CKD CORE Kidney Project (Cheshire and Mersey ICB)

• Improve identification and coding of patients within the Cheshire and Mersey region with CKD 
• Prevent progression and CVD by ensuring eligible patients receive statin, RAASi, SGLT2i, BP<140/90
• Embed Kidney Failure Risk Equation (KFRE) in laboratory information management systems to improve risk stratification in Primary care, as per NICE guidance.
• Regional dashboard with agreed CKD measures
• ICB collaboration on care management of CKD within Primary care
• Collaboration with the University of Liverpool.
• Collaboration with public health and Liverpool University Hospital Trust to target inclusion health populations

This initiative aims to test a hands-on approach to:

• Standardise Enzymatic Creatinine Assay and CKD EPI across the region
• Process map current CKD pathways in selected pilot practices
• Revise identification elements of the pathway using a Clinical Digital Resource Collaborative (CDRC)
• Improve CKD coding and accuracy
• Medicine Optimisation for patients who require access to NICE (NG203)- recommended medications
• Build a CKD dashboard with CIPHA
• Improve Education and training across the region for CKD
• Establish primary care as the frontline for CKD diagnosis and initiation

Scalable Interventions at practice/PCN CORE4

• Practice based facilitation of good CKD coding through CDRC training
• CKD (clinical/pathway) education delivered to MDT at practice/PCN level
• Sharing treatment decision aids
• Resourcing medicine optimisation

To seek funding to progress to phase two, Healthy Kidney Project embedding roll out of CORE4, Kidney project and establish a gold standard for CKD across the region.

Phase 2 Objectives

• Rolling out CORE4 to 350+ practices, prioritising those in greatest need
• Complete CKD Lab ‘tackling variation work’
• Leverage Combined Intelligence for Population Health Action (CIPHA) case-Finding tool to drive proactive care & achieve a left shift in healthcare delivery

Phase 2 delivery plans

• CKD team delivering CORE4 intervention (1 to 3) at PCN level through workshops
• The medicine optimisation element of CORE4 needs innovative & collaborative solution
• Enhancing proactive care for CKD patients by identifying high-risk individuals using the CIPHA ECF tool and exploring new ways of delivering proactive care