decided to
develop an intervention consisting of
six visits to cover the scope of the
educational content and reflect the
Medicare Part B coverage for up to
six CKD education visits (Centers for
Medicare and Medicaid Services
[CMS], 2013).
Transtheoretical Model and Chronic
Care Model
The five stages of change within
the Transtheoretical Model (Prochaska
& DiClemente, 1983) and the Chron-
ic Care Model (Wagner et al., 2001)
guided the development and imple-
mentation of our pilot intervention.
These models support behavior change
and management of chronic diseases,
respectively.
Transtheoretical Model
The Transtheoretical Model and
the five stages of change are impor-
tant to this initiative because the
model views change as a process
where individuals may move through
the stages of readiness to change
Nephrology Nursing Journal May-June 2015
(Cancer Prevention Research Center,
n.d.). It also supports the approach of
individualizing programs to match
the needs of potential participants
and their respective stages of change
(Prochaska & DiClemente, 1982).
The five stages of change within
the Transtheoretical Model that was
refined by Prochaska and DiClemente
(1983) include precontemplation, con-
templation, preparation, action, and
maintenance. In the precontempla-
tion stage, individuals do not intend
to change behavior and may not be
aware of the risks associated with spe-
cific behaviors. Persons in the con-
templation stage are considering
making changes, generally within the
next six months and may understand
the risks associated with their behav-
ior, yet may be ambivalent because of
the perceived disadvantages of chang-
ing behavior. Persons who are in the
preparation stage intend to take
action in the short-term, usually with-
in a month, and have a plan of action
to move forward with a change.
These individuals are often ready to
be recruited for a specific health
behavior program. Individuals in the
action stage have made specific
behavior changes, generally within
the past six months, which are suffi-
cient for reducing risks for a specific
disease or injury. In the maintenance
stage, individuals have continued
with a new behavior, generally for at
least six months (Cancer Prevention
Research Center, n.d.).
Chronic Care Model
The Chronic Care Model recog-
nizes that health care for persons with
chronic illnesses occurs within three
interacting contexts: the community;
health systems, and provider organi-
zations (Bodenheimer, Wagner, &
Grumbach, 2002). Within this broad-
er context, the Chronic Care Model
includes six essential elements: com-
munity resources and policies; health
care organization; self-management
support; delivery system design; deci-
sion support; and clinical information
systems (Bodenheimer et al., 2002;
p. 1776).
Vol. 42, No. 3
Community Care of North Carolina
Pilot Project
The context of our pilot project,
Community Care of North Carolina
(CCNC), is structured as an enhanc-
ed primary care case management
program that serves North Carolina
Medicaid beneficiaries, with disease
management initiatives that reflect
the six major elements of the chronic
disease model (Dubard & Cockerham,
2008; Wagner et al., 2001). The first
element of the model, community re-
sources and policies, indicates that
chronic care needs to be supported
by resources and linkages with the
community, for example, through
community-based care management
services, which are a primary element
of the CCNC Medicaid delivery
model (Dubard & Cockerham, 2008).
Second, health services organizations
need to view chronic care manage-
ment as a priority and provide re-
wards, incentives, or resources to
meet chronic care needs. Within the
CCNC program, chronic care is sup-
ported through small monthly per
member per month reimbursement
to primary care providers for care
management activities. The third ele-
ment, self-management support, fo-
cuses on the need for delivery sys-
tems to help patients and families
acquire knowledge, skills, and feel-
ings of self-efficacy to manage their
care. This pilot project builds on the
existing self-management support sys-
tems of the CCNC disease manage-
ment programs. The fourth element,
delivery system design, includes the
redesign of practices to engage non-
physicians in supporting patients with
chronic care management and follow-
up. Fifth, decision support systems,
such as evidence-based clinical prac-
tice guidelines, should guide the care
for chronic illnesses. Within CCNC,
disease management programs are
based on evidence-based guidelines.
Sixth, clinical information systems,
such as reminder systems, audit and
feedback, and registries, should sup-
port care. Within the CCNC net-
works, a care management electronic
information system serves to identify
241
Nursing Intervention Aimed at Improving Self-Management for Persons with Chronic
Kidney Disease in North Carolina Medicaid: A Pilot Project
persons in need of care management,
document care management inter-
ventions and outcomes, communicate
across providers, and track compli-
ance with disease management proto-
cols. Our pilot intervention was
embedded into the existing CCNC
infrastructure and was supported by
the larger disease management sys-
tems.
Study Aims
In response to the concerns about
delayed access to care for persons
with CKD, our team developed and
implemented a pilot project aimed at
1) using population-based approaches
to identify and quantify North
Carolina Medicaid and dually eligible
Medicare and Medicaid beneficiaries
who have CKD Stage 3b (30 to 45
mL/minute/1.73 m2) or Stage 4 (15 to
29 mL/minute/1.73m2) and have not
been linked with needed care
providers and services; and 2) evalu-
ating the effect of a nurse education
intervention on patients self-per-
ceived health status, health services
utilization patterns, costs of care, self-
efficacy in managing chronic kidney
disease, and CKD-related short-term
outcomes. It was expected that taking
a population-based approach would
facilitate reaching patients earlier in
the care and decision-making process.
In the longer term, it is expected that
earlier access to CKD education and
linkage with care providers may help
to improve care and reduce emer-
gency department and inpatient uti-
lization.
Methods
Setting and Project Partners
The setting for this project is the
UNC CKD Clinic, which opened in
2008. The project was implemented
in two of three clinic locations, Chapel
Hill and Burlington, North Carolina.
The purpose of this clinic is to educate
patients about CKD, complications of
the disease, and care options. The
clinic is directed by a physician and
staffed by nurses who provide educa-
242
tion to supplement the care given by
physicians. The UNC CKD clinic cli-
nicians partnered with AccessCare,
one of the 14 CCNC Medicaid
provider networks, to plan, imple-
ment, and evaluate this pilot project.
The CCNC networks engage in pop-
ulation-based care management and
disease management initiatives that
enhance access and quality of care for
Medicaid beneficiaries while facilitat-
ing appropriate health services utiliza-
tion and cost-containment goals. The
CCNC networks serve approximately
1.2 million Medicaid beneficiaries
(CCNC, 2014).
Intervention
The study intervention was
developed and delivered by the CKD
nurse educator who is a family nurse
practitioner (FNP). The intervention
components and steps were docu-
mented in detail in the written plan
for CKD Education Program. This
intervention consisted of the CKD
educational sessions with the CKD
nurse educator, assessment of readi-
ness to change, a CKD toolkit indi-
vidualized for each participant, and
collaborative goal-setting between the
CKD nurse educator and the patient.
The CKD educational content was
based on the NKDEP (2012), an ini-
tiative of the National Institute of
Diabetes and Digestive and Kidney
Diseases (NIDDK). The content con-
sisted of 20 categories of topics classi-
fied into five content areas: overview
of CKD; general CKD management;
co-morbidities and special issues for
persons with CKD; effect of CKD on
symptoms and self-care management
strategies and behaviors; and treat-
ment options and/or modalities (see
Table 1).
Major concepts were displayed
in visual tools during the visits, for
example, by using handouts and a
whiteboard, to reinforce educational
content that was discussed. Each par-
ticipant was provided with a UNC
Kidney Center canvas tote bag to
carry intervention handouts, which
were developed by the CKD nurse
educator. These handouts included a
12-page Patients Guide to Chronic
Nephrology Nursing Journal
Kidney Disease booklet, which
included educational materials for all
topics in the curriculum and a list of
helpful websites; supplemental hand-
outs that covered topics such as heart
health; a laminated kidney-friendly
shopping list for CKD patients; and
a laminated helpful hints for a kid-
ney friendly diet. The intervention
was supported by the Stages of
Change construct within the Trans-
theoretical Model (Prochaska &
DiClemente, 1983). The CKD nurse
educator met individually with eligi-
ble Medicaid and dually eligible ben-
eficiaries who agreed to participate in
the intervention for up to six clinic
visits to discuss the 20 categories of
topics related to CKD and self care
(see Table 1). At the visits, the CKD
nurse educator assessed the partici-
pants Transtheoretical Model stage of
change: precontemplation, contem-
plation, preparation, action, or main-
tenance (Prochaska & DiClemente,
1983).
The intervention also consisted of
a brief collaborative goal-setting
process at each patient visit with the
CKD nurse educator. The educational
intervention was delivered in segments
over the six visits that were each
expected to last approximately 60
minutes. The intervention was individ-
ualized based on patient needs, clinical
status, co-morbidities, understanding,
and the assessed Transtheoretical
Model stage of change.
Evaluation Design
A pre-intervention post-interven-
tion design and case series approach
was used to evaluate the pilot project.
The study was approved by the UNC-
Chapel Hill School of Medicine Insti-
tutional Review Board.
Eligibility Criteria
Persons were eligible for this inter-
vention and study if a) 18 years of age
or older at the time of enrollment; b)
living in the service areas of at least
one of the two UNC Chronic Kidney
Disease Clinic locations; c) insured by
NC Medicaid as primary or secondary
payer, for example, Medicare may be
primary for dually eligible beneficiar-
May-June 2015 Vol. 42, No. 3
 Table 1
Topic List of CKD Educational Intervention and Number and Percent of Participants Who
Demonstrated Improvement in Knowledge by Meeting Established Evaluation Criteria after
Receiving the Educational Intervention.

