Nursing Intervention Aimed at Improving

Nursing Intervention Aimed at Improving
Self-Management for Persons with

Chronic Kidney Disease in North Carolina
Medicaid: A Pilot Project
Julie C. Jacobson Vann
Jenny Hawley
Steven Wegner
hronic kidney disease (CKD)
is a health condition characterized by kidney damage that
persists and generally worsens
over time (National Kidney Foundation [NKF], 2002). Kidney damage
can range from a decline in kidney
function to kidney failure (NKF,
2002). The disease has been classified
into five stages based on glomerular
filtration rates (GFR), ranging from
Stage 1, which can be described as
having kidney damage with normal
or elevated GFR (90 mL/min/1.73m2
or higher), to Stage 5, described as
kidney failure or end stage renal disease (ESRD) (GFR less than 15 mL/
min/1.73m2 (Kidney Disease Improving Global Outcomes [KDIGO],
2013; NKF, 2002). The disease can
also be classified by cause or albuminuria category (KDIGO, 2013).
More than 10% of adults in the
United States (U.S.), or more than 20
million people, are estimated to have
CKD (Centers for Disease Control
and Prevention [CDC], 2014). The
prevalence of CKD is increasing most
rapidly among persons 60 years of
age and over; and incidence among
those 65 years of age and older more
than doubled between 2000 and 2008
(National Kidney and Urologic Diseases Information Clearinghouse
[NKUDIC], 2012). At year-end 2012,
Publishers Note: Author biographical statements and acknowledgments can be found on the
following page.
Statements of Disclosure: Abhijit V. Kshirsagar
is on the Fresenius Medical Care Advisory Board.
All other authors reported no actual or potential
conflict of interest in relation to this continuing
nursing education activity.
Note: Additional statements of disclosure and
instructions for CNE evaluation can be found on
page 256.
Nephrology Nursing Journal
Continuing Nursing
Education
Ronald J. Falk
Donna H. Harward
Abhijit V. Kshirsagar
Copyright 2015 American Nephrology Nurses Association.
Jacobson Vann, J.C., Hawley, J., Wegner, S., Falk, R.J., Harward, D.H., & Kshiragar, A.V.
(2015). Nursing intervention aimed at improving self-management for persons with
chronic kidney disease in North Carolina Medicaid: A pilot project. Nephrology
Nursing Journal, 42(3), 239-255.
This pilot project aimed to improve knowledge and self-management among Medicaid
beneficiaries with Stage 3b and 4 chronic kidney disease who were identified using a
population-based approach. Participants received up to six in-person educational sessions delivered by a nurse practitioner. Increases in knowledge and self-reported behavior changes were generally observed among participants.
Key Words: Chronic kidney disease, self-management, nurse intervention, education, and population-based approach.
Goal
To provide an overview of a pilot project designed to improve knowledge and self-management among Medicaid beneficiaries with chronic kidney disease 9CKD) Stages 3b and 4.
Objectives
1.
2.
Discuss the use of a population-based approach to identify individuals with CKD

Stages 3b and 4..
Describe the results of a nurse-led education intervention pilot study to improve
knowledge and self-management individuals with CKD Stages 3b and 4.
approximately 636,905 persons were

reported to have ESRD in the U.S.
(NKUDIC, 2012), up from an estimated 391,321 in 2000 (United States
Renal Data System [USRDS], 2014).
The incidence rates of ESRD were
3.25 times higher among African
Americans (908.0 per million population) in the U.S. than for whites (279.2
per million population) during 2012
(USRDS, 2014). In North Carolina,

the estimated prevalence of ESRD
was 21,140 persons as of December 31,
2012; with an incident count of
approximately 3,618 new cases during
2012 (USRDS, 2014). Approximately
15,389 persons in North Carolina
were receiving hemodialysis or peritoneal dialysis at year-end 2013; and
an estimated 5,092 had previously re-
This offering for 1.5 contact hours is provided by the American Nephrology Nurses
Association (ANNA).
American Nephrology Nurses Association is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center Commission on Accreditation.
ANNA is a provider approved by the California Board of Registered Nursing, provider number
CEP 00910.
This CNE article meets the Nephrology Nursing Certification Commissions (NNCCs) continuing nursing education requirements for certification and recertification.
May-June 2015
Vol. 42, No. 3
239
Nursing Intervention Aimed at Improving Self-Management for Persons with Chronic

Kidney Disease in North Carolina Medicaid: A Pilot Project
ceived a kidney transplant (Southeastern Kidney Council, 2013). The

prevalence of ESRD per 1,000,000
population adjusted for age, race and
sex in North Carolina increased from
approximately 864 as of December
31, 1990, to 1,870 as of December 31,
2012 (USRDS, 2014).
The progression of CKD to kidney failure can be prevented or
delayed with appropriate interventions (CDC, 2014). For example, tight
glucose control for persons with type
1 diabetes mellitus, adequate blood
pressure control for persons with
hypertension, and reducing elevated
urine albumin levels are three strategies shown to reduce the progression
of CKD (Formica, 2003). These goals
may be achieved with medications
that are appropriately taken, dietary
changes, and other lifestyle changes,
such as physical activity and quitting
smoking (National Kidney Disease
Education Program [NKDEP], 2013).
Several dietary approaches include
limiting dietary sodium to 1,500 mg
per day, avoiding some salt substitutes if rich in potassium, consuming
adequate but not excessive protein,
limiting dietary phosphorous and
potassium, and eating foods that are
heart healthy (NKDEP, 2013).
Patient-centered education and management in the early stages of CKD
may provide the greatest potential to
slow disease progression.
It is important to intervene with

patients about their CKD at the earliest possible point in the disease progression to have the greatest effect on
health status and/or treatment decisions. Yet persons in the early stages of
CKD may not be aware of common
but subtle symptoms (CDC, 2014;
Flessner et al., 2009; Moyer, 2012).
Early intervention for patients with
CKD may also be challenged by
inconsistent identification, management, and referral of patients by primary care providers (Allen et al., 2010;
Bouleware, Troll, Jaar, Myers, & Powe,
2006). Problems with access to care
may also contribute to delays in receiving treatments and educational interventions (North Carolina Institute of
Medicine [NCIOM], 2007).
Within the CKD Clinic at the
University of North Carolina (UNC),
there were concerns that some
patients with kidney failure may not
have been aware of CKD in earlier
stages, may not have received care for
kidney disease by a health professional prior to being seen in the emergency department with acute kidney
episodes, and may not have been
given information about treatment
options. From July 2008 through June
2009, approximately 64% of patients
seen for CKD education were in Stage
4 and 22% in Stage 5 at the time of
referral to the CKD clinic. For some
patients, hemodialysis therapy was
Julie C. Jacobson Vann, PhD, MS, RN, is a Senior Researcher, American Institutes for Research, Chapel Hill,
NC; an Evaluation Consultant, AccessCare, Morrisville, ND; and an Adjunct Assistant Professor, University of
North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC. She may be contacted directly via email at
jjacobsonvann@air.org
Jenny Hawley, MSN, RN, FNP-BC, is a Family Nurse Practitioner, University of North Carolina at Chapel
Hill, UNC Kidney Center, Chapel Hill, NC, and a member of ANNAs Cardinal Chapter.
Steven Wegner, MD, JD, is President, AccessCare, Morrisville, NC; a Professor, University of North Carolina
at Chapel Hill, Department of Pediatrics, Chapel Hill, NC; and Senior Vice President & Chief Innovations
Officer, Community Care of North Carolina, Raleigh, NC.
Ronald J. Falk, MD, is a Doc J. Thurston Professor of Medicine; Chief, Division of Nephrology & Hypertension;
and Director, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Donna H. Harward, is Director of Education and Outreach, University of North Carolina at Chapel Hill,
UNC Kidney Center, Chapel Hill, NC.
Abhijit V. Kshirsagar, MD, MPH, is an Assistant Professor of Medicine, University of North Carolina at
Chapel Hill, UNC Kidney Center, Chapel Hill, NC.
Acknowledgments: This pilot project was conducted as a collaboration between the North Carolina Kidney
Center and AccessCare. The authors wish to acknowledge the support of NC Tracs, the North Carolina
Community Care Network (CCNC), and the CCNC care coordinators.
240
initiated after being admitted emergently to the hospital. Such patients

