CommunityRx-Chronic Kidney Disease (CRx-CKD) in Rural North Carolina

Approximately one in seven adults in the United States lives with chronic kidney disease (CKD). CKD typically worsens with time and, in its final stage, can result in kidney failure. Contextual factors in rural, eastern North Carolina communities impede optimal management of CKD multimorbidity. In these communities, geographical barriers to medical care, dwindling resources, and underdeveloped health infrastructure have worsened CKD outcomes. CommunityRx-CKD (CRx-CKD) is an evidence-based, low-intensity, health information technology-driven intervention designed to support CKD management in rural eastern North Carolina. CRx-CKD integrates medical (e.g., blood pressure and glucose monitoring, eye and foot care), social (food, housing, transportation), and self-care (weight and stress management, exercise) resources. CRx-CKD comprises three components: brief education on integrated CKD needs, a CKD care plan that includes integrated care referrals, and clinic navigator-led, longitudinal support (12 months) for CKD patients in our trial. Our multidisciplinary, community- engaged research team will test the effects of CRx-CKD through three related aims. In Aim 1, we will assess contextual factors that influence the implementation of an integrated care intervention. We will employ a participatory science approach, known as group model building, to engage patients, caregivers, providers, and other stakeholders and elicit their perspectives on how (a) community factors affect CKD progression in rural North Carolina and (b) how integrated care interventions like CRx-CKD can address CKD multimorbidity in rural North Carolina. In Aim 2, we will develop an implementation blueprint based on the findings of Aim 1 and an assessment of organizational readiness to implement change. We will engage providers and clinic navigators, train them on the CRx-CKD intervention, and test the CRx-CKD integrated clinical workflow using quality improvement strategies. In Aim 3, we will conduct a pragmatic individual-randomized, two- arm (usual care + CRx-CKD (treatment) and usual care (control)) single-blind trial in 25 rural primary care clinics in 12 rural eastern North Carolina counties (N=634 adults with CKD) to assess the effect of CRx-CKD on acute healthcare utilization (primary outcome), self-efficacy for finding resources, knowledge and sharing of integrated care resources, resource use, number of unmet needs over time, ambulatory care utilization, and health-related quality of life. We hypothesize that 12-month acute healthcare utilization will differ between participants receiving CRx-CKD and those receiving usual care.