Met Knowledge Criteria # (n)

Pre- Post- %
List of CKD Educational Topics Sample Knowledge Assessment Questions Test Test Improved
Overview of CKD
1. Normal kidney function What are two normal functions of the kidneys? 2 (9) 8 (9) 66.7
2. Chronic kidney disease (CKD) What is chronic kidney disease or CKD and what 4 (9) 7 (9) 33.3
does this mean to you?

3. Lab work and meaning of test results What two blood tests tell how well your kidneys 1 (9) 6 (9) 55.6
(eGFR, creatinine, blood urea nitrogen are working?
[BUN], chemistries, hemoglobin, urine What do GFR and creatinine mean? 0 (9) 4 (9) 44.4
dipstick)

4. Relationship of CKD to diabetes and What are the two leading causes of chronic 2 (9) 8 (9) 66.7
hypertension kidney disease?
How does diabetes affect your kidneys? 1 (7) 5 (7) 57.1
How does high blood pressure affect your 1 (9) 8 (9) 77.8
kidneys?
General CKD Management
5. Common medications for CKD and What medicines are you taking for your kidney 4 (8) 7 (8) 37.5
medicines to avoid disease? What does each medicine do?
What are three medicines or substances that you 1 (8) 8 (8) 87.5
should avoid because of your kidney disease?
What pain medicine is safe or okay to take when 4 (8) 8 (8) 50.0
you have chronic kidney disease?
6. Diet and/or nutritional management of What are the three things in foods that you need 0 (8) 7 (8) 87.5
CKD, including fluid control to limit or eat less of in your diet?
7. Exercise and sexual activity What are two benefits or good things about 2 (8) 8 (8) 75.0
getting regular exercise?
8. Overall strategies and/or therapy to What are three things that you can do to help 3 (8) 6 (8) 37.5
slow the progression of CKD slow down the damage to your kidneys?
Co-Morbidities and Special Issues for Persons with CKD
9. Heart health Prevention and What are two things that you can do to keep your 5 (7) 7 (7) 28.6
management heart as healthy as possible and lower your
risk of heart disease?
10. Anemia and its management Why do some people with kidney disease have 0 (7) 2 (7) 28.6
anemia, which you may know as low red
blood cells or low blood?
What treatments are given for this anemia? 0 (7) 5 (7) 71.4
11. Bone disease and management Why do some people with kidney disease have 0 (7) 4 (7) 57.1
bone disease?
What can you do to prevent or slow down bone 0 (7) 5 (7) 71.4
disease?

continued on next page

Nephrology Nursing Journal May-June 2015 Vol. 42, No. 3 243

Nursing Intervention Aimed at Improving Self-Management for Persons with Chronic
Kidney Disease in North Carolina Medicaid: A Pilot Project

Table 1 (continued)
Topic List of CKD Educational Intervention and Number and Percent of Participants Who
Demonstrated Improvement in Knowledge by Meeting Established Evaluation Criteria after
Receiving the Educational Intervention.