subsequently found, for the first time,
that they had ESRD and would not
have received the prior education
about options, such as peritoneal dialysis. Peritoneal dialysis would only be
an option at a later time, after discharge from the hospital.
To address the concerns that
Medicaid beneficiaries with CKD
may not be receiving information
about self-care and treatment options
prior to being diagnosed with ESRD,
our team developed a populationbased intervention aimed at identifying and educating persons with CKD
about kidney disease and self-care.
Previously published studies have
shown mixed results in the effectiveness of educational interventions on
improving knowledge and self-management for persons with CKD
(Bonner et al., 2014) or other chronic
conditions.
However, several previously
published interventions provided evidence to support the development
and implementation of our intervention. One study evaluated the effectiveness of a brief intervention on
knowledge of dietary phosphorus
control among patients receiving
hemodialysis (Brogdon, 2013). The
intervention consisted of an educational brochure that was reviewed
individually with patients by the
investigator. The intervention was
reinforced by reviewing the pre-test
results and related educational content with patients and by sending the
brochure home with the patients to
use as a source for review prior to
completing the post-test. One month
later, the average level of participant
knowledge, as assessed by a 20 multiple-choice question pre- and post-test,
increased from 40.0% to 72.5%
(Brogdon, 2013).
A second study was conducted in
a group of 30 patients in Japan with
type 2 diabetic neuropathy and
eGFR levels of 15 to 59 mL/min/
1.73m2 (Kazawa & Moriyama, 2013).
The nurse-led intervention consisted
of six educational visits; the first four
were face-to-face in the home or clin-
May-June 2015
Vol. 42, No. 3

ceived a kidney transplant (Southeastern Kidney Council, 2013). The

prevalence of ESRD per 1,000,000
population adjusted for age, race and
sex in North Carolina increased from
approximately 864 as of December
31, 1990, to 1,870 as of December 31,
2012 (USRDS, 2014).
The progression of CKD to kidney failure can be prevented or
delayed with appropriate interventions (CDC, 2014). For example, tight
glucose control for persons with type
1 diabetes mellitus, adequate blood
pressure control for persons with
hypertension, and reducing elevated
urine albumin levels are three strategies shown to reduce the progression
of CKD (Formica, 2003). These goals
may be achieved with medications
that are appropriately taken, dietary
changes, and other lifestyle changes,
such as physical activity and quitting
smoking (National Kidney Disease
Education Program [NKDEP], 2013).
Several dietary approaches include
limiting dietary sodium to 1,500 mg
per day, avoiding some salt substitutes if rich in potassium, consuming
adequate but not excessive protein,
limiting dietary phosphorous and
potassium, and eating foods that are
heart healthy (NKDEP, 2013).
Patient-centered education and management in the early stages of CKD
may provide the greatest potential to
slow disease progression.
It is important to intervene with

patients about their CKD at the earliest possible point in the disease progression to have the greatest effect on
health status and/or treatment decisions. Yet persons in the early stages of
CKD may not be aware of common
but subtle symptoms (CDC, 2014;
Flessner et al., 2009; Moyer, 2012).
Early intervention for patients with
CKD may also be challenged by
inconsistent identification, management, and referral of patients by primary care providers (Allen et al., 2010;
Bouleware, Troll, Jaar, Myers, & Powe,
2006). Problems with access to care
may also contribute to delays in receiving treatments and educational interventions (North Carolina Institute of
Medicine [NCIOM], 2007).
Within the CKD Clinic at the
University of North Carolina (UNC),
there were concerns that some
patients with kidney failure may not
have been aware of CKD in earlier
stages, may not have received care for
kidney disease by a health professional prior to being seen in the emergency department with acute kidney
episodes, and may not have been
given information about treatment
options. From July 2008 through June
2009, approximately 64% of patients
seen for CKD education were in Stage
4 and 22% in Stage 5 at the time of
referral to the CKD clinic. For some
patients, hemodialysis therapy was
Julie C. Jacobson Vann, PhD, MS, RN, is a Senior Researcher, American Institutes for Research, Chapel Hill,
NC; an Evaluation Consultant, AccessCare, Morrisville, ND; and an Adjunct Assistant Professor, University of
North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC. She may be contacted directly via email at
jjacobsonvann@air.org
Jenny Hawley, MSN, RN, FNP-BC, is a Family Nurse Practitioner, University of North Carolina at Chapel
Hill, UNC Kidney Center, Chapel Hill, NC, and a member of ANNAs Cardinal Chapter.
Steven Wegner, MD, JD, is President, AccessCare, Morrisville, NC; a Professor, University of North Carolina
at Chapel Hill, Department of Pediatrics, Chapel Hill, NC; and Senior Vice President & Chief Innovations
Officer, Community Care of North Carolina, Raleigh, NC.
Ronald J. Falk, MD, is a Doc J. Thurston Professor of Medicine; Chief, Division of Nephrology & Hypertension;
and Director, UNC Kidney Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Donna H. Harward, is Director of Education and Outreach, University of North Carolina at Chapel Hill,
UNC Kidney Center, Chapel Hill, NC.
Abhijit V. Kshirsagar, MD, MPH, is an Assistant Professor of Medicine, University of North Carolina at
Chapel Hill, UNC Kidney Center, Chapel Hill, NC.
Acknowledgments: This pilot project was conducted as a collaboration between the North Carolina Kidney
Center and AccessCare. The authors wish to acknowledge the support of NC Tracs, the North Carolina
Community Care Network (CCNC), and the CCNC care coordinators.
240
initiated after being admitted emergently to the hospital. Such patients

subsequently found, for the first time,
that they had ESRD and would not
have received the prior education
about options, such as peritoneal dialysis. Peritoneal dialysis would only be
an option at a later time, after discharge from the hospital.
To address the concerns that
Medicaid beneficiaries with CKD
may not be receiving information
about self-care and treatment options
prior to being diagnosed with ESRD,
our team developed a populationbased intervention aimed at identifying and educating persons with CKD
about kidney disease and self-care.
Previously published studies have
shown mixed results in the effectiveness of educational interventions on
improving knowledge and self-management for persons with CKD
(Bonner et al., 2014) or other chronic
conditions.
However, several previously
published interventions provided evidence to support the development
and implementation of our intervention. One study evaluated the effectiveness of a brief intervention on
control among patients receiving
hemodialysis (Brogdon, 2013). The
intervention consisted of an educational brochure that was reviewed
individually with patients by the
investigator. The intervention was
reinforced by reviewing the pre-test
results and related educational content with patients and by sending the
brochure home with the patients to
use as a source for review prior to
completing the post-test. One month
later, the average level of participant
knowledge, as assessed by a 20 multiple-choice question pre- and post-test,
increased from 40.0% to 72.5%
(Brogdon, 2013).
A second study was conducted in
a group of 30 patients in Japan with
type 2 diabetic neuropathy and
eGFR levels of 15 to 59 mL/min/
1.73m2 (Kazawa & Moriyama, 2013).
The nurse-led intervention consisted
of six educational visits; the first four
were face-to-face in the home or clin-
May-June 2015
Vol. 42, No. 3
ic, and the remaining two occurred

by telephone or email. Improvements
in participant self-efficacy, self-management, and hemoglobin A1c levels
were observed among participants.
Another study utilized a combination
of peer and professional instructors in
a group intervention called the
Chronic Disease Self Management
Program (Lorig, Sobel, Ritter, Laurent,
& Hobbs, 2001). This intervention
was delivered as a 17-hour course
over seven weeks in groups of 8 to 20
participants with various diagnoses.
In this initiative, there was an emphasis on helping participants learn to
problem solve, make decisions, and
build confidence in self-care. Family
members were also invited to participate in the program. Participants in
this study, with a range of chronic illnesses, were observed to have
improved health behaviors, such as
exercise, self-efficacy, and health status, and had fewer visits to the emergency department.
The intensity of the interventions
in previously published studies has
varied; therefore, our team decided to
develop an intervention consisting of
six visits to cover the scope of the
educational content and reflect the
Medicare Part B coverage for up to
six CKD education visits (Centers for
Medicare and Medicaid Services
[CMS], 2013).
Transtheoretical Model and Chronic

