NEPHrOLOgy NursINg JOurNaL
Utilizing Telehealth Education for Persons with Chronic
Kidney Disease Stages 4-5: Eliminating Barriers
at the Patient and Provider Level
Vicki Montoya, PhD, APRN, FNP-BC, Desiree A. Díaz, PhD, APRN, FNP-BC, CNE, CHSE-A,
ANEF, FSSH, FAAN, and Gregory E. Gilbert, EdD, MSPH, PStat
NCPD 1.3 contact hours/CEPTCs
Home dialysis rates for patients with end stage kidney
disease (ESKD) are improving slowly in relation to the Copyright 2024 American Nephrology Nurses Association
lofty goal set by the Advancing American Kidney Health
Montoya, V., Diaz, D.A., & Gilbert, G.E. (2024). Utilizing tele-
(AAKH) Executive Order in 2019 that states 80% of new
health education for persons with chronic kidney disease
patients with ESKD receive home dialysis or a transplant stages 4-5: Eliminating barriers at the patient and provider
by 2025 (U.S. Department of Health and Human Services level. Nephrology Nursing Journal, 51(5), 443-452.
[HHS], n.d.). Data show that home dialysis rates have https://doi.org/10.37526/1526-744X.2024.51.5.443
improved minimally from 12.6% in 2019 (United States
Renal Data System [USRDS], 2021) to 13.3% in 2021 Home dialysis rates have improved little over the past five
(USRDS, 2023). Kidney transplantation rates also show years. Lack of pre-dialysis patient education persists as an
little improvement through 2021, with 4 in 100 person- obstacle precluding greater improvement. In this study, bar-
years receiving a transplanted kidney (USRDS, 2023). riers to chronic kidney disease (CKD) education at patient
Most persons initiating dialysis in 2021 did so with in-cen- and provider levels were addressed using telehealth educa-
ter hemodialysis instead of home dialysis (USRDS, 2023). tion for patients with CKD Stages 4-5 in a nonacademic out-
The stagnated progress toward the AAKH goal indicates patient nephrology practice. A quasi-experimental design
that additional effort is needed at multiple levels, but espe- was used to compare patients (n = 31) who received tele-
cially at the intersection of the patient and clinical level, health education to those in usual care. CKD Knowledge
where nursing can have a major impact. subscales of kidney function, slowing the progression of
CKD, and options for treatment of kidney failure were
Background and Significance measured pre-education, post-education, and three
months later. There was no significant difference in CKD
One policy goal of the AAKH initiative is to “improve Knowledge scores over time or in treatment groups.
access to and the quality of patient-centered treatment Telehealth CKD education offers flexible options to address
options” (HHS, n.d., p. 4). The first objective under this patient/provider barriers and potentially improve patient
goal includes improved patient education for people liv- choice of home dialysis therapies.
ing with kidney disease and their caregivers, and facilitat-
Keywords:
Vicki Montoya, PhD, APRN, FNP-BC, is an Assistant Professor, Telehealth, chronic kidney disease, CKD, CKD education, home
College of Nursing, University of Central Florida, Orlando FL; a dialysis, Stages 4-5 CKD, barriers.
Nephology Nurse Practitioner, Central Florida Kidney Specialists of
Central Florida; and a member of the Nephrology Nursing Journal
Editorial Board.
Desiree A. Díaz, PhD, APRN, FNP-BC, CNE, CHSE-A, ANEF, FSSH, Learning Outcome
FAAN, is Director, the Hispanic Serving Healthcare Professionals After completing this learning activity, the learner will utilize flexible
Certificate Program, an Undergraduate Simulation Coordinator, the telehealth delivery options and resources for pre-dialysis chronic
ENFERMERIA Faculty Excellence Scholar, and a Professor, College of kidney disease patient education.
Nursing, University of Central Florida, Orlando FL.
Gregory E. Gilbert, EdD, MSPH, PStat, is a Statistician,
SigmaStatsTM Consulting, LLC, Charleston, SC. Instructions for NCPD Contact Hours and CEPTCs
Funding: Funding for this study was received from the American 1) Read the article and complete the evaluation through the ANNA
Nephrology Nurses Association. Online Library at annanurse.org/library
Acknowledgment: The authors would like to thank the nephrologists 2) Visit “My Account” to view/print certificate.
at the Oakwater office of Central Florida Kidney Specialists who par- 3) Deadline for submission October 31, 2026.
ticipated in this study, including Dr. Jeffrey Cohen, Dr. Arvind Madan, Fees: Member: $15.00 | Non-Member: $30.00 NNJ 2427
Dr. Joaquin Rosario, and Dr. Javed Syed.