Met Knowledge Criteria # (n)

Pre- Post- %
List of CKD Educational Topics Sample Knowledge Assessment Questions Test Test Improved
Co-Morbidities and Special Issues for Persons with CKD (continued)
12. Diabetes management, including What blood test is used to check your overall 1 (5) 2 (5) 20.0
neuropathy blood sugar or blood glucose control?
What are two ways that you can keep your blood 3 (5) 3 (5) 0.0
sugar under control?
Why is keeping your blood sugar under control 2 (5) 4 (5) 40.0
so important?
13. Hypertension management What is the target or goal for your blood pressure 2 (7) 3 (7) 14.3
level?
What are two ways that you can keep your blood 4 (7) 5 (7) 14.3
pressure under control?
Why is keeping your blood pressure under 2 (7) 5 (7) 42.9
control so important?
Effect of CKD on Symptoms and Self-Care Management Strategies and Behaviors
14. Physical symptoms, impairment of What are some symptoms that you have that you 4 (5) 5 (5) 20.0
functioning and well-being think are due to your kidney disease?
What can you do to make these symptoms less? 2 (5) 5 (5) 60.0
15. Coping with CKD: emotional issues, What are your feelings and emotions related to 3 (5) 5 (5) 40.0
effect on family and social life, work having kidney disease?
and finances What one thing can you do to deal with these 4 (5) 5 (5) 20.0
feelings and emotions in a healthy way?
Treatment Options and/or Modalities
16. Symptoms of kidney disease and What are three signs and symptoms of 0 (5) 4 (5) 80.0
kidney failure worsening kidney disease or kidney failure?
17. Hemodialysis at home and in-center; How often do most people have hemodialysis 1 (5) 5 (5) 80.0
and access options treatments?
What special procedure or operation is required 1 (5) 4 (5) 60.0
before you can start hemodialysis?

18. Peritoneal dialysis and access: What is one advantage of peritoneal dialysis as a 0 (5) 3 (5) 60.0
continuous ambulatory peritoneal treatment option?
dialysis (CAPD) and continuous What special procedure or operation and training 0 (5) 2 (5) 40.0
cycling peritoneal dialysis (CCPD) are required before peritoneal dialysis can be
started?
19. Kidney transplant: living donor and What is one advantage of having a kidney 1 (5) 4 (5) 60.0
deceased donor transplant?
What are the two types of kidney transplants? 0 (5) 5 (5) 100.0
What two things do you need to do after a kidney
transplant? 0 (5) 1 (5) 20.0
20. Right to refuse treatment If a person with kidney failure decides not to 5 (5) 5 (5) 0.0
have dialysis or a transplant, what will
eventually happen?
What document or papers should be completed if 2 (5) 5 (5) 60.0
a person decides not to have treatment for
kidney failure?

Note: n = the number of persons in the denominator for measuring improvement in knowledge.