Care Model
The five stages of change within
the Transtheoretical Model (Prochaska
& DiClemente, 1983) and the Chronic Care Model (Wagner et al., 2001)
guided the development and implementation of our pilot intervention.
These models support behavior change
and management of chronic diseases,
respectively.
Transtheoretical Model
The Transtheoretical Model and
the five stages of change are important to this initiative because the
model views change as a process
where individuals may move through
the stages of readiness to change
(Cancer Prevention Research Center,

n.d.). It also supports the approach of
individualizing programs to match
the needs of potential participants
and their respective stages of change
(Prochaska & DiClemente, 1982).
The five stages of change within
the Transtheoretical Model that was
refined by Prochaska and DiClemente
(1983) include precontemplation, contemplation, preparation, action, and
maintenance. In the precontemplation stage, individuals do not intend
to change behavior and may not be
aware of the risks associated with specific behaviors. Persons in the contemplation stage are considering
making changes, generally within the
next six months and may understand
the risks associated with their behavior, yet may be ambivalent because of
the perceived disadvantages of changing behavior. Persons who are in the
preparation stage intend to take
action in the short-term, usually within a month, and have a plan of action
to move forward with a change.
These individuals are often ready to
be recruited for a specific health
behavior program. Individuals in the
action stage have made specific
behavior changes, generally within
the past six months, which are sufficient for reducing risks for a specific
disease or injury. In the maintenance
stage, individuals have continued
with a new behavior, generally for at
least six months (Cancer Prevention
Research Center, n.d.).
Chronic Care Model

The Chronic Care Model recognizes that health care for persons with
chronic illnesses occurs within three
interacting contexts: the community;
health systems, and provider organizations (Bodenheimer, Wagner, &
Grumbach, 2002). Within this broader context, the Chronic Care Model
includes six essential elements: community resources and policies; health
care organization; self-management
support; delivery system design; decision support; and clinical information
systems (Bodenheimer et al., 2002;
p. 1776).
May-June 2015
Vol. 42, No. 3
Community Care of North Carolina

Pilot Project
The context of our pilot project,
(CCNC), is structured as an enhanced primary care case management
program that serves North Carolina
Medicaid beneficiaries, with disease
management initiatives that reflect
the six major elements of the chronic
disease model (Dubard & Cockerham,
2008; Wagner et al., 2001). The first
element of the model, community resources and policies, indicates that
chronic care needs to be supported
by resources and linkages with the
community, for example, through
community-based care management
services, which are a primary element
of the CCNC Medicaid delivery
model (Dubard & Cockerham, 2008).
Second, health services organizations
need to view chronic care management as a priority and provide rewards, incentives, or resources to
meet chronic care needs. Within the
CCNC program, chronic care is supported through small monthly per
member per month reimbursement
to primary care providers for care
management activities. The third element, self-management support, focuses on the need for delivery systems to help patients and families
acquire knowledge, skills, and feelings of self-efficacy to manage their
care. This pilot project builds on the
existing self-management support systems of the CCNC disease management programs. The fourth element,
delivery system design, includes the
redesign of practices to engage nonphysicians in supporting patients with
chronic care management and followup. Fifth, decision support systems,
such as evidence-based clinical practice guidelines, should guide the care
for chronic illnesses. Within CCNC,
disease management programs are
based on evidence-based guidelines.
Sixth, clinical information systems,
such as reminder systems, audit and
feedback, and registries, should support care. Within the CCNC networks, a care management electronic
information system serves to identify
241

persons in need of care management,

document care management interventions and outcomes, communicate
across providers, and track compliance with disease management protocols. Our pilot intervention was
embedded into the existing CCNC
infrastructure and was supported by
the larger disease management systems.
Study Aims
In response to the concerns about
delayed access to care for persons
with CKD, our team developed and
implemented a pilot project aimed at
1) using population-based approaches
to identify and quantify North
Carolina Medicaid and dually eligible
Medicare and Medicaid beneficiaries
who have CKD Stage 3b (30 to 45
mL/minute/1.73 m2) or Stage 4 (15 to
29 mL/minute/1.73m2) and have not
been linked with needed care
providers and services; and 2) evaluating the effect of a nurse education
intervention on patients self-perceived health status, health services
utilization patterns, costs of care, selfefficacy in managing chronic kidney
disease, and CKD-related short-term
outcomes. It was expected that taking
a population-based approach would
facilitate reaching patients earlier in
the care and decision-making process.
In the longer term, it is expected that
earlier access to CKD education and
linkage with care providers may help
to improve care and reduce emergency department and inpatient utilization.
Methods
Setting and Project Partners
The setting for this project is the
UNC CKD Clinic, which opened in
2008. The project was implemented
in two of three clinic locations, Chapel
Hill and Burlington, North Carolina.
The purpose of this clinic is to educate
patients about CKD, complications of
the disease, and care options. The
clinic is directed by a physician and
staffed by nurses who provide educa-
242
tion to supplement the care given by

physicians. The UNC CKD clinic clinicians partnered with AccessCare,
one of the 14 CCNC Medicaid
provider networks, to plan, implement, and evaluate this pilot project.
The CCNC networks engage in population-based care management and
disease management initiatives that
enhance access and quality of care for
Medicaid beneficiaries while facilitating appropriate health services utilization and cost-containment goals. The
CCNC networks serve approximately
1.2 million Medicaid beneficiaries
(CCNC, 2014).
Intervention
The study intervention was
developed and delivered by the CKD
nurse educator who is a family nurse
practitioner (FNP). The intervention
components and steps were documented in detail in the written plan
for CKD Education Program. This
intervention consisted of the CKD
educational sessions with the CKD
nurse educator, assessment of readiness to change, a CKD toolkit individualized for each participant, and
collaborative goal-setting between the
CKD nurse educator and the patient.
The CKD educational content was
based on the NKDEP (2012), an initiative of the National Institute of
Diabetes and Digestive and Kidney
Diseases (NIDDK). The content consisted of 20 categories of topics classified into five content areas: overview
of CKD; general CKD management;
co-morbidities and special issues for
persons with CKD; effect of CKD on
symptoms and self-care management
strategies and behaviors; and treatment options and/or modalities (see
Table 1).
Major concepts were displayed
in visual tools during the visits, for
example, by using handouts and a
whiteboard, to reinforce educational
content that was discussed. Each participant was provided with a UNC
Kidney Center canvas tote bag to
carry intervention handouts, which
were developed by the CKD nurse
educator. These handouts included a
12-page Patients Guide to Chronic
Kidney Disease booklet, which

included educational materials for all
topics in the curriculum and a list of
helpful websites; supplemental handouts that covered topics such as heart
health; a laminated kidney-friendly
shopping list for CKD patients; and
a laminated helpful hints for a kidney friendly diet. The intervention
was supported by the Stages of
Change construct within the Transtheoretical Model (Prochaska &
DiClemente, 1983). The CKD nurse
educator met individually with eligible Medicaid and dually eligible beneficiaries who agreed to participate in
the intervention for up to six clinic
visits to discuss the 20 categories of
topics related to CKD and self care
(see Table 1). At the visits, the CKD
nurse educator assessed the participants Transtheoretical Model stage of
change: precontemplation, contemplation, preparation, action, or maintenance (Prochaska & DiClemente,
1983).
The intervention also consisted of
a brief collaborative goal-setting
process at each patient visit with the
CKD nurse educator. The educational
intervention was delivered in segments
over the six visits that were each
expected to last approximately 60
minutes. The intervention was individualized based on patient needs, clinical
status, co-morbidities, understanding,
and the assessed Transtheoretical
Model stage of change.
Evaluation Design
A pre-intervention post-intervention design and case series approach
was used to evaluate the pilot project.
The study was approved by the UNCChapel Hill School of Medicine Institutional Review Board.
Eligibility Criteria
Persons were eligible for this intervention and study if a) 18 years of age
or older at the time of enrollment; b)
living in the service areas of at least
one of the two UNC Chronic Kidney
Disease Clinic locations; c) insured by
NC Medicaid as primary or secondary
payer, for example, Medicare may be
primary for dually eligible beneficiar-
May-June 2015
Vol. 42, No. 3
Table 1
Topic List of CKD Educational Intervention and Number and Percent of Participants Who
Demonstrated Improvement in Knowledge by Meeting Established Evaluation Criteria after
Receiving the Educational Intervention.
Met Knowledge Criteria # (n)
List of CKD Educational Topics
Sample Knowledge Assessment Questions
PreTest
PostTest
%
Improved
Overview of CKD
1.
Normal kidney function
What are two normal functions of the kidneys?
2 (9)
8 (9)
66.7
2.
Chronic kidney disease (CKD)
What is chronic kidney disease or CKD and what

