AKHOMM initiative curriculum and learning and action collaborative

Abstract

Individuals with chronic conditions often require multiple medications and are at risk for suboptimal therapy and medication-related harm. Comprehensive medication management (CMM) is a standard-of-care process to address complex medical conditions and existing and potential medication-related problems. Persons with kidney disease have a demonstrable need for CMM given their multiple comorbidities, altered pharmacokinetics, and frequent polypharmacy. Currently, there is a void in advanced pharmacy education and training pathways focused on kidney diseases to allow for more uniform provision of CMM by pharmacists to the large number of individuals with kidney disease. The broad profession of pharmacy needs concentrated and direct training to provide evidence-based care to patients with kidney disease and mitigate the high cardiovascular risk. As highlighted in this special issue, numerous medications have recently been demonstrated with clear evidence to slow chronic kidney disease (CKD) progression and reduce cardiovascular risk. These medications are now integrated into clinical practice guidelines, many with strong evidence-based recommendations for use.^1,2 Inclusion of a pharmacist on the multidisciplinary care team is also recommended by these guidelines as an evidence-based best practice.^1,2 However, implementation of guideline-directed medication therapy to slow CKD progression and reduce cardiovascular risk in routine clinical practice is lacking. This is an area that pharmacists are ideally positioned to address with appropriate training and integration into ambulatory and nephrology-based practice settings. While many pharmacists complete postgraduate training through residencies (general residency with or without additional specialty training), there is no formal training pathway to further develop clinical expertise in kidney disease. There is also no board certification in nephrology for pharmacists as there is for other specialty areas (eg, cardiology, infectious diseases). Even more importantly, training pathways do not exist for cardiovascular-kidney-metabolic (CKM) syndrome, and such pathways will be critical to optimal holistic care of these patients.³ It is well documented that pharmacists are integral members of the multidisciplinary kidney care team in diverse patient care settings; however, many more pharmacists are needed.⁴ Thus, we argue that additional education and implementation strategies are essential to fill this void.

The Advancing Kidney Health through Optimal Medication Management initiative (AKHOMM) set out to address these education and training needs through formation of 2 workgroups focused on curriculum development and creation of a learning and action collaborative (LAC), respectively. The overarching vision of AKHOMM is to accelerate implementation of CMM services across the United States to ensure every person with kidney disease receives optimal medication management through team-based care including a pharmacist. The goal of the curriculum development workgroup is to design learning modules for pharmacists and other interprofessional members of the kidney care team to develop the necessary knowledge and skills to be practice ready to provide CMM for patients with CKM. The goal of the LAC workgroup is to develop a program to implement CMM in CKM using evidence-based practices in ambulatory care settings. To achieve this goal, the LAC aims to advance the inclusion of pharmacists on nephrology and primary care teams, ensure best practices in the care of patients with CKD, and capitalize on new value-based payment models and emerging wraparound kidney care to serve as evidence-generating hubs for interdisciplinary CKM care. The purpose of this report is to emphasize the increasing need for pharmacist education in kidney disease and CKM syndrome while raising awareness of the resources that AKHOMM provides.

AKHOMM curriculum

The AKHOMM curriculum was developed to enhance the education and skills of healthcare professionals in areas related to kidney disease and the secondary complications, thus facilitating provision of CMM for individuals with kidney disease. The development process was iterative, incorporating input from a diverse group of experts, including persons with kidney disease and their care partners, who provided a unique patient perspective. The involved professionals represented the pharmacy, medicine, nursing, dietary science, and social work fields from both inpatient and ambulatory settings. This group was intentionally selected to cover a broad spectrum of kidney disease areas, such as medication dosing, kidney function evaluation, CKD progression, diabetes, acute kidney injury, cardiovascular disease, and metabolic disorders. Those with more in-depth knowledge of the relatively new value-based kidney care models were also involved. An interprofessional curriculum advisory panel (CAP) included 2 patient representatives and their care partners, 2 clinical pharmacists, a nephrologist, a nurse practitioner, a nurse, a social worker, and a dietitian. The CAP served to provide structured feedback on the topics, objectives, outlines, and final content of each module. A “reactionary panel” of experts assisted in prioritizing topics, ensuring comprehensive and relevant content.

The core planning group designed the curriculum in phases, with the first course series titled Slowing CKD Progression. The group developed the initial topic list, emphasizing topics on CKM syndrome. The AKHOMM curriculum planning group also recognized the importance of health disparities in determining access to care and developing an individualized plan for a patient that considers these factors. These topics were prioritized given pharmaco-inequities noted in Black individuals in terms of kidney disease care. Therefore, a second course (Reducing Medication-Related Disparities in Black Persons with Chronic Kidney Disease) was developed. This course included 5 modules, which were developed following a similar review and editing process based on CAP input.

The 2 courses, with a total of 18 modules, are available through the AKHOMM website and free to access with registration.⁵ Modules are video based, with interactive slides and cases included to allow for integration of self-assessment questions, and real-time feedback is provided to the learner. Topics in the courses are included in Table 1. Most modules were designed tolast 30 to 45 minutes, to facilitate completion by busy healthcare professionals. Interprofessional continuing education credits (0.5-0.75 credits) are available for pharmacists, physicians, and nurses. Since many of these topics include medication therapies for which new data are being generated from clinical studies, content in each module will be updated as new information becomes available.