244 Nephrology Nursing Journal May-June 2015 Vol. 42, No. 3

ies; d) have CKD Stage 3b or 4 with an
estimated GFR (eGFR) of 15 to 29
(Stage 4) or 30 to 45 (Stage 3b)
mL/minute/1.73 m2, on two separate
measurements a minimum of one
month apart; and e) not linked with
needed CKD services, such as patient
education. Persons were excluded if a)
previously participated in a CKD edu-
cational intervention or clinic, or b)
eGFR of less than 15 or of 45 or mL/
minutes/1.73m2 or higher at enrollment.
Study Procedures
Population-based approach to
identifying participants. Popula-
tion-based strategies were used to
identify potentially eligible Medicaid
beneficiaries using a series of steps. In
step one, electronic files of eGFR lab-
oratory values for North Carolina
Medicaid beneficiaries drawn be-
tween May 1, 2009, and December 2,
2011, were screened to identify partic-
ipants with eGFR values in the eligi-
bility range. This step was intended to
be sensitive but not specific. In step
two, the CKD nurse educator re-
viewed electronic health records and
Medicaid files of potentially eligible
persons to further screen for eligibili-
ty. Because laboratory value data
were reported for a range of dates, the
screening lab data needed to be sup-
ported with a review of records to fur-
ther assess eligibility, such as whether
the person was currently living, the
current CKD stage, and whether
treatment, such as dialysis, was being
received. In step three, the CKD
nurse educator checked North
Carolina Medicaid care management
records to determine whether the
potentially eligible person was receiv-
ing community-based care manage-
ment services. If so, the AccessCare
community-based care manager was
asked to make the initial contact with
the person to assess potential interest
in receiving CKD education. The
CKD nurse educator contacted the
person by telephone and/or letter to
describe the program, determine
whether the person was interested in
participating, and assess potential bar-
riers to participation if not interested.
Patients were eligible to receive the
Nephrology Nursing Journal May-June 2015
educational intervention whether or
not they agreed to participate in the
study. However, all who were inter-
ested in the intervention agreed to
participate in the study.
Intervention process. The CKD
nurse educator scheduled the initial in-
clinic visit for persons who were poten-
tially eligible for the intervention. At
the initial visit, the educator ordered
laboratory work to further assess CKD
status and stage, conducted informed
consent, and administered baseline
assessments of patient knowledge, self-
perceived health status, healthcare uti-
lization patterns, and self-efficacy in
managing CKD.
During each visit, the CKD nurse
educator delivered a module of the
educational intervention, assessed
patient understanding of CKD con-
cepts discussed and Transtheoretical
Model stage of change, worked col-
laboratively with patients to set small
measurable behavior change goals,
and assessed goal achievement from
prior visits. The educational interven-
tion was guided by a standardized
curriculum and supported by supple-
mental patient resources. The mutual-
ly established goals were intentionally
small, targeted, and achievable based
on what participants believed they
could accomplish in the short-term.
New goals were established at each
visit, building on the previous accom-
plishments.
Data Sources
Data for this study were obtained
from a hospital database extract, elec-
tronic health records, population-
based electronic Medicaid files, patient
questionnaires and assessment tools,
and documentation of interactions
with patients. A series of three data
requests were made to UNC Health
Care between May 2010 and
December 2011 to obtain records of all
adult Medicaid beneficiaries who had
received health services at UNC
Health Care in any department and
had an eGFR laboratory result during
the previous year for the first request
and during the previous six months for
subsequent requests. Data were pro-
vided in ExcelTM files on a secured
Vol. 42, No. 3
server. Data elements for each poten-
tial participant were Medicaid identifi-
cation number, date of service, gender,
race, and eGFR. Medical records at
UNC Health Care were reviewed for
beneficiaries who had eGFR lab val-
ues within the range of 15 to 45 mL/
minute/1.73m2. The North Carolina
Medicaid Clinical Management Infor-
mation System (CMIS) is the primary
database used by care managers to
document care management needs
and services provided. It also includes
some data extracted from the North
Carolina Medicaid claims database.
This database was reviewed to assess
whether or not beneficiaries received
care management services.
Measurement
During visits with participants,
self-report data were collected using
four tools: four-item Healthy Days
component of the Health-Related
Quality-Of-Life 14-Item Measure
(HRQOL-14) (CDC, 2011); four-item
Health Care Utilization measure
(Stanford Patient Education Research
Center, n.d.); eight-item Perceived
Kidney Self-Management Scale (see
Table 2); and the Nurse Education
Intervention Checklist. The four-item
Healthy Days Measure is a standard
set of questions that is included in the
State-Based Behavioral Risk Factor
Surveillance System, National Health
and Nutrition Examination Survey,
and the Medicare Health Outcome
Survey (CDC, 2011). Psychometric
testing of the four-item Health Care
Utilization measure has been report-
ed in a study that compared self-
reported health services utilization
with health records (Ritter, Kaymaz,
Stewart, Sobel & Lorig, 2001). This
study demonstrated that participants
have a tendency to under-report
physician visits (r = 0.64) and over-
report emergency department visits (r
= 0.60); however, the authors con-
cluded that self-reported utilization is
a potentially viable alternative to
reviewing provider records (Ritter et
al., 2001). The Perceived Kidney Self-
Management Scale is a modified ver-
sion of the eight-item Perceived
Medical Condition Self-Management
245
Nursing Intervention Aimed at Improving Self-Management for Persons with Chronic
Kidney Disease in North Carolina Medicaid: A Pilot Project
List of Study Instruments and Frequency and Timing of Administration
Tool Name
Intake Tool and Demographic
Information
Patient Interview tool
Part I Healthy Days
Part II Health Care Utilization
Part III Perceived Kidney
Self-Management Scale
Nurse Education Intervention
Checklist
Part A. Measurement of Patient
Knowledge or Understanding
Part B. Measurement of Patient-
Directed Goals and Goal
Achievement
Part C. Measurement (Time) of Nurse
Intervention (Education)
Health Measures Abstract Tool
Part A. Agencies and Services Involved
in Care
Part B. Diagnoses
Part C. Medications
Part D: Lab Values and Other Health
Measures
Scale (PMCSMS) (Wallston, Osborn,
Wagner, & Hilker, 2011) and the Per-
ceived Diabetes Self-Management
Scale (PDSMS) (Wallston, Rothman,
& Cherrington, 2007), which was cre-
ated by replacing medical condi-
tion or diabetes with kidney dis- ures in the previous six months: visits
ease in the PMCSMS and PDSMS,
respectively. The PMCSMS was adapt-
ed from the validated Perceived Health
Competence Scale (PHCS) (Smith,
Wallston & Smith, 1995), and was found
to have internal consistency among
persons with HIV (Cronbachs alpha
= 0.78) and diabetes (Cronbachs
alpha = 0.82) (Wallston et al., 2011)
and validity when correlating results
with other validated measures of self-
efficacy. The PMCSMS is intended to
be a generic tool that can be adapted
for different conditions.
The Healthy Days tool assessed
four components of self-perceived
health status: general health, physical
246
Table 2
Types of Measures
(# of Questions)
Demographic and contact information.
Self-perceived health status (4).
Self-perceived utilization (4).
Self-perceived self-management (8).
Knowledge and understanding of CKD
and related concepts.
Individualized patient behavior change
goals, baseline measures, and goal
achievement.
Duration of educational intervention.
Agencies actively involved in care of
patient.
Renal diagnosis and co-morbidities.
Medications, dose, frequency and route
of administration.
Intermediate health measures, such as
eGFR, other lab values, blood pressure
and weight.
health, mental health, and restrictions
in completing usual activities because
of health (see Table 3). The Health
Care Utilization tool was used to
assess the self-reported frequency of
occurrence for the following meas-
unsuccessful literature search to find a
to a physician, visits to a hospital
emergency department, overnight
stays in a hospital, and nights in a hos-
pital (see Table 3). The eight Manag-
ing Your Health Problem questions
were adapted from the validated Dia-
betes Self-Management Scale (Wallston
et al., 2007). These items were posed
as statements asking participants to
rate agreement with a series of nega-
tive and positive statements about
self-care for CKD (see Table 3). These
measures were assessed at baseline
and completion of the full interven-
tion. For the Health Care Utilization
items, the follow-up measurement
occurred six months after baseline be-
Nephrology Nursing Journal
Frequency and Timing
of Administration
Baseline.
Baseline and sixth educational visit.
Every educational visit.
Knowledge: Pre-intervention and post-
intervention for each visit for the
content covered.
Parts A, B, and C: baseline and as
changes occur.
Part D: Monthly during intervention
period.
cause the questions asked about uti-
lization over the past six-month time
period.
The Nurse Education Interven-
tion Checklist was developed by the
research team after conducting an
tool that would guide the CKD edu-
cational intervention and assess learn-
ing. However, the knowledge assess-
ment component was modeled after
the Spoken Knowledge in Low Liter-
acy patients with Diabetes (SKILLD)
(Rothman et al., 2005). The CKD
knowledge checklist assessed the fol-
lowing: CKD content taught, baseline
knowledge for 20 topics, post-inter-
vention knowledge, health behavior
goals and goal achievement, and
duration of the CKD nurse educa-
tional session in minutes (see Table 1).
The educational intervention
process was measured by indicating
for each topic whether it was covered,
May-June 2015 Vol. 42, No. 3
 Table 3
Survey Questions and Participant Responses Assessing Self-Perceived Health Status, Health Care
Utilization, and Self-Perceived Self Management