does this mean to you?
4 (9)
7 (9)
33.3
3.
Lab work and meaning of test results

(eGFR, creatinine, blood urea nitrogen
[BUN], chemistries, hemoglobin, urine
dipstick)
What two blood tests tell how well your kidneys

are working?
What do GFR and creatinine mean?
1 (9)
6 (9)
55.6
0 (9)
4 (9)
44.4
Relationship of CKD to diabetes and

hypertension
What are the two leading causes of chronic

kidney disease?
How does diabetes affect your kidneys?
How does high blood pressure affect your
kidneys?
2 (9)
8 (9)
66.7
1 (7)
1 (9)
5 (7)
8 (9)
57.1
77.8
What medicines are you taking for your kidney

disease? What does each medicine do?
What are three medicines or substances that you
should avoid because of your kidney disease?
What pain medicine is safe or okay to take when
you have chronic kidney disease?
4 (8)
7 (8)
37.5
1 (8)
8 (8)
87.5
4 (8)
8 (8)
50.0
4.
General CKD Management

5.
Common medications for CKD and

medicines to avoid
6.
Diet and/or nutritional management of

CKD, including fluid control
What are the three things in foods that you need

to limit or eat less of in your diet?
0 (8)
7 (8)
87.5
7.
Exercise and sexual activity
What are two benefits or good things about

getting regular exercise?
2 (8)
8 (8)
75.0
8.
Overall strategies and/or therapy to

slow the progression of CKD
What are three things that you can do to help

slow down the damage to your kidneys?
3 (8)
6 (8)
37.5
What are two things that you can do to keep your

heart as healthy as possible and lower your
risk of heart disease?
5 (7)
7 (7)
28.6
Why do some people with kidney disease have

anemia, which you may know as low red
blood cells or low blood?
What treatments are given for this anemia?
0 (7)
2 (7)
28.6
0 (7)
5 (7)
71.4
Why do some people with kidney disease have

bone disease?
What can you do to prevent or slow down bone
disease?
0 (7)
4 (7)
57.1
0 (7)
5 (7)
71.4
Co-Morbidities and Special Issues for Persons with CKD

9.
Heart health Prevention and

management
10. Anemia and its management
11. Bone disease and management
continued on next page
May-June 2015
Vol. 42, No. 3
243

Table 1 (continued)
Topic List of CKD Educational Intervention and Number and Percent of Participants Who
Demonstrated Improvement in Knowledge by Meeting Established Evaluation Criteria after
Receiving the Educational Intervention.
Met Knowledge Criteria # (n)
List of CKD Educational Topics
Sample Knowledge Assessment Questions
PreTest
PostTest
%
Improved
Co-Morbidities and Special Issues for Persons with CKD (continued)

12. Diabetes management, including
neuropathy
13. Hypertension management
What blood test is used to check your overall

blood sugar or blood glucose control?
What are two ways that you can keep your blood
sugar under control?
Why is keeping your blood sugar under control
so important?
1 (5)
2 (5)
20.0
3 (5)
3 (5)
0.0
2 (5)
4 (5)
40.0
What is the target or goal for your blood pressure

level?
What are two ways that you can keep your blood
pressure under control?
Why is keeping your blood pressure under
control so important?
2 (7)
3 (7)
14.3
4 (7)
5 (7)
14.3
2 (7)
5 (7)
42.9
Effect of CKD on Symptoms and Self-Care Management Strategies and Behaviors

14. Physical symptoms, impairment of
functioning and well-being
15. Coping with CKD: emotional issues,
effect on family and social life, work
and finances
What are some symptoms that you have that you

think are due to your kidney disease?
What can you do to make these symptoms less?
4 (5)
5 (5)
20.0
2 (5)
5 (5)
60.0
What are your feelings and emotions related to

having kidney disease?
What one thing can you do to deal with these
feelings and emotions in a healthy way?
3 (5)
5 (5)
40.0
4 (5)
5 (5)
20.0
Treatment Options and/or Modalities

16. Symptoms of kidney disease and
kidney failure
What are three signs and symptoms of

worsening kidney disease or kidney failure?
0 (5)
4 (5)
80.0
17. Hemodialysis at home and in-center;

and access options
How often do most people have hemodialysis

treatments?
What special procedure or operation is required
before you can start hemodialysis?
1 (5)
5 (5)
80.0
1 (5)
4 (5)
60.0
18. Peritoneal dialysis and access:

continuous ambulatory peritoneal
dialysis (CAPD) and continuous
cycling peritoneal dialysis (CCPD)
What is one advantage of peritoneal dialysis as a

treatment option?
What special procedure or operation and training
are required before peritoneal dialysis can be
started?
0 (5)
3 (5)
60.0
0 (5)
2 (5)
40.0
19. Kidney transplant: living donor and

deceased donor
What is one advantage of having a kidney

transplant?
What are the two types of kidney transplants?
What two things do you need to do after a kidney
transplant?
1 (5)
4 (5)
60.0
0 (5)
5 (5)
100.0
0 (5)
1 (5)
20.0
If a person with kidney failure decides not to

have dialysis or a transplant, what will
eventually happen?
What document or papers should be completed if
a person decides not to have treatment for
kidney failure?
5 (5)
5 (5)
0.0
2 (5)
5 (5)
60.0
20. Right to refuse treatment
Note: n = the number of persons in the denominator for measuring improvement in knowledge.
244
May-June 2015
Vol. 42, No. 3
ies; d) have CKD Stage 3b or 4 with an

estimated GFR (eGFR) of 15 to 29
(Stage 4) or 30 to 45 (Stage 3b)
mL/minute/1.73 m2, on two separate
measurements a minimum of one
month apart; and e) not linked with
needed CKD services, such as patient
education. Persons were excluded if a)
previously participated in a CKD educational intervention or clinic, or b)
eGFR of less than 15 or of 45 or mL/
minutes/1.73m2 or higher at enrollment.
Study Procedures
Population-based approach to
identifying participants. Population-based strategies were used to
identify potentially eligible Medicaid
beneficiaries using a series of steps. In
step one, electronic files of eGFR laboratory values for North Carolina
Medicaid beneficiaries drawn between May 1, 2009, and December 2,
2011, were screened to identify participants with eGFR values in the eligibility range. This step was intended to
be sensitive but not specific. In step
two, the CKD nurse educator reviewed electronic health records and
Medicaid files of potentially eligible
persons to further screen for eligibility. Because laboratory value data
were reported for a range of dates, the
screening lab data needed to be supported with a review of records to further assess eligibility, such as whether
the person was currently living, the
current CKD stage, and whether
treatment, such as dialysis, was being
received. In step three, the CKD
nurse educator checked North
Carolina Medicaid care management
records to determine whether the
potentially eligible person was receiving community-based care management services. If so, the AccessCare
community-based care manager was
asked to make the initial contact with
the person to assess potential interest
in receiving CKD education. The
CKD nurse educator contacted the
person by telephone and/or letter to
describe the program, determine
whether the person was interested in
participating, and assess potential barriers to participation if not interested.
Patients were eligible to receive the
educational intervention whether or