AKHOMM LAC

While education provided by the curriculum helps fill the gap in knowledge, the LAC provides the implementation component of training. AKHOMM created an LAC with the goal of implementing CMM for patients with CKM syndrome. The inaugural LAC began in July 2024. Participants were selected through an application process. The AKHOMM curriculum is a tool that can equip LAC participants with requisite therapeutic knowledge, though completion of the curriculum is not a requirement. Participants are required to complete a CMM implementation certificate course. Additional LAC resources, as described below, are available exclusively to participants.

The LAC was developed by a team of experts in implementation science, CMM, and value-based healthcare models. Critical examination of previous implementation strategies for medication optimization services served as the foundation for AKHOMM LAC development.⁶ The successful framework for medication optimization in primary care was utilized for ambulatory care–based nephrology practices.⁷ Implementation science was used to guide each stage of the LAC.⁸ Key metrics of CMM implementation were ingrained in the reporting for quality improvement according to validated surveys.⁹ These metrics will aid in fidelity assessment, which is to ensure that the intervention is applied as intended. Fidelity assessments were built into the LAC rollout using a standard framework.¹⁰

Each training site selected to participate in the LAC has an implementation team comprised of a pharmacist, a provider champion, and others based on the site’s unique needs (eg, nurse practitioner, care coordinator, administrator, information technology, scheduler, pharmacy technician). The implementation team is paired with an LAC implementation coach and a field expert. The coach guides the team in advancing their CMM practice via direct coaching support, accountability, and providing tools and resources. The field expert is a pharmacist or nephrologist with expertise in kidney diseases who is available for practice-specific questions, mentoring, and providing education. Together, the LAC teams progress through a 16-month program (Figure 1). The first 4 months are the planning and design phase to prepare for implementation of the pharmacist into the practice. Components include assessing team readiness for implementation, building a CMM practice, establishing improvement and performance measurement strategies, and finalizing the team’s “bold aims.” A bold aim is a site-specific, achievable goal the team will focus on during LAC implementation. An example bold aim could be that 80% of eligible CKD patients receive a sodium-glucose cotransporter 2 inhibitor. Teams quickly move into the 12-month implementation and improvement phase, which includes ongoing self-assessments of (1) establishment of program structure, (2) delivery system implementation, (3) measurement and refinement, and (4) demonstration of value, scale-up, and spread. This phase follows a continuous quality improvement framework of a plan-do-study-act cycle that drives successful implementation. Teams and coaches meet regularly to review progress, report on key performance measures, develop action plans, and overcome barriers to implementation. The LAC sites and teams are in the initial phases of the program, and assessment of their success will be evaluated as they move through the program.

Figure 1.

Summary of Advancing Kidney Health through Optimal Medication Management (AKHOMM) learning and action collaborative to implement comprehensive medication management (CMM) for patients with kidney disease.

Open in new tabDownload slide

Experience with the initiative

The initial series of courses on CKD progression was launched in the spring of 2023, and the courses on health disparities followed in late summer. Postactivity evaluation data from inception until April 30, 2024, was used to evaluate the impact of the curriculum. Among the 18 available modules, there were a total of 1,540 viewings, with 1,063 completed postactivity evaluations. Participants may have viewed multiple modules, so the overall number of unique participants is not known. To evaluate the quality of the curriculum and its impact on practice, postactivity survey questions were combined for each module. Participants indicated high quality of the modules: 91% (860/940) of survey respondents answered “excellent” or “good” when asked to rate the overall quality of a particular module, 85% (888/1,051) indicated they plan to make changes in their practice based on the information in the activity, and 93% (970/1,044) agreed or strongly agreed that the activity will improve their ability to treat and manage their patients (note that differences in the denominators exist because participants were not required to answer the questions in postactivity evaluations).The continued success of the curriculum will be evaluated in the future by the number of practitioners completing a module, the number of modules completed, and practitioner discipline.

The first group of participants in the LAC started in July 2024. There are 8 teams across the US that are participating. The initial 4-month planning and design phase ended in November 2024, with transition into the 12-month implementation phase occurring this year.

Conclusion

The future of nephrology pharmacy is ripe with opportunity to improve the quality and outcomes of care for our patients. To that end, we have aimed to better equip the healthcare workforce to implement CMM for patients with kidney disease using education initiatives and implementation science. These will continue to evolve with the field, providing new education offerings in specialty areas such as glomerular disease and complications of kidney replacement therapy while simultaneously launching the first round of participants in the LAC. There is much work to be done on behalf of our patients. We are eager to engage with practitioners who are passionate about optimizing medication management in patients with CKM disorders to reduce CKD progression and cardiovascular risk. For more information about the AKHOMM curriculum and LAC, please go to www.kidneymedicationmanagement.org.

Future areas of work include defining the training path for pharmacists to provide CMM for patients with CKM syndrome, expanding pharmacy-based CKD screening efforts in the community, and integrating pharmacists into multidisciplinary kidney care teams. Concerted efforts across the field are necessary to achieve improved care for patients with kidney disease.

Data availability

No new data were generated or analyzed in support of this article.

Disclosures

The authors have declared no potential conflicts of interest.

This article is part of a special AJHP theme issue on management of chronic kidney disease. Contributions to this issue were coordinated by Wendy L. St. Peter, PharmD, FCCP, FASN, FNKF; Rebecca A. Maxson, PharmD, BCPS; and Katie E. Cardone, PharmD, BCACP, FNKF, FASN, FCCP.

References