B25(T)
DEVELOPING AND IMPLEMENTING KIDNEY CARE PLANS FOR PATIENTS
WITH CHRONIC KIDNEY DISEASE – A PILOT STUDY
Gerrard, K¹, Henriksson, M¹, O’Riordan, A¹
¹Low Clearance, Chronic Kidney Disease, Royal Free Hampstead NHS Trust
BACKGROUND: Most patients with Chronic Kidney Disease (CKD) spend little time in faceto-face consultations with their health care providers resulting in them having responsibility for
the day-to-day management of their illness (Thomas-Hawkins and Zazworsky, 2005).
Improving knowledge and encouraging self-management has been associated with significant
improvements in function and well-being (Wingard, 2005). Thus it is essential for health care
professionals to provide information and education about their condition, its long term
consequences and how to manage their illness on a daily basis (Thomas-Hawkins and
Zazworsky, 2005). Nephrology nurses are able to engage in teaching and supporting patients in
self-management skills by using patient held treatment or care plans (Schatell, 2005). These
plans are essential features of patient centered care and effective self-management for patients
with chronic conditions (Renal National Service Framework Part Two, 2005 and High Quality
Care for All, 2008). If done in partnership with the patient, they are likely to result in an
increase concordance with treatment and ultimately an increase in patient satisfaction (Wagner,
2000). Following the literature review a pilot study was conducted to develop and implement
individualised hand-held care plans.
OBJECTIVES: To develop and implement a care plan in order to encourage patients to
manage their own condition, promote empowerment, develop partnerships in care and
communicate information to other health care providers.
METHOD: The national kidney care plan (NHS Kidney Care, 2009) was used as a template
and adapted into a local version; ‘My Kidney Care Plan’ which was reviewed and agreed by
members of the renal team, the Trust patient information lead and the local Kidney Patients’
Association. The care plan included a medication list, laboratory results, blood pressure and
weight measurements, treatment options and a page for patients to list any questions they may
have. The care plan was patient held and managed; the CKD specialist nurses instructed and
supported patients in the use of the care plan. Thirty patients were randomly selected to trial the
care plan for three months at which point a telephone patient satisfaction survey was conducted.
RESULTS: Twenty five of thirty patients responded to this survey. Of those 76% said the care
plan was very useful or extremely useful and 76% were able to understand all or most of the
care plan. Eighty percent of patients remembered to bring it to all of their low clearance
appointments, 56% remembered to take it to their appointments with other health care
professionals. Patients reported that their GPs found the care plan generally “very helpful”. The
main section that patients found useful was the blood results section with comments such as “I
liked writing my blood results in so I could see how my kidneys were getting on”. Four patients
found the size of the care plan too big to carry and two patients would have liked it in other
languages. Patients were asked if this care plan had improved their care, 64% of patient
responded to this question and of them 81% agreed.
CONCLUSION AND FUTURE DEVELOPMENT: ‘My Kidney Care Plan’ has proved to be
very popular with both patients and staff. Overall most patients found it useful and reported that
it has improved their care. Initial results are promising and proved the care plan to be beneficial.
It will be launched to all Low Clearance Patients for further evaluation on a larger scale to
assess its long term benefits in terms of self-management.