not they agreed to participate in the
study. However, all who were interested in the intervention agreed to
participate in the study.
Intervention process. The CKD
nurse educator scheduled the initial inclinic visit for persons who were potentially eligible for the intervention. At
the initial visit, the educator ordered
laboratory work to further assess CKD
status and stage, conducted informed
consent, and administered baseline
assessments of patient knowledge, selfperceived health status, healthcare utilization patterns, and self-efficacy in
managing CKD.
During each visit, the CKD nurse
educator delivered a module of the
educational intervention, assessed
patient understanding of CKD concepts discussed and Transtheoretical
Model stage of change, worked collaboratively with patients to set small
measurable behavior change goals,
and assessed goal achievement from
prior visits. The educational intervention was guided by a standardized
curriculum and supported by supplemental patient resources. The mutually established goals were intentionally
small, targeted, and achievable based
on what participants believed they
could accomplish in the short-term.
New goals were established at each
visit, building on the previous accomplishments.
Data Sources
Data for this study were obtained
from a hospital database extract, electronic health records, populationbased electronic Medicaid files, patient
questionnaires and assessment tools,
and documentation of interactions
with patients. A series of three data
requests were made to UNC Health
Care between May 2010 and
December 2011 to obtain records of all
adult Medicaid beneficiaries who had
received health services at UNC
Health Care in any department and
had an eGFR laboratory result during
the previous year for the first request
and during the previous six months for
subsequent requests. Data were provided in ExcelTM files on a secured
May-June 2015
Vol. 42, No. 3
server. Data elements for each potential participant were Medicaid identification number, date of service, gender,
race, and eGFR. Medical records at
UNC Health Care were reviewed for
beneficiaries who had eGFR lab values within the range of 15 to 45 mL/
minute/1.73m2. The North Carolina
Medicaid Clinical Management Information System (CMIS) is the primary
database used by care managers to
document care management needs
and services provided. It also includes
some data extracted from the North
Carolina Medicaid claims database.
This database was reviewed to assess
whether or not beneficiaries received
care management services.
Measurement
During visits with participants,
self-report data were collected using
four tools: four-item Healthy Days
component of the Health-Related
Quality-Of-Life 14-Item Measure
(HRQOL-14) (CDC, 2011); four-item
Health Care Utilization measure
(Stanford Patient Education Research
Center, n.d.); eight-item Perceived
Kidney Self-Management Scale (see
Table 2); and the Nurse Education
Intervention Checklist. The four-item
Healthy Days Measure is a standard
set of questions that is included in the
State-Based Behavioral Risk Factor
Surveillance System, National Health
and Nutrition Examination Survey,
and the Medicare Health Outcome
Survey (CDC, 2011). Psychometric
testing of the four-item Health Care
Utilization measure has been reported in a study that compared selfreported health services utilization
with health records (Ritter, Kaymaz,
Stewart, Sobel & Lorig, 2001). This
study demonstrated that participants
have a tendency to under-report
physician visits (r = 0.64) and overreport emergency department visits (r
= 0.60); however, the authors concluded that self-reported utilization is
a potentially viable alternative to
reviewing provider records (Ritter et
al., 2001). The Perceived Kidney SelfManagement Scale is a modified version of the eight-item Perceived
Medical Condition Self-Management
245

Table 2
List of Study Instruments and Frequency and Timing of Administration
Tool Name
Intake Tool and Demographic
Information
Patient Interview tool
Part I Healthy Days
Part II Health Care Utilization
Part III Perceived Kidney
Self-Management Scale
Nurse Education Intervention
Checklist
Part A. Measurement of Patient
Knowledge or Understanding
Part B. Measurement of PatientDirected Goals and Goal
Achievement
Part C. Measurement (Time) of Nurse
Intervention (Education)
Health Measures Abstract Tool
Part A. Agencies and Services Involved
in Care
Part B. Diagnoses
Part C. Medications
Part D: Lab Values and Other Health
Measures
Scale (PMCSMS) (Wallston, Osborn,

Wagner, & Hilker, 2011) and the Perceived Diabetes Self-Management
Scale (PDSMS) (Wallston, Rothman,
& Cherrington, 2007), which was created by replacing medical condition or diabetes with kidney disease in the PMCSMS and PDSMS,
respectively. The PMCSMS was adapted from the validated Perceived Health
Competence Scale (PHCS) (Smith,
Wallston & Smith, 1995), and was found
to have internal consistency among
persons with HIV (Cronbachs alpha
= 0.78) and diabetes (Cronbachs
alpha = 0.82) (Wallston et al., 2011)
and validity when correlating results
with other validated measures of selfefficacy. The PMCSMS is intended to
be a generic tool that can be adapted
for different conditions.
The Healthy Days tool assessed
four components of self-perceived
health status: general health, physical
246
Types of Measures
(# of Questions)
Demographic and contact information.
Frequency and Timing

of Administration
Baseline.
Baseline and sixth educational visit.
Self-perceived health status (4).

Self-perceived utilization (4).
Self-perceived self-management (8).
Knowledge and understanding of CKD

and related concepts.
Individualized patient behavior change
goals, baseline measures, and goal
achievement.
Duration of educational intervention.
Every educational visit.

Knowledge: Pre-intervention and postintervention for each visit for the
content covered.
Agencies actively involved in care of

patient.
Renal diagnosis and co-morbidities.
Medications, dose, frequency and route
of administration.
Intermediate health measures, such as
eGFR, other lab values, blood pressure
and weight.
Parts A, B, and C: baseline and as

changes occur.
health, mental health, and restrictions

in completing usual activities because
of health (see Table 3). The Health
Care Utilization tool was used to
assess the self-reported frequency of
occurrence for the following measures in the previous six months: visits
to a physician, visits to a hospital
emergency department, overnight
stays in a hospital, and nights in a hospital (see Table 3). The eight Managing Your Health Problem questions
were adapted from the validated Diabetes Self-Management Scale (Wallston
et al., 2007). These items were posed
as statements asking participants to
rate agreement with a series of negative and positive statements about
self-care for CKD (see Table 3). These
measures were assessed at baseline
and completion of the full intervention. For the Health Care Utilization
items, the follow-up measurement
occurred six months after baseline be-
Part D: Monthly during intervention

period.
cause the questions asked about utilization over the past six-month time
period.
The Nurse Education Intervention Checklist was developed by the
research team after conducting an
unsuccessful literature search to find a
tool that would guide the CKD educational intervention and assess learning. However, the knowledge assessment component was modeled after
the Spoken Knowledge in Low Literacy patients with Diabetes (SKILLD)
(Rothman et al., 2005). The CKD
knowledge checklist assessed the following: CKD content taught, baseline
knowledge for 20 topics, post-intervention knowledge, health behavior
goals and goal achievement, and
duration of the CKD nurse educational session in minutes (see Table 1).
The educational intervention
process was measured by indicating
for each topic whether it was covered,
May-June 2015
Vol. 42, No. 3
Table 3
Survey Questions and Participant Responses Assessing Self-Perceived Health Status, Health Care
Utilization, and Self-Perceived Self Management
Survey Questions
Response Options
Pre-Test
Post-Test
1 (9)
1 (9)
3 (9)
3 (9)
1 (9)
0 (4)
1 (4)
2 (4)
1 (4)
0 (4)
Self-Perceived Health Status: Healthy Days

1.
Would you say that in general your health is:
Excellent
Very good
Good
Fair
Poor
2.
Now thinking about your physical health, which includes physical

illness and injury, for how many days during the past 30 days was
your physical health not good?
Number of days
Mean
Range
7.1 (8)
0 to 15
6.5 (4)
0 to 14
Now thinking about your mental health, which includes stress,

depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
Number of days
Mean
Range
10.1 (9)
0 to 30
5.3 (4)
0 to 16
During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities,
such as self-care, work, or recreation?
Number of days
Mean
Range
0.8 (9)
0 to 5
4.0 (4)
0 to 14
3.
4.
Health Care Utilization