Nephrology Nursing Journal September-October 2024 Vol. 51, No. 5 443
, Utilizing Telehealth Education for Persons with Chronic Kidney Disease Stages 4-5:
Eliminating Barriers at the Patient and Provider Level
ing patient-centered transitions to safe and effective treat- Aim
ments for kidney failure. The goal of this study was to offer pre-dialysis tele-
One obstacle precluding substantial improvement in health CKD education in a nonacademic nephrology
home dialysis rates has been identified as lack of pre-dial- office setting using readily available tools to close the
ysis patient education (Chan et al., 2019; Shukla et al., learning gap related to the patient: knowledge of kidney
2019). According to Narva and colleagues (2016), barriers function, steps to slow the progression of CKD, and treat-
to pre-dialysis patient chronic kidney disease (CKD) edu- ment options for kidney failure. Specific aims included:
cation can occur at three levels, the patient level (e.g., low • To determine the best practices to deliver pre-dialysis
health literacy and numeracy, access to CKD informa- CKD education to nephrology office patients regard-
tion), the provider level (e.g., lack of time, lack of agree- ing kidney function, slowing the progression of CKD,
ment on timing and suitability for initiating education), and options for treatment of kidney failure.
and the system level (e.g., limited incentives for educa- • To evaluate patient/caregiver perceived ease of learn-
tion, limited decision support tools, lack of interdiscipli- ing for pre-dialysis CKD education via the telehealth
nary care models). The reimbursement for kidney disease CKD education platform (TCEP) vs. education meth-
education has been available to physicians, advanced ods used in usual care.
practice nurses, and physician assistants through the
Centers for Medicare & Medicaid Services (CMS, n.d.) Methods
since 2010. It is disappointing that provider reimburse-
ment for CKD education does not appear to be the key
to more patient CKD education. Shukla and colleagues Design
(2022) examined the rate of home dialysis initiation in A quasi-experimental interrupted time series compari-
adult Medicare recipients as associated with the available son group design was used to evaluate best practices for
kidney disease education reimbursement. Of the nearly delivery of pre-dialysis education via TCEP. Non-
400,000 Medicare beneficiaries who received their first- equivalent groups were used. A portion of the participants
ever dialysis during the study, only 0.9% received any received current pre-dialysis CKD education as a part of
pre-dialysis education, with lower odds of education for usual nephrology care and the other participants received
persons with African-American race, Hispanic ethnicity, pre-dialysis education via the TCEP. Inclusion of the
or the presence of heart failure or albuminemia. Further patient’s care partner in education was encouraged.
multivariate analysis showed that recipients of the kidney
disease education were twice as likely to begin dialysis Sample/Setting
with a home therapy. Thirty-one patients participated in the study.
While CKD education provided by a multidisciplinary Convenience sampling was used for patients with a diag-
team, typically composed of a nephrologist, advanced nosis of CKD Stages 4-5. The sample was drawn from
practice nurse, dialysis nurse, dietician, and a social work- supporting physicians’ (n = 4) patient list at a single site in
er, has shown improved patient adoption of home dialysis a large urban nephrology practice. A computerized reg-
therapies (Cassidy et al., 2018; Manns et al., 2005, Polner istry was used to identify potential participants based on
et al., 2022), many nephrology teams or providers func- the ICD-10 code. Inclusion criteria for participants were
tion in a nonacademic setting, and access to a true multi- based on an estimated glomeruler filtration rate (eGFR) of
disciplinary team or new innovative options for pre-dialy- less than 30mL/min/1.73m2 and age greater than 18
sis CKD education are limited or not readily accessible. years. Exclusion criteria were limited to disabilities that
CKD education via telehealth is a potential option to limit the patient’s ability to communicate effectively, pri-
teach the patient with CKD much-needed information to mary language that was not English, or history of dialysis
make informed decisions on the management of their kid- or transplantation.
ney disease (Tuot & Boulware, 2017). The setting for the study was a single, large nephrolo-
gy practice in central Florida with 35 nephrologists and 20
Operational Definition advanced practitioners (nurse practitioners and physician
Telehealth is “the use of electronic information and assistants). One primary office location of the practice was
telecommunication technologies to support long-distance used.
clinical health care, patient and professional health-relat-
ed education, health administration, and public health” Procedures
(Health Resources and Services Administration, 2022, p. This study was approved by the university Interna-
1). Allen and colleagues (2024) found that most patients tional Review Board (IRB). Patient verbal consent was
with CKD are amenable to online or digital methods for obtained prior to participation. Small gift cards were
education, with 68% of the patients using the Internet or given to participants after completion of data at each of
other technologies daily (e.g., cell phone or tablet), and the three time points.
