Contributor: Data, Education, and Community: The Winning Formula for Addressing SDOH for Kidney Care Patients

Chronic kidney disease (CKD) affects more than 37 million Americans, yet it garners only a fraction of the attention dedicated to other widespread illnesses like diabetes. This disparity is compounded by the troubling fact that only 10% of patients with CKD are even aware they have the condition, leaving millions of individuals vulnerable to progressing to late-stage kidney disease without early intervention.

These challenges are intensified within underserved populations. For example, Black Americans are 4 times more likely than White Americans to develop kidney disease, and Hispanic and Native American populations face roughly twice the risk. While some genetic factors contribute, the glaring role of social determinants of health (SDOH)—such as food insecurity, housing instability, limited health care access, and health literacy—cannot be ignored.

The costs of inaction are profound. Traditional Medicare alone incurs $76.8 billion annually in CKD-related expenses. While the financial burden for health care systems is substantial, the human cost is even greater. For our health care community—including payers, providers, and policymakers—addressing SDOH isn't merely a commitment to equity; it's a pathway to improving outcomes and containing costs for one of the nation's most vulnerable populations.

How do we meet this challenge? The answer lies in blending data, education, and community partnerships. By leveraging these foundational elements, nephrologists and health care providers can develop actionable, patient-centered solutions that mitigate the burdens of CKD and empower at-risk populations.

Kareen Simpson | Image credit: Interwell Health

Turning Data into Actionable Insights

Robust and accurate data is the bedrock of effective CKD management. Layering clinical, claims, pharmacy, and SDOH data provides a comprehensive picture of a patient's risk factors and needs. However, the key isn't merely collecting data—it's turning that data into actionable insights that drive meaningful interventions.

For example, risk stratification models can identify the CKD patients most at risk of disease progression or hospitalization, often months in advance. Using advanced data analytics, nephrologists can develop personalized action plans, tailoring care strategies to prioritize the right services for the right patients at the right time. For populations with significant SDOH challenges, this might mean flagging food insecurity and integrating referrals to local food assistance programs.

Electronic health records (EHRs) enhance the ability to identify and address risks in real time. Specialty-specific EHRs, such as Acumen Epic Connect, can be programmed to alert clinicians when a patient exhibits risk factors for CKD or related complications. These alerts can trigger proactive interventions, such as ordering additional screenings, adjusting treatment plans, or referring patients to specialists. This technology-driven approach ensures that care teams can act swiftly, improving patient outcomes and preventing disease progression.

At Interwell Health, a focus on streamlined, data-driven processes and an EHR purpose-built for nephrology workflows have enabled care teams to identify patients at risk at earlier stages of disease. Combined with predictive analytics, nephrologists can proactively start conversations about preventing dialysis or exploring transplantation options. Patients no longer need to wait for a crisis before receiving guidance, drastically improving engagement and outcomes.

Data alone, however, doesn't solve the problem. It's the first step in aligning care to meet the needs of populations far beyond the clinical walls.

Naz Urooj | Image credit: Interwell Health

Building Trust Through Education and Relationships

It is frustrating and saddening to witness enduring disparities in patient care and outcomes. For instance, in Chicago there are 6 transplant centers in a 20-mile radius, yet the preemptive transplant rate among the greater Chicago minority community remains abysmal. Data can highlight these disparities and identify resource gaps, but education and relationship-building form the bridge between insights, meaningful patient engagement, and effective solutions that bring about real change.

For patients with CKD, particularly those facing socioeconomic barriers, trust and empathy are the cornerstones of successful care delivery. When patients feel supported, they’re more likely to engage in their health decisions, from following diets to managing treatments. For example, care coordinators have helped our patients regain stability, despite homelessness and systemic challenges, by connecting them with local housing programs. By fostering trust and communication, care teams can address clinical needs while considering the complex social realities patients face.

Culturally appropriate education is vital to building trust and delivering equitable, patient-centered CKD care. By tailoring education programs to align with patients’ values, traditions, and language, we can empower patients with accessible, meaningful knowledge and tools that respect their unique cultural contexts and preferences. This approach not only boosts health literacy but also builds confidence, encouraging patients to actively participate in their own care.

Health care providers alone can't comprehensively address social barriers like transportation, affordable medication, or housing instability. Partnerships with community-based organizations are essential to creating a holistic support system for patients with CKD, creating referral pipelines to food pantries, transportation services, and financial aid programs for patients with CKD in resource-limited areas. Innovative approaches, such as collaborating with community gardens to supply fresh produce or deploying mobile health clinics for screenings in underserved areas, help expand health care access beyond traditional clinical settings. These partnerships aren't about isolated problem-solving—they represent long-term commitments to shared accountability in health equity.

Recognizing the importance of person-centered, holistic patient education and care, an increasing number of nephrology practices are adopting a value-based care approach that enables wraparound, comprehensive support and care to meet each patient's needs. For many people with CKD, an interdisciplinary approach that includes support from renal care coordinators, social workers, and renal dietitians is invaluable. These relationships do more than provide clinical assistance—they instill confidence and empower patients to navigate the health system.

The Path Forward

By focusing on data, education, and community partnerships, we can create a health care ecosystem that delivers equitable, person-centered care for patients with CKD that addresses both clinical and social needs. This holistic approach fosters trust, reduces barriers, and optimizes outcomes for vulnerable populations. It also enables preventive interventions and more proactive care to slow disease progression and prevent further health issues--helping delay the need for dialysis, curtail unnecessary hospitalizations and readmissions, and bring down the total costs of care.

Nephrologists, guided by actionable insights and supported by a robust network of care providers and community partners, have the opportunity to transform kidney care for underserved communities. The barriers are significant, but the solutions are within our collective reach.

Now is the time to align innovation with empathy and reshape kidney care to reflect the needs of patients—not just as individuals within a system but as people striving for dignity and health in the face of immense challenges.