5.
In the past 6 months, how many times did you visit a physician?
Do not include visits while in the hospital or to a hospital emergency room. Fill in with 0 or another number.
Number of times
Mean
Range
7.3 (9)
4 to 25
8.8 (4)
3 to 8
In the past 6 months, how many times did you go to a hospital

emergency room? Fill in with 0 or another number.
Number of times
Mean
Range
1.1 (9)
0 to 4
1.5 (4)
0 to 4
How many different times did you stay in a hospital overnight or

longer in the past 6 months? Fill in with 0 or another number.
Number of times
Mean
Range
0.4 (9)
0 to 2
0.25 (4)
0 to 4
How many total nights did you spend in the hospital in the past 6
months? Fill in with 0 or another number.
Number of nights
Mean
Range
1.1 (9)
0 to 7
1.8 (4)
0 to 7
1 = Strongly Disagree
to 5 = Strongly Agree
Pre-Test
Post-Test
1 to 2
3
4 to 5
3 (9)
3 (9)
3 (9)
4 (4)
0 (4)
0 (4)
10. I find that efforts to change things I dont like about my kidney disease arent helpful.
12
3
4 to 5
4 (9)
3 (9)
2 (9)
3 (4)
1 (4)
0 (4)
11. I handle myself well with respect to my kidney disease.
1 to 2
3
4 to 5
2 (9)
0 (9)
7 (9)
0 (4)
0 (4)
4 (4)
12. I am able to manage things related to my kidney disease as well

as most other people.
1 to 2
3
4 to 5
1 (9)
0 (9)
8 (9)
0 (4)
0 (4)
4 (4)
13. I succeed in the goals I undertake to manage my kidney disease.
1 to 2
3
4 to 5
2 (9)
0 (9)
7 (9)
0 (4)
0 (4)
4 (4)
6.
7.
8.
Managing Your Health Problem:

Perceived Kidney Disease Self-Management Scale
9.
It is hard for me to find effective ways to deal with problems that

occur with managing my kidney disease.
continued on next page
May-June 2015
Vol. 42, No. 3
247

Table 3 (continued)
Survey Questions and Participant Responses Assessing Self-Perceived Health Status, Health Care
Utilization, and Self-Perceived Self Management
Managing Your Health Problem:
Perceived Kidney Disease Self-Management Scale
1 = Strongly Disagree
to 5 = Strongly Agree
Pre-Test
Post-Test
14. Typically, my plans for managing my kidney disease dont work

out well.
1 to 2
3
4 to 5
5 (9)
1 (9)
3 (9)
4 (4)
0 (4)
0 (4)
15. No matter how hard I try, managing my kidney disease doesnt

turn out the way I would like.
1 to 2
3
4 to 5
5 (9)
0 (9)
4 (9)
3 (4)
1 (4)
0 (4)
16. Im generally able to accomplish my goals with respect to managing my kidney disease.
1 to 2
3
4 to 5
2 (9)
2 (9)
5 (9)
0 (4)
0 (4)
4 (4)
not covered, or not applicable for

each visit. Participant knowledge of
each content area was assessed by the
CKD nurse educator by asking a standard set of questions for the respective content areas covered during the
visit. Participant responses to each
question were compared with standardized responses that would be
considered acceptable. The CKD
nurse educator rated the participant
responses to each question as: yes
(met all established criteria) or no (did
not meet criteria); or not applicable.
The full set of educational assessment
questions was asked again at the last
education visit to measure knowledge
retention. Health behavior goal setting was documented on the checklist
within both a statement and a matrix
to document goals and goal achievement over time, including baseline
date for goal, measurable goal and
description, baseline value, target
goal, target date, and follow-up measure. Revisions to goals were documented during each visit.
Analysis
Data from this pilot project were
assessed using descriptive approaches. First, changes in participant knowledge, as assessed using the Nurse
Education Intervention Checklist,
were summarized as the number and
percentage of participants who did
not provide an accurate response to
the knowledge assessment prior to
receiving the educational intervention
248
Figure 1
Screening, Selection, and Enrollment of Study Participants
Patients screened for eligibility

through review of eGFR lab values
(3,029).
Not eligible based on screening
eGFR lab values (1,889)
Potentially eligible for
intervention based on 1 eGFR
lab value (1,140)
Not eligible based on review of
health records (1,087)
Potentially eligible based on
review of health records (53)
Declined to participate or no
longer eligible (44)
Participated in pilot study (9)
for the specified content area yet

responded correctly after receiving
the intervention. Second, responses to
the 16-patient interview tool questions
regarding self-perceived health status,
health services utilization, and disease
self-management were measured and
compared over time. Third, participant-specific health behavior goals,
baseline measures and follow-up
measured were documented. These
behavioral assessments are summarized in brief case descriptions.
Results
Of the 3,029 patients who were
screened for potential eligibility, 53
(1.7%) were found to be eligible for
the pilot project based on a review of
health records. Of these, 9 (0.3%) persons screened agreed to participate in
the study (see Figure 1). Persons
screened were identified as being
ineligible because of: improved
eGFR after initial screening, declining eGFR, on dialysis, status post kid-
May-June 2015
Vol. 42, No. 3
Table 4
Demographic Characteristics of Study Participants
Frequency
(%)
Demographic Characteristic
Age
50 to 59 years
60 to 69 years
70 to 79 years
80 to 89 years
Gender
Male
Female
Ethnicity
Not Hispanic or Latino
Hispanic or Latino
Race
Black or African American
White
Asian
American Indian or Alaskan Native
Native Hawaiian or Pacific Islander
Patients Preferred Language
English
Spanish
Marital Status
Single, never married
Married
Widowed
Divorced
Highest Level of Education Achieved
Elementary School (K 5)
Middle School (6 8)
Some High School
High School or GED
Some College
2-Year College Degree (Associates) or higher
Type of Residence
Owns Home
Rents Home or Apartment
Other
Number of People at Residence (for past 2 months)
One person
Two persons
Three persons
Four persons
May-June 2015
Vol. 42, No. 3
2
2
3
2
(22.2)
(22.2)
(33.3)
(22.2)
4
5
(44.4)
(55.6)
9 (100.0)
0
(0.0)
6
2
1
0
0
(66.7)
(22.2)
(11.1)
(0.0)
(0.0)
9 (100.0)
0
(0.0)
3
1
3
2
(33.3)
(11.1)
(33.3)
(22.2)
1
2
1
3
2
0
(11.1)
(22.2)
(11.1)
(33.3)
(22.2)
(0.0)
2
5
2
(22.2)
(55.6)
(22.2)
3
4
0
2
(33.3)
(44.4)
(0.0)
(22.2)
ney transplant, medically inappropriate, residing in institutional setting or

on hospice care, other worsening
comorbidities, or deceased. Eligible
persons who declined to participate
in the study indicated lack of transportation to the clinic or cost of auto
fuel to travel to the clinic (n = 11), lack
of interest (n = 12), or not aware of or
denying CKD (n = 3).
Participants in this pilot ranged in
age from 52 to 82 years, with three
participants 70 to 79 years of age, and
two each in 50 to 59, 60 to 69, and 80
to 89 years of age categories (see
Table 4). Five participants (55.6%)
were female, all were non-Hispanic
and English-speaking, and six (66.7%)
were black or African American.
Three (33.3%) participants were single, three (33.3%) were widowed, two
(22.2%) were divorced, and one
(11.1%) was married. Only two
(22.2%) participants had completed
some college, three (33.3%) had completed high school or a GED, four
(44.4%) had less than a high school
education. More than half (n = 5;
55.6%) rented a home or apartment,
two (22.2%) owned their own homes,
one lived with a daughter, and one
lived with a friend.
The average number of interventional visits completed with the CKD
nurse educator per participant was
4.2 with a range of one to six (see
Table 5). Four participants completed
all six visits and reviewed all relevant
content areas. The mean visit duration was 63.4 minutes with a range of
45 to 90 minutes. The initial visit was
generally the longest, with an average
length of 81.7 minutes, ranging from
60 to 90 minutes. The length of visits
two through six averaged 57.8 minutes with a range of 45 to 75 minutes.
Changes in Participant
Knowledge
The percent of participants
whose knowledge of CKD concepts
increased after the intervention varied by content type. Knowledge
improvement was generally more
consistent among participants for the
content areas of overview of CKD,
general CKD management, and treat-
249

Table 5
Frequency and Length of Participant Visits with CKD Nurse Educator
Measure
Frequency
Mean
Range
N/A
4.3
1 to 6
1 visit
N/A
N/A
3 visits
N/A
N/A
5 visits
N/A
N/A
6 visits
N/A
N/A
All visits
N/A
63.4
45 to 90
Initial visits only
N/A
81.7
60 to 90
Second through sixth visits
N/A
57.8
45 to 75
Number of participant visits with CKD nurse educator

Number of participants completing visits
Visit duration in minutes
ment options and/or modalities.