Survey Questions Response Options Pre-Test Post-Test

Self-Perceived Health Status: Healthy Days
1. Would you say that in general your health is: Excellent 1 (9) 0 (4)
Very good 1 (9) 1 (4)
Good 3 (9) 2 (4)
Fair 3 (9) 1 (4)
Poor 1 (9) 0 (4)
2. Now thinking about your physical health, which includes physical Number of days
illness and injury, for how many days during the past 30 days was Mean 7.1 (8) 6.5 (4)
your physical health not good? Range 0 to 15 0 to 14
3. Now thinking about your mental health, which includes stress, Number of days
depression, and problems with emotions, for how many days dur- Mean 10.1 (9) 5.3 (4)
ing the past 30 days was your mental health not good? Range 0 to 30 0 to 16
4. During the past 30 days, for about how many days did poor physi- Number of days
cal or mental health keep you from doing your usual activities, Mean 0.8 (9) 4.0 (4)
such as self-care, work, or recreation? Range 0 to 5 0 to 14
Health Care Utilization
5. In the past 6 months, how many times did you visit a physician? Number of times
Do not include visits while in the hospital or to a hospital emer- Mean 7.3 (9) 8.8 (4)
gency room. Fill in with 0 or another number. Range 4 to 25 3 to 8
6. In the past 6 months, how many times did you go to a hospital Number of times
emergency room? Fill in with 0 or another number. Mean 1.1 (9) 1.5 (4)
Range 0 to 4 0 to 4
7. How many different times did you stay in a hospital overnight or Number of times
longer in the past 6 months? Fill in with 0 or another number. Mean 0.4 (9) 0.25 (4)
Range 0 to 2 0 to 4
8. How many total nights did you spend in the hospital in the past 6 Number of nights
months? Fill in with 0 or another number. Mean 1.1 (9) 1.8 (4)
Range 0 to 7 0 to 7
Managing Your Health Problem: 1 = Strongly Disagree
Perceived Kidney Disease Self-Management Scale to 5 = Strongly Agree Pre-Test Post-Test
9. It is hard for me to find effective ways to deal with problems that 1 to 2 3 (9) 4 (4)
occur with managing my kidney disease. 3 3 (9) 0 (4)
4 to 5 3 (9) 0 (4)
10. I find that efforts to change things I dont like about my kidney dis- 12 4 (9) 3 (4)
ease arent helpful. 3 3 (9) 1 (4)
4 to 5 2 (9) 0 (4)
11. I handle myself well with respect to my kidney disease. 1 to 2 2 (9) 0 (4)
3 0 (9) 0 (4)
4 to 5 7 (9) 4 (4)
12. I am able to manage things related to my kidney disease as well 1 to 2 1 (9) 0 (4)
as most other people. 3 0 (9) 0 (4)
4 to 5 8 (9) 4 (4)
13. I succeed in the goals I undertake to manage my kidney disease. 1 to 2 2 (9) 0 (4)
3 0 (9) 0 (4)
4 to 5 7 (9) 4 (4)

continued on next page

Nephrology Nursing Journal May-June 2015 Vol. 42, No. 3 247

Nursing Intervention Aimed at Improving Self-Management for Persons with Chronic
Kidney Disease in North Carolina Medicaid: A Pilot Project

Table 3 (continued)
Survey Questions and Participant Responses Assessing Self-Perceived Health Status, Health Care
Utilization, and Self-Perceived Self Management

Managing Your Health Problem: 1 = Strongly Disagree

Perceived Kidney Disease Self-Management Scale to 5 = Strongly Agree Pre-Test Post-Test
14. Typically, my plans for managing my kidney disease dont work 1 to 2 5 (9) 4 (4)
out well. 3 1 (9) 0 (4)
4 to 5 3 (9) 0 (4)
15. No matter how hard I try, managing my kidney disease doesnt 1 to 2 5 (9) 3 (4)
turn out the way I would like. 3 0 (9) 1 (4)
4 to 5 4 (9) 0 (4)
16. Im generally able to accomplish my goals with respect to manag- 1 to 2 2 (9) 0 (4)
ing my kidney disease. 3 2 (9) 0 (4)
4 to 5 5 (9) 4 (4)

not covered, or not applicable for Figure 1

each visit. Participant knowledge of
each content area was assessed by the
CKD nurse educator by asking a stan-
dard set of questions for the respec-
tive content areas covered during the
visit. Participant responses to each
question were compared with stan-
dardized responses that would be
considered acceptable. The CKD
nurse educator rated the participant
responses to each question as: yes
(met all established criteria) or no (did
not meet criteria); or not applicable.
The full set of educational assessment
questions was asked again at the last
education visit to measure knowledge
retention. Health behavior goal set-
ting was documented on the checklist
within both a statement and a matrix
to document goals and goal achieve-
ment over time, including baseline
date for goal, measurable goal and
description, baseline value, target
goal, target date, and follow-up meas-
ure. Revisions to goals were docu-
mented during each visit.
Analysis
Data from this pilot project were
assessed using descriptive approach-
es. First, changes in participant know-
ledge, as assessed using the Nurse
Education Intervention Checklist,
were summarized as the number and
percentage of participants who did
not provide an accurate response to
the knowledge assessment prior to
receiving the educational intervention
Screening, Selection, and Enrollment of Study Participants
Patients screened for eligibility
through review of eGFR lab values
(3,029).
Potentially eligible for
intervention based on 1 eGFR
lab value (1,140)
Potentially eligible based on
review of health records (53)
Participated in pilot study (9)
for the specified content area yet
responded correctly after receiving
the intervention. Second, responses to
the 16-patient interview tool questions
regarding self-perceived health status,
health services utilization, and disease
self-management were measured and
compared over time. Third, partici-
pant-specific health behavior goals,
baseline measures and follow-up
measured were documented. These
behavioral assessments are summa-
rized in brief case descriptions.
Not eligible based on screening
eGFR lab values (1,889)
Not eligible based on review of
health records (1,087)
Declined to participate or no
longer eligible (44)
Results
Of the 3,029 patients who were
screened for potential eligibility, 53
(1.7%) were found to be eligible for
the pilot project based on a review of
health records. Of these, 9 (0.3%) per-
sons screened agreed to participate in
the study (see Figure 1). Persons
screened were identified as being
ineligible because of: improved
eGFR after initial screening, declin-
ing eGFR, on dialysis, status post kid-

