Honoring Individual Goals and Hopes: Implementing Advance Care Planning for Persons with Kidney Disease
The HIGHway Project is an implementation project to empower social workers and nurse case managers in dialysis centers to incorporate advance care planning (ACP) into their current workflow. Persons with kidney disease on dialysis are at a high risk of dying, especially if they have comorbidities. However, less than 10% of patients with kidney failure report having conversations about their end-of-life wishes, despite wanting their providers to know their wishes. The HIGHway Project seeks to provide the resources and training to assist social workers in initiating and documenting ACP conversations.
The HIGHway project builds upon a previous project called SDM-RSC (Shared Decision-Making Renal Supportive Care). HIGHway trains and supports social workers and nurse case managers to communicate with their patients about their hopes and goals for their future care plans.
The project objectives are to:
- Implement the HIGHway intervention with a project team consisting of a social worker, nephrologist and nurse at 50 clinics, and train them to conduct ACP using best practices.
- Assist social workers and nurses to implement ACP into their regular workflow with personal coaching, webinars and multimedia teaching materials.
- Use a dedicated web-based application software to guide social workers and nurses on the ACP process of patients in dialysis centers and provide resources for holding ACP conversations.
- Provide ongoing coaching through monthly teleconferences to bolster social worker and nurse skills through case discussion and mentoring.
- Evaluate the ACP training received by the nurses and social workers.
- Develop a long-term implementation and scale-up plan for training social workers and nurses in ACP in different dialysis centers in conjunction with the Coalition for Supportive Care of Kidney Patients, Forum of ESRD Networks, the National Council of Nephrology Social Workers, the National Renal Administrators Association, and dialysis organizations.
Funding The Project
The HIGHway project is funded by the Patient-Centered Outcomes Research Institute (PCORI). PCORI aims to improve the quality and relevance of evidence available to help patients, caregivers, clinicians, employers, insurers, and policy makers make better-informed health decisions. Visit https://www.pcori.org/research-results/2021/implementing-advance-care-planning-dialysis-patients to view the PCORI page for this research project.
The HIGHway Project is a project by the Coalition for Supportive Care of Kidney Patients. Visit the Coalition webpage for more information and resources in providing supportive care to kidney patients for both patients and providers. Please follow the Coalition for Supportive Care of Kidney Patients on X, formerly known as Twitter, at @kidneycoalition.