Knowledge improvement generally
occurred less frequently among participants for most topics in the content
areas of co-morbidities and special
issues for persons with CKD; and the
effect of CKD on symptoms and selfcare management strategies and
behaviors. All five participants who
discussed transplant types with the
CKD nurse educator were able to
recall and state the two types of kidney transplants post-intervention, but
none prior to receiving the intervention. All participants described the
consequences of not getting care for
ESRD both before and after the intervention.
At least two-thirds of participants
demonstrated knowledge improvement after the intervention on questions focused on medicines and substances to avoid (87.5%), foods to limit
(87.5%), signs and symptoms of worsening kidney disease or kidney failure
(80.0%), frequency of hemodialysis
treatments (80.0%), effect of high
blood pressure on kidneys (77.8%),
benefits of getting regular exercise
(75.0%), treatments for anemia
(71.4%), preventing or slowing the
progression of bone disease (71.4%),
normal functions of the kidneys
(66.7%), and leading causes of kidney
disease (66.7%). The observed posttest knowledge improvement occurred with the lowest frequency for
250
questions focused on blood sugar

management for persons with diabetes (0.0%), target blood pressure
values (14.3%), strategies for blood
pressure management (14.3%), blood
test used to assess blood glucose control (20.0%), symptoms that are related to CKD (20.0%), self-care after a
kidney transplant (20.0%), and strategies for coping with feelings about
CKD (20.0%). Conclusions that can
be made from these results are limited because the number of respondents is very small.
Changes in Participant Health

Behaviors and Health-Related
Outcomes
The mutually developed measurable goals typically focused on nutrition and physical activity. Examples
included reducing salt use at the table,
walking more, grilling and baking
foods instead of frying them, lowering
potassium and phosphorus in the diet,
and consuming more fresh and frozen
vegetables. In general, participants
achieved the established behavioral
goals during the study period (see
Table 6). One participant achieved a
nine-pound weight loss. At least two
participants reduced their blood pressure levels. Two participants reported
an increase in physical activity. Other
behaviors changes and outcomes
included, decreased use of salt substitutes, improved energy level, reduced
intake of fried foods, eating more

fruits and vegetables, and avoiding
over-the-counter medications that are
generally contraindicated for persons
with CKD.
Self-perceived health status, selfreported health care utilization, and
perceived self-management of CKD
were assessed for all nine participants
at baseline (see Table 3). The results of
these self-reported measures are also
reported for the four participants who
completed six visits with the CKD
nurse educator. The post-test survey
was generally completed approximately four months after the pre-test
survey. Pre-test/post-test comparisons
are not very meaningful because of
the small numbers and the intervention, especially for the post-test.
Acknowledging data limitations,
there was a reported decrease in days
where mental health was not good
over the past 30 days from a mean of
10.1 to 5.3 days. The average number
of physician visits during the previous
six months remained relatively stable
from the pre-test (7.3 visits) to post-test
(8.8 visits) period. The four participants who completed the six educational visits generally reported agreement with the four positively-stated
questions about self-management of
CKD, and disagreement with the four
negatively stated questions about selfmanagement. For example, four of
four participants at post-test indicated
May-June 2015
Vol. 42, No. 3
Table 6
Examples of Individualized Behavioral Goals and Outcomes for Study Participants
Demographic
Characteristics
CKD Stage
Brief History
60-year-old AfricanAmerican female
CKD Stage 3b;

hypertension; type 2
diabetes; HIV; asthma,
sleep apnea
53-year-old AfricanAmerican male
CKD Stage 3b;

polycystic kidney
disease; hypertension;
cerebral aneurysm
CKD Stage 4;
hypertension; diabetes
mellitus; obese; focal
segmental glomerulosclerosis; gout
CKD Stage 3b,

hypertension, diabetes
mellitus, history of
myocardial infarction,
gout, hyperlipidemia
May-June 2015
General Goal
Outcomes
Weight loss
Achieved 9 pound weight loss over 12 months.
Exercise
Began walking to mailbox daily.
Lower salt intake
Reduced table salt use from 2 to 3 shakes to 1

shake.
Decrease fat intake
Consumed less fried foods; removed skin from

chicken; changed to lower fat milk.
Improve blood pressure

monitoring and control
Blood pressure dropped from ~ 146/90 to 124/80.

Took blood pressure at home daily.
Decrease salt intake
Stopped use of table salt; cooked with less salt;

consumed more fresh and frozen vegetables.
Decrease fatty food

consumption
Consumed less fried foods, only twice in 4 weeks;

changed to canola oil; grilled and baked meats.
Follow CKD diet
Lower potassium and phosphorus in diet; increased

water intake; stopped drinking soda.
Weight loss
Lost weight intermittently with weight fluctuation.
Better blood pressure

control
Reduced systolic blood pressure from 160s to 140s.
Exercise
Increased exercise and walking.
Reduce sugar and fat

intake
Changed to sugar-free sweetener, diet sodas and

low-fat milk.
Reduce salt intake
Not cooking with or adding salt to foods; consuming

lower-sodium foods.
Increase exercise
Increased length and duration of walking from 1-2

brief walks per day to 5.
Avoid contraindicated
over-the-counter
medications
Switched to a recommended laxative.
Decrease weight
Lost 2.5 pounds by visit 2, lost 7 pounds by visit 3.
Decrease salt intake
Decreased salt consumption by rinsing canned

foods that contain salt & removing salt shaker from
table.
Vol. 42, No. 3
251

agreement to the statement, I succeed in the goals I undertake to manage my kidney disease. And, four of
four participants at post-test indicated
disagreement to the statement, It is
hard for me to find effective ways to
deal with problems that occur with
managing my kidney disease. In
contrast, the pre-test responses were
generally distributed across the
response options.
Discussion
The results of this pilot project
were mixed because the populationbased approach to identify persons
with CKD during Stages 3b and 4
was minimally successful. The officebased approach was not very accessible for patients; however, the educational intervention demonstrated
short-term successes for those persons
who participated in the pilot project.
In general, the population-based strategy used to identify persons with
CKD Stage 3b or 4 was relatively
time-intensive and resulted in identifying only 53 people who were eligible for the intervention. This finding
was somewhat lower than expected
because of the clinics history of having more than 80% of referrals to clinic being patients in CKD Stage 4 or 5.
One possible explanation for
identifying a relatively small number
of eligible persons was the use of
datasets that included eGFR results
obtained over a 6- to 12-month period.
Some potentially eligible persons had
progressed to CKD Stage 5, were on
dialysis, had received a kidney transplant, or had died by the time we
reviewed health records to further
assess eligibility. Of those eligible for
the intervention, 83% declined to participate. The most frequently reported
reasons for declining the educational
intervention were transportation-related barriers, including costs, and lack of
interest. An office-based educational
intervention was not sufficiently convenient for many persons with CKD
who expressed initial interest in receiving the intervention. The NP-delivered
intervention was the most successful
component of the pilot project.
252
Knowledge improvement was observed to increase in at least 50% of participants for approximately 60% of the
questions. Participants also reported
making incremental health behavior
changes generally related to nutrition
and physical activity.
Population-Based Strategies
to Identify Persons with CKD
Our effort to implement a population-based strategy to identify persons
with CKD Stage 3b or 4 who were not
linked with appropriate specialty care
services appears to be less successful
than in other published studies. For
example, a population-based disease
management approach was implemented in the West Lincolnshire
Primary Care Trust (WLPCT) area in
the United Kingdom (UK) to identify
persons 15 years of age and older with
CKD Stage 4 and not known to a
nephrologist (Richards et al., 2008). In
the WLPCT study, eGFR was calculated using the four-variable Modification of Diet in Renal Disease
(MDRD) formula and reported to
requesting physicians for 47,119
patients of the 185,434 persons in the
population database. More than 1,200
persons with CKD Stage 4 and not
known to nephrologists were identified. The proportion of participants
identified with CKD Stage 4 in the UK
study (2.5%) was somewhat higher
than the proportion eligible in our
study (1.75%); however, because of differences in age ranges and CKD stages
between the studies, these are not ideal
comparisons. In the UK study, referrals to nephrologists initially spiked to
approximately 2.7 times higher than
the
pre-eGFR-reporting
period
(Richards et al., 2008). After introduction of a referral assessment process to
review appropriateness, referrals to
nephrologists remained elevated at
about 1.5 times the pre-eGFR identification and notification period
(Richards et al., 2008). Approximately
40% of referrals did not follow guidelines. Yet the availability of a population-based database and use of a
prospective approach may have been
a more successful strategy than our use
of retrospective lab data.
A study conducted in Ontario,