248 Nephrology Nursing Journal May-June 2015 Vol. 42, No. 3

 Table 4 ney transplant, medically inappropri-
Demographic Characteristics of Study Participants ate, residing in institutional setting or
on hospice care, other worsening
Frequency comorbidities, or deceased. Eligible
Demographic Characteristic (%) persons who declined to participate
Age in the study indicated lack of trans-
portation to the clinic or cost of auto
50 to 59 years 2 (22.2)
fuel to travel to the clinic (n = 11), lack
60 to 69 years 2 (22.2) of interest (n = 12), or not aware of or
70 to 79 years 3 (33.3) denying CKD (n = 3).
80 to 89 years 2 (22.2) Participants in this pilot ranged in
Gender age from 52 to 82 years, with three
participants 70 to 79 years of age, and
Male 4 (44.4) two each in 50 to 59, 60 to 69, and 80
Female 5 (55.6) to 89 years of age categories (see
Ethnicity Table 4). Five participants (55.6%)
Not Hispanic or Latino 9 (100.0) were female, all were non-Hispanic
and English-speaking, and six (66.7%)
Hispanic or Latino 0 (0.0)
were black or African American.
Race Three (33.3%) participants were sin-
Black or African American 6 (66.7) gle, three (33.3%) were widowed, two
White 2 (22.2) (22.2%) were divorced, and one
Asian 1 (11.1)
(11.1%) was married. Only two
(22.2%) participants had completed
American Indian or Alaskan Native 0 (0.0) some college, three (33.3%) had com-
Native Hawaiian or Pacific Islander 0 (0.0) pleted high school or a GED, four
Patients Preferred Language (44.4%) had less than a high school
English 9 (100.0) education. More than half (n = 5;
55.6%) rented a home or apartment,
Spanish 0 (0.0)
two (22.2%) owned their own homes,
Marital Status one lived with a daughter, and one
Single, never married 3 (33.3) lived with a friend.
Married 1 (11.1) The average number of interven-
tional visits completed with the CKD
Widowed 3 (33.3)
nurse educator per participant was
Divorced 2 (22.2) 4.2 with a range of one to six (see
Highest Level of Education Achieved Table 5). Four participants completed
Elementary School (K 5) 1 (11.1) all six visits and reviewed all relevant
Middle School (6 8) 2 (22.2) content areas. The mean visit dura-
tion was 63.4 minutes with a range of
Some High School 1 (11.1) 45 to 90 minutes. The initial visit was
High School or GED 3 (33.3) generally the longest, with an average
Some College 2 (22.2) length of 81.7 minutes, ranging from
2-Year College Degree (Associates) or higher 0 (0.0) 60 to 90 minutes. The length of visits
two through six averaged 57.8 min-
Type of Residence
utes with a range of 45 to 75 minutes.
Owns Home 2 (22.2)
Rents Home or Apartment 5 (55.6) Changes in Participant
Other 2 (22.2) Knowledge
Number of People at Residence (for past 2 months)
The percent of participants
whose knowledge of CKD concepts
One person 3 (33.3) increased after the intervention var-
Two persons 4 (44.4) ied by content type. Knowledge
Three persons 0 (0.0) improvement was generally more
Four persons 2 (22.2) consistent among participants for the
content areas of overview of CKD,
general CKD management, and treat-

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Nursing Intervention Aimed at Improving Self-Management for Persons with Chronic
Kidney Disease in North Carolina Medicaid: A Pilot Project

Table 5
Frequency and Length of Participant Visits with CKD Nurse Educator

Measure Frequency Mean Range

Number of participant visits with CKD nurse educator N/A 4.3 1 to 6
Number of participants completing visits
1 visit 1 N/A N/A
3 visits 3 N/A N/A
5 visits 1 N/A N/A
6 visits 4 N/A N/A
Visit duration in minutes
All visits N/A 63.4 45 to 90
Initial visits only N/A 81.7 60 to 90
Second through sixth visits N/A 57.8 45 to 75

ment options and/or modalities.
Knowledge improvement generally
occurred less frequently among par-
ticipants for most topics in the content
areas of co-morbidities and special
issues for persons with CKD; and the
effect of CKD on symptoms and self-
care management strategies and
behaviors. All five participants who
discussed transplant types with the
CKD nurse educator were able to
recall and state the two types of kid-
ney transplants post-intervention, but
none prior to receiving the interven-
tion. All participants described the
consequences of not getting care for
ESRD both before and after the inter-
vention.
At least two-thirds of participants
demonstrated knowledge improve-
ment after the intervention on ques-
tions focused on medicines and sub-
stances to avoid (87.5%), foods to limit
(87.5%), signs and symptoms of wors-
ening kidney disease or kidney failure
(80.0%), frequency of hemodialysis
treatments (80.0%), effect of high
blood pressure on kidneys (77.8%),
benefits of getting regular exercise
(75.0%), treatments for anemia
(71.4%), preventing or slowing the
progression of bone disease (71.4%),
normal functions of the kidneys
(66.7%), and leading causes of kidney
disease (66.7%). The observed post-
test knowledge improvement oc-
curred with the lowest frequency for
questions focused on blood sugar
management for persons with dia-
betes (0.0%), target blood pressure
values (14.3%), strategies for blood
pressure management (14.3%), blood
test used to assess blood glucose con-
trol (20.0%), symptoms that are relat-
ed to CKD (20.0%), self-care after a
kidney transplant (20.0%), and strate-
gies for coping with feelings about
CKD (20.0%). Conclusions that can
be made from these results are limit-
ed because the number of respon-
dents is very small.
Changes in Participant Health
Behaviors and Health-Related
Outcomes
The mutually developed measur-
able goals typically focused on nutri-
tion and physical activity. Examples
included reducing salt use at the table,
walking more, grilling and baking
foods instead of frying them, lowering
potassium and phosphorus in the diet,
and consuming more fresh and frozen
vegetables. In general, participants
achieved the established behavioral
goals during the study period (see
Table 6). One participant achieved a
nine-pound weight loss. At least two
participants reduced their blood pres-
sure levels. Two participants reported
an increase in physical activity. Other
behaviors changes and outcomes
included, decreased use of salt substi-
tutes, improved energy level, reduced
intake of fried foods, eating more
fruits and vegetables, and avoiding
over-the-counter medications that are
generally contraindicated for persons
with CKD.
Self-perceived health status, self-
reported health care utilization, and
perceived self-management of CKD
were assessed for all nine participants
at baseline (see Table 3). The results of
these self-reported measures are also
reported for the four participants who
completed six visits with the CKD
nurse educator. The post-test survey
was generally completed approxi-
mately four months after the pre-test
survey. Pre-test/post-test comparisons
are not very meaningful because of
the small numbers and the interven-
tion, especially for the post-test.
Acknowledging data limitations,
there was a reported decrease in days
where mental health was not good
over the past 30 days from a mean of
10.1 to 5.3 days. The average number
of physician visits during the previous
six months remained relatively stable
from the pre-test (7.3 visits) to post-test
(8.8 visits) period. The four partici-
pants who completed the six educa-
tional visits generally reported agree-
ment with the four positively-stated
questions about self-management of
CKD, and disagreement with the four
negatively stated questions about self-
management. For example, four of
four participants at post-test indicated

250 Nephrology Nursing Journal May-June 2015 Vol. 42, No. 3

 Table 6
Examples of Individualized Behavioral Goals and Outcomes for Study Participants

Demographic CKD Stage

Characteristics Brief History General Goal Outcomes
60-year-old African- CKD Stage 3b; Weight loss Achieved 9 pound weight loss over 12 months.
American female hypertension; type 2
diabetes; HIV; asthma, Exercise Began walking to mailbox daily.
sleep apnea
Lower salt intake Reduced table salt use from 2 to 3 shakes to 1
shake.

