Pathways Phase 2


Implementation Approach for Phase 2 (Nov 2018 – Oct 2020)

Phase Two of the Pathways Project will address the central research question: Will a Collaborative quality improvement approach to spreading supportive care best practices at independent ESCOs and affiliated clinics measurably increase the provision of supportive care best practices leading to more effective goal-concordant care?

The IHI Collaborative Model for Achieving Breakthrough Improvement will be used.  This model is a tested systematic approach to quality improvement designed to help organizations close the gap between current and future practice based on evidence-based best practices.[vii] [viii]

Collaborative Participants

Partners in Phase Two are fifteen dialysis facilities involved in innovative practice and payment approaches. These facilities will send change teams to the learning collaborative. Many of the facilities are participating in the CMS End-stage renal care Seamless Care Organization (ESCO). The goal of the CMS ESCO model is to test innovations fostered by an integrated provider and payment structure.  In an ESCO, dialysis facilities, nephrologists, and other providers join together to form a cohesive organization that is responsible for the cost and quality of all kidney-related care for aligned beneficiaries, thus creating a fertile environment for implementing innovations in supportive care.

Collaborative Content

Fifteen (15) kidney care change teams will attend three 2-day Learning Sessions focusing on how to:

  1. Implement shared decision making for current and advance care planning for future care options
  2. Prioritize seriously ill patients with CKD and ESRD for primary and specialty supportive care interventions
  3. Offer palliative dialysis and systematic withdrawal process for appropriate patients.
    Led by expert faculty the sessions will be followed by action periods when the teams continue to engage with one another through the use of multiple supports that promote shared learning; collect and submit monthly data; review monthly feedback reports; attend Pathways Project webinars and conference calls facilitated by subject matter experts (SMEs) and exemplars; and plan and study iterative tests of the change package recommendations via the Plan-Do-Study-Act (PDSA) approach.


The Pathways team will work with Stanford University (external evaluators) to evaluate the overall project  As noted, the central research question centers on measuring effective goal-concordant care, which will be operationalized as patient-reported shared decision-making, advance care planning, palliative dialysis, and transition to hospice.  The primary outcome is patient-reported quality of communication, as measured by the Engelberg quality of communication questionnaire.(52) This outcome was chosen because in phase 1, the TEP advised that improved communication was the foundational practice needed to improve supportive care.

The project uses a before and after design supplemented by several nonequivalent dependent variables.  The primary patient-reported outcome for the intervention will be engagement in advanced care planning. A secondary measure will be a chart review tool assessing the quality of advance care planning as well as measures of the quality of communication and shared decision-making. Staff perception of improvements in supportive care will also be measured using the Kidney Supportive Care Implementation Quotient (KSC-IQ), developed by the Pathways team. The KSC-IQ assesses perceived implementation of each change concept in the change package. Changes in utilization, such as hospitalizations, hospice use, and cost of care, will be monitored for exploratory analysis, since the study will not be powered to detect changes in care of patients who die during the relatively short implementation period

Dissemination: Potential Contribution to Innovation in Kidney Care

The Pathways Collaborative is the first attempt to implement supportive care at multiple sites in the United States. While supportive kidney care is growing in other countries, notably Canada, Australia, and Great Britain, it is not yet known how to integrate it into the unique nephrology environment in the United States. The lessons learned about implementation during Pathways Phase 2 will inform CMS as it seeks to move kidney care to a value-based model. The findings will also be useful to other specialties, such as cardiology, seeking to integrate more primary palliative care into care models for patients with other diseases.