Canada, tested the validity of a method to detect CKD using algorithms
that combined hospital encounter
and physician claims database diagnostic codes among persons 66 years
of age and older (Fleet et al., 2013).
The algorithm results were compared
with eGFR values as the reference
standard. All patients in a database of
123,499 patients had a baseline serum
creatinine value for estimating eGFR.
The sensitivity of the algorithm in
detecting CKD was 32.7%, meaning
that only 32.7% of persons with CKD
in the population, as defined by the
eGFR threshold, were identified
using the algorithm. The specificity of
the algorithm was greater than 94%,
meaning that more than 94% of persons who did not have CKD based on
the eGRF threshold had a negative
result using the algorithm. The positive predictive value or true positives
was 65.4%, meaning that 65.4% of
those identified as possibly having
CKD using the algorithm actually
had CKD based on the eGFR results.
Further, the negative predictive value
of the algorithm was found to be
88.8%, meaning that 88.8% of negative algorithm results did not have
CKD based on the eGFR threshold
(Fleet et al., 2013). This method
required the use of linked populationbased databases.
Another study examined the
cost-effectiveness and cost-utility of
conducting CKD screening using
eGFR within a large publicly funded
Canadian healthcare system (Manns
et al., 2010). The study focused on
screening to identify persons with
CKD for purposes of initiating medical management, such as treating
persons with angiotensin blockers
rather than on initiating educational
interventions. This study concluded
that population-based screening to
identify persons with CKD was not
cost-effective overall or in any subgroup analyses (Manns et al., 2010).
The United States Preventive Services
Task Force (USPSTF) also concluded
that current evidence is insufficient to
recommend screening for CKD
among asymptomatic adults (Moyer,
May-June 2015
Vol. 42, No. 3
2012). Our study did not involve

screening methods, but had a similar
intent to identify persons with CKD
Stages 3b and 4 to initiate educational
interventions.
CKD Educational
Interventions
The success of our CKD educational intervention on changing participant health behaviors and improving
health status seems comparable to
other published interventions. However, a number of these other interventions focused on more targeted
health education topics and behaviors
with varying intensity of interventions,
whereas our intervention covered the
full range of CKD health education
topics and only included a NP-led
educational intervention. For example, one controlled trial in Australia
with 36 intervention patients with
CKD Stage 3 or 4 evaluated the effect
of a lifestyle intervention and aerobic
and resistance exercise training on
cardiorespiratory
fitness
levels
(Howden et al., 2013). This intervention consisted of usual care, cardiovascular risk factor management provided by a CKD nurse practitioner and
other health professionals, 150 minutes of moderate intensity exercise per
week with eight weeks of training
supervised by an exercise physiologist
(including gym sessions with aerobic
exercise and weight and resistance
training, telephone, and email follow
up), and four weeks of group behavior
and lifestyle modification facilitated
by a dietician and psychologist. This
intensive intervention was associated
with an average weight loss of 1.8 kilograms, increased peak VO2 (2.8 mL/
kg/minute), and improved diastolic
function (Howden et al., 2013). A less
intense intervention was studied
among 150 patients on hemodialysis
to assess the effect of watching a 45minute educational video on serum
phosphate levels (Baldwin, 2013). In
the month following the video viewing, serum phosphorous levels were reduced, on average, from 6.82 to 6.35
g/dL among participating patients.
Study Limitations
There are several limitations to
consider when interpreting the findings from our pilot project. One limitation is the small sample of persons
with CKD who completed the intervention. The small sample precludes
the ability to make valid pre-intervention/post-intervention comparisons in
self-efficacy, and changes to participant knowledge and health behaviors. However, the series of cases provides some evidence to suggest that
the intensive educational intervention
was associated with increases in
understanding of CKD and incremental behavior changes. Second, the
lack of a comparison group further
weakens the ability to link the
changes in behavior to the intervention because other influences in the
participants lives could account for
these changes. The post-intervention
assessment of understanding of CKD
tends to support the intervention as
the catalyst for these changes. Third,
because patients self-selected to
receive the intervention, it is possible
that those who participated and completed the study were more motivated
to exhibit positive changes in knowledge and behaviors than those who
refused to participate. It is not clear
whether this intervention would be
effective among persons who are not
interested in making the effort to
come to the clinic if, for example, the
intervention were offered at a more
convenient location.
Implications for Practice

and Future Research
To slow or prevent the progression of CKD and reduce associated
health care utilization and costs, there
are a number of research questions
that could be answered with future
research. When thinking about population-based strategies to identify persons with CKD who could benefit
from educational or other interventions aimed at changing behavior, it
may be important to explore whether
the same goals can be accomplished
using broader population-based stra-
May-June 2015
Vol. 42, No. 3
tegies. For example, would it be feasible and more effective to reduce the
overall societal burden of CKD by
testing interventions aimed at improving health behaviors and health
status for persons at high risk for
CKD, such as those with hypertension, diabetes, obesity, and/or a family history of CKD? Additionally, as
U.S. health care delivery systems
expand the use of integrated electronic health records, more automated
processes for identifying persons with
CKD could be explored and tested.
The second set of future research
questions pertains to behavior change
strategies, including access to interventions.
In our study, the office-based intervention was not very convenient
for many potential participants. To
reach a larger audience, it would be
helpful to develop and test interventions that are community-based, perhaps using outreach and/or group
models of outreach with multiple
encounters with each participant. For
example, the mobile outreach unit of
the UNC Kidney Centers Kidney
Education Outreach Program (KEOP)
provides targeted CKD screening
and educational programs for underserved high-risk populations in locations where nephrologists are absent
and primary care providers are
scarce. However, the existing outreach screening and educational interventions are short-term, whereas
our pilot intervention involved up to
six encounters per participant. The
acceptability of interventions that are
provided in the context of a targeted,
community-based program with or
without a mobile unit that can reduce
patients travel could be tested in
future studies.
Because some CKD topics in our
pilot project did not seem to be as
well-understood as others, future
studies could examine other teaching
and learning strategies to enhance
participant learning as well as tools,
such as reminders, to help patients
achieve established goals for behavior
change. For example, it may be helpful to identify the amount of content
that can be learned on average by
253

participants in one session or learning

module, and the number of visits or
contacts that are needed to cover the
content and facilitate sustainable positive behavior changes. Future research could also focus on comparing
the Medicare Part B model that covers up to six CKD education visits for
persons with Stage 4 CKD to models
that vary the number of visits and
CKD stage inclusion criteria (CMS,
2013).
Conclusions
Improvements in CKD-related
knowledge were observed among all
participants after receiving the educational intervention in this pilot project. However, knowledge improvement did not occur for all topics. Incremental behavior changes were
observed for participants with multiple visits with the CKD nurse educator. Further, participants who completed the full intervention reported
overall agreement with their ability to
self-manage their CKD. Even though
improvements were observed among
participants, the population-based
approach used to identify persons
who met the eligibility criteria was
time-intensive and not efficient. In
addition, the clinic-based setting did
not seem to be accessible to the majority of persons eligible to receive the
intervention. This study highlights the
need to learn more about strategies
for identifying persons with CKD
who have not been linked with
appropriate care and health education, and strategies for effectively
delivering interventions in acceptable
and accessible locations.
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