Decrease fat intake Consumed less fried foods; removed skin from
chicken; changed to lower fat milk.
60-year-old African- CKD Stage 3b; Improve blood pressure Blood pressure dropped from ~ 146/90 to 124/80.
American female polycystic kidney monitoring and control Took blood pressure at home daily.
disease; hypertension;
cerebral aneurysm Decrease salt intake Stopped use of table salt; cooked with less salt;
consumed more fresh and frozen vegetables.

Decrease fatty food Consumed less fried foods, only twice in 4 weeks;
consumption changed to canola oil; grilled and baked meats.

Follow CKD diet Lower potassium and phosphorus in diet; increased

water intake; stopped drinking soda.

53-year-old African- CKD Stage 4; Weight loss Lost weight intermittently with weight fluctuation.
American male hypertension; diabetes
mellitus; obese; focal Better blood pressure Reduced systolic blood pressure from 160s to 140s.
segmental glomerulo- control
sclerosis; gout
Exercise Increased exercise and walking.

Reduce sugar and fat Changed to sugar-free sweetener, diet sodas and
intake low-fat milk.

Reduce salt intake Not cooking with or adding salt to foods; consuming
lower-sodium foods.
81-year-old African- CKD Stage 3b, Increase exercise Increased length and duration of walking from 1-2
American female hypertension, diabetes brief walks per day to 5.
mellitus, history of
myocardial infarction, Avoid contraindicated Switched to a recommended laxative.
gout, hyperlipidemia over-the-counter
medications

Decrease weight Lost 2.5 pounds by visit 2, lost 7 pounds by visit 3.

Decrease salt intake Decreased salt consumption by rinsing canned

foods that contain salt & removing salt shaker from
table.

