Community Health Worker–integrated outpatient care to boost home dialysis use

Is this trial a fit for you?

A plain-English reading of the study's rules. Only the study team can confirm whether you qualify.

What this trial studies

Participants with advanced chronic kidney disease who are followed at Montefiore will be assigned to receive interdisciplinary care with a Community Health Worker (CHW) integrated into care or to interdisciplinary care alone. The team will use mixed quantitative and qualitative measures organized by the RE-AIM framework to evaluate feasibility, acceptability, and possible effects. Main outcomes include changes in home dialysis selection or initiation, patient-reported health-related social needs, and patient engagement at one year. The protocol was refined with input from community partners and brings together experts in CKD care, social determinants of health, and implementation science.

Why it matters

Who can join: the full rules

Inclusion Criteria:

* Age ≥ 18 years
* Advanced CKD (defined by estimated glomerular filtration rate (eGFR) of 25 ml/min/1.73m2 or less using the 2021 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation)
* English or Spanish speaking
* Provide informed consent
* Followed by a nephrologist at Montefiore and seen within last 12 months
* Willing to receive interdisciplinary care (i.e., nurse practitioner facilitated CKD education and care coordination)

Exclusion Criteria:

* Active malignancy
* Anticipated survival is less than 1 year as determined by the patient's treating nephrologist
* Opting to do medical management only (non- dialysis supportive care) for management of their kidney failure
* Plan to relocate outside of New York City within the next 12 months

Where it's running

• Albert Einstein College of Medicine
  The Bronx, New York, United States Recruiting

Study contacts

• Principal investigator: Tanya S Johns, MD, MHS — Albert Einstein College of Medicine
• Study coordinator: Yaxkyn A Mejia, BS
• Email: yaxkyn.mejia@einsteinmed.edu
• Phone: 718-430-2064

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How to take part

1. Review the eligibility criteria above with your treating physician.
2. Check the official listing on ClinicalTrials.gov for the latest contact details and recruitment status.
3. Contact the study coordinator or principal investigator to ask for pre-screening. Pre-screening is free and never obligates you to enroll.