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Nursing Intervention Aimed at Improving Self-Management for Persons with Chronic
Kidney Disease in North Carolina Medicaid: A Pilot Project
agreement to the statement, I suc-
ceed in the goals I undertake to man-
age my kidney disease. And, four of
four participants at post-test indicated
disagreement to the statement, It is
hard for me to find effective ways to
deal with problems that occur with
managing my kidney disease. In
contrast, the pre-test responses were
generally distributed across the
response options.
Discussion
The results of this pilot project
were mixed because the population-
based approach to identify persons
with CKD during Stages 3b and 4
was minimally successful. The office-
based approach was not very accessi-
ble for patients; however, the educa-
tional intervention demonstrated
short-term successes for those persons
who participated in the pilot project.
In general, the population-based strat-
egy used to identify persons with
CKD Stage 3b or 4 was relatively
time-intensive and resulted in identi-
fying only 53 people who were eligi-
ble for the intervention. This finding
was somewhat lower than expected
because of the clinics history of hav-
ing more than 80% of referrals to clin-
ic being patients in CKD Stage 4 or 5.
One possible explanation for
identifying a relatively small number
of eligible persons was the use of
datasets that included eGFR results
obtained over a 6- to 12-month period.
Some potentially eligible persons had
progressed to CKD Stage 5, were on
dialysis, had received a kidney trans-
plant, or had died by the time we
reviewed health records to further
assess eligibility. Of those eligible for
the intervention, 83% declined to par-
ticipate. The most frequently reported
reasons for declining the educational
intervention were transportation-relat-
ed barriers, including costs, and lack of
interest. An office-based educational
intervention was not sufficiently con-
venient for many persons with CKD
who expressed initial interest in receiv-
ing the intervention. The NP-delivered
intervention was the most successful
component of the pilot project.
252
Knowledge improvement was observ-
ed to increase in at least 50% of partic-
ipants for approximately 60% of the
questions. Participants also reported
making incremental health behavior
changes generally related to nutrition
and physical activity.
Population-Based Strategies
to Identify Persons with CKD
Our effort to implement a popula-
tion-based strategy to identify persons
with CKD Stage 3b or 4 who were not
linked with appropriate specialty care
services appears to be less successful
than in other published studies. For
example, a population-based disease
management approach was imple-
mented in the West Lincolnshire
Primary Care Trust (WLPCT) area in
the United Kingdom (UK) to identify
persons 15 years of age and older with
CKD Stage 4 and not known to a
nephrologist (Richards et al., 2008). In
the WLPCT study, eGFR was calcu-
lated using the four-variable Modi-
fication of Diet in Renal Disease
(MDRD) formula and reported to
requesting physicians for 47,119
patients of the 185,434 persons in the
population database. More than 1,200
persons with CKD Stage 4 and not
known to nephrologists were identi-
fied. The proportion of participants
identified with CKD Stage 4 in the UK
study (2.5%) was somewhat higher
than the proportion eligible in our
study (1.75%); however, because of dif-
ferences in age ranges and CKD stages
between the studies, these are not ideal
comparisons. In the UK study, refer-
rals to nephrologists initially spiked to
approximately 2.7 times higher than
the pre-eGFR-reporting period
(Richards et al., 2008). After introduc-
tion of a referral assessment process to
review appropriateness, referrals to
nephrologists remained elevated at
about 1.5 times the pre-eGFR identifi-
cation and notification period
(Richards et al., 2008). Approximately
40% of referrals did not follow guide-
lines. Yet the availability of a popula-
tion-based database and use of a
prospective approach may have been
a more successful strategy than our use
of retrospective lab data.
Nephrology Nursing Journal
A study conducted in Ontario,
Canada, tested the validity of a meth-
od to detect CKD using algorithms
that combined hospital encounter
and physician claims database diag-
nostic codes among persons 66 years
of age and older (Fleet et al., 2013).
The algorithm results were compared
with eGFR values as the reference
standard. All patients in a database of
123,499 patients had a baseline serum
creatinine value for estimating eGFR.
The sensitivity of the algorithm in
detecting CKD was 32.7%, meaning
that only 32.7% of persons with CKD
in the population, as defined by the
eGFR threshold, were identified
using the algorithm. The specificity of
the algorithm was greater than 94%,
meaning that more than 94% of per-
sons who did not have CKD based on
the eGRF threshold had a negative
result using the algorithm. The posi-
tive predictive value or true positives
was 65.4%, meaning that 65.4% of
those identified as possibly having
CKD using the algorithm actually
had CKD based on the eGFR results.
Further, the negative predictive value
of the algorithm was found to be
88.8%, meaning that 88.8% of nega-
tive algorithm results did not have
CKD based on the eGFR threshold
(Fleet et al., 2013). This method
required the use of linked population-
based databases.
Another study examined the
cost-effectiveness and cost-utility of
conducting CKD screening using
eGFR within a large publicly funded
Canadian healthcare system (Manns
et al., 2010). The study focused on
screening to identify persons with
CKD for purposes of initiating med-
ical management, such as treating
persons with angiotensin blockers
rather than on initiating educational
interventions. This study concluded
that population-based screening to
identify persons with CKD was not
cost-effective overall or in any sub-
group analyses (Manns et al., 2010).
The United States Preventive Services
Task Force (USPSTF) also concluded
that current evidence is insufficient to
recommend screening for CKD
among asymptomatic adults (Moyer,
May-June 2015 Vol. 42, No. 3
2012). Our study did not involve
screening methods, but had a similar
intent to identify persons with CKD
Stages 3b and 4 to initiate educational
interventions.
CKD Educational
Interventions
The success of our CKD educa-
tional intervention on changing partic-
ipant health behaviors and improving
health status seems comparable to
other published interventions. How-
ever, a number of these other inter-
ventions focused on more targeted
health education topics and behaviors
with varying intensity of interventions,
whereas our intervention covered the
full range of CKD health education
topics and only included a NP-led
educational intervention. For exam-
ple, one controlled trial in Australia
with 36 intervention patients with
CKD Stage 3 or 4 evaluated the effect
of a lifestyle intervention and aerobic
and resistance exercise training on
cardiorespiratory fitness levels
(Howden et al., 2013). This interven-
tion consisted of usual care, cardiovas-
cular risk factor management provid-
ed by a CKD nurse practitioner and
other health professionals, 150 min-
utes of moderate intensity exercise per
week with eight weeks of training
supervised by an exercise physiologist
(including gym sessions with aerobic
exercise and weight and resistance
training, telephone, and email follow
up), and four weeks of group behavior
and lifestyle modification facilitated
by a dietician and psychologist. This
intensive intervention was associated
with an average weight loss of 1.8 kilo-
grams, increased peak VO2 (2.8 mL/
kg/minute), and improved diastolic
function (Howden et al., 2013). A less
intense intervention was studied
among 150 patients on hemodialysis
to assess the effect of watching a 45-
minute educational video on serum
phosphate levels (Baldwin, 2013). In
the month following the video view-
ing, serum phosphorous levels were re-
duced, on average, from 6.82 to 6.35
g/dL among participating patients.
Study Limitations
There are several limitations to
consider when interpreting the find-
ings from our pilot project. One limi-
tation is the small sample of persons
with CKD who completed the inter-
vention. The small sample precludes
the ability to make valid pre-interven-
tion/post-intervention comparisons in
self-efficacy, and changes to partici-
pant knowledge and health behav-
iors. However, the series of cases pro-
vides some evidence to suggest that
the intensive educational intervention
was associated with increases in
understanding of CKD and incre-
mental behavior changes. Second, the
lack of a comparison group further
weakens the ability to link the
changes in behavior to the interven-
tion because other influences in the
participants lives could account for
these changes. The post-intervention
assessment of understanding of CKD
tends to support the intervention as
the catalyst for these changes. Third,
because patients self-selected to
receive the intervention, it is possible
that those who participated and com-
pleted the study were more motivated
to exhibit positive changes in knowl-
edge and behaviors than those who
refused to participate. It is not clear
whether this intervention would be
effective among persons who are not
interested in making the effort to
come to the clinic if, for example, the
intervention were offered at a more
convenient location.
Implications for Practice
and Future Research
To slow or prevent the progres-
sion of CKD and reduce associated
health care utilization and costs, there
are a number of research questions
that could be answered with future
research. When thinking about popu-
lation-based strategies to identify per-
sons with CKD who could benefit
from educational or other interven-
tions aimed at changing behavior, it
may be important to explore whether
the same goals can be accomplished
using broader population-based stra-
tegies. For example, would it be feasi-
ble and more effective to reduce the
overall societal burden of CKD by
testing interventions aimed at im-
proving health behaviors and health
status for persons at high risk for
CKD, such as those with hyperten-
sion, diabetes, obesity, and/or a fami-
ly history of CKD? Additionally, as
U.S. health care delivery systems
expand the use of integrated electron-
ic health records, more automated
processes for identifying persons with
CKD could be explored and tested.
The second set of future research
questions pertains to behavior change
strategies, including access to inter-
ventions.
In our study, the office-based in-
tervention was not very convenient
for many potential participants. To
reach a larger audience, it would be
helpful to develop and test interven-
tions that are community-based, per-
haps using outreach and/or group
models of outreach with multiple
encounters with each participant. For
example, the mobile outreach unit of
the UNC Kidney Centers Kidney
Education Outreach Program (KEOP)
provides targeted CKD screening
and educational programs for under-
served high-risk populations in loca-
tions where nephrologists are absent
and primary care providers are
scarce. However, the existing out-
reach screening and educational in-
terventions are short-term, whereas
our pilot intervention involved up to
six encounters per participant. The
acceptability of interventions that are
provided in the context of a targeted,
community-based program with or
without a mobile unit that can reduce
patients travel could be tested in
future studies.
Because some CKD topics in our
pilot project did not seem to be as
well-understood as others, future
studies could examine other teaching
and learning strategies to enhance
participant learning as well as tools,
such as reminders, to help patients
achieve established goals for behavior
change. For example, it may be help-
ful to identify the amount of content
that can be learned on average by

Nephrology Nursing Journal May-June 2015 Vol. 42, No. 3 253

Nursing Intervention Aimed at Improving Self-Management for Persons with Chronic
Kidney Disease in North Carolina Medicaid: A Pilot Project
participants in one session or learning
module, and the number of visits or
contacts that are needed to cover the
content and facilitate sustainable pos-
itive behavior changes. Future re-
search could also focus on comparing
the Medicare Part B model that cov-
ers up to six CKD education visits for
persons with Stage 4 CKD to models
that vary the number of visits and
CKD stage inclusion criteria (CMS,
2013).
Conclusions
Improvements in CKD-related
knowledge were observed among all
participants after receiving the educa-
tional intervention in this pilot proj-
ect. However, knowledge improve-
ment did not occur for all topics. In-
cremental behavior changes were
observed for participants with multi-
ple visits with the CKD nurse educa-
tor. Further, participants who com-
pleted the full intervention reported
overall agreement with their ability to
self-manage their CKD. Even though
improvements were observed among
participants, the population-based
approach used to identify persons
who met the eligibility criteria was
time-intensive and not efficient. In
addition, the clinic-based setting did
not seem to be accessible to the ma-
jority of persons eligible to receive the
intervention. This study highlights the
need to learn more about strategies
for identifying persons with CKD
who have not been linked with
appropriate care and health educa-
tion, and strategies for effectively
delivering interventions in acceptable
and accessible locations.
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