33% using some form of social media daily (e.g., All participants received CKD education in one of two
Twitter/X, Facebook). ways: via TCEP or usual care (i.e., literature/handouts,
discussion with the nephrologist, and/or CKD education
444 Nephrology Nursing Journal September-October 2024 Vol. 51, No. 5
Utilizing Telehealth Education for Persons with Chronic
Kidney Disease Stages 4-5: Eliminating Barriers
at the Patient and Provider Level
Vicki Montoya, PhD, APRN, FNP-BC, Desiree A. Díaz, PhD, APRN, FNP-BC, CNE, CHSE-A,
ANEF, FSSH, FAAN, and Gregory E. Gilbert, EdD, MSPH, PStat
NCPD 1.3 contact hours/CEPTCs
Home dialysis rates for patients with end stage kidney
disease (ESKD) are improving slowly in relation to the Copyright 2024 American Nephrology Nurses Association
lofty goal set by the Advancing American Kidney Health
Montoya, V., Diaz, D.A., & Gilbert, G.E. (2024). Utilizing tele-
(AAKH) Executive Order in 2019 that states 80% of new
health education for persons with chronic kidney disease
patients with ESKD receive home dialysis or a transplant stages 4-5: Eliminating barriers at the patient and provider
by 2025 (U.S. Department of Health and Human Services level. Nephrology Nursing Journal, 51(5), 443-452.
[HHS], n.d.). Data show that home dialysis rates have https://doi.org/10.37526/1526-744X.2024.51.5.443
improved minimally from 12.6% in 2019 (United States
Renal Data System [USRDS], 2021) to 13.3% in 2021 Home dialysis rates have improved little over the past five
(USRDS, 2023). Kidney transplantation rates also show years. Lack of pre-dialysis patient education persists as an
little improvement through 2021, with 4 in 100 person- obstacle precluding greater improvement. In this study, bar-
years receiving a transplanted kidney (USRDS, 2023). riers to chronic kidney disease (CKD) education at patient
Most persons initiating dialysis in 2021 did so with in-cen- and provider levels were addressed using telehealth educa-
ter hemodialysis instead of home dialysis (USRDS, 2023). tion for patients with CKD Stages 4-5 in a nonacademic out-
The stagnated progress toward the AAKH goal indicates patient nephrology practice. A quasi-experimental design
that additional effort is needed at multiple levels, but espe- was used to compare patients (n = 31) who received tele-
cially at the intersection of the patient and clinical level, health education to those in usual care. CKD Knowledge
where nursing can have a major impact. subscales of kidney function, slowing the progression of
CKD, and options for treatment of kidney failure were
Background and Significance measured pre-education, post-education, and three
months later. There was no significant difference in CKD
One policy goal of the AAKH initiative is to “improve Knowledge scores over time or in treatment groups.
access to and the quality of patient-centered treatment Telehealth CKD education offers flexible options to address
options” (HHS, n.d., p. 4). The first objective under this patient/provider barriers and potentially improve patient
goal includes improved patient education for people liv- choice of home dialysis therapies.
ing with kidney disease and their caregivers, and facilitat-
Keywords:
Vicki Montoya, PhD, APRN, FNP-BC, is an Assistant Professor, Telehealth, chronic kidney disease, CKD, CKD education, home
College of Nursing, University of Central Florida, Orlando FL; a dialysis, Stages 4-5 CKD, barriers.
Nephology Nurse Practitioner, Central Florida Kidney Specialists of
Central Florida; and a member of the Nephrology Nursing Journal
Editorial Board.
Desiree A. Díaz, PhD, APRN, FNP-BC, CNE, CHSE-A, ANEF, FSSH, Learning Outcome
FAAN, is Director, the Hispanic Serving Healthcare Professionals After completing this learning activity, the learner will utilize flexible
Certificate Program, an Undergraduate Simulation Coordinator, the telehealth delivery options and resources for pre-dialysis chronic
ENFERMERIA Faculty Excellence Scholar, and a Professor, College of kidney disease patient education.
Nursing, University of Central Florida, Orlando FL.
Gregory E. Gilbert, EdD, MSPH, PStat, is a Statistician,
SigmaStatsTM Consulting, LLC, Charleston, SC. Instructions for NCPD Contact Hours and CEPTCs
Funding: Funding for this study was received from the American 1) Read the article and complete the evaluation through the ANNA
Nephrology Nurses Association. Online Library at annanurse.org/library
Acknowledgment: The authors would like to thank the nephrologists 2) Visit “My Account” to view/print certificate.
at the Oakwater office of Central Florida Kidney Specialists who par- 3) Deadline for submission October 31, 2026.
ticipated in this study, including Dr. Jeffrey Cohen, Dr. Arvind Madan, Fees: Member: $15.00 | Non-Member: $30.00 NNJ 2427
Dr. Joaquin Rosario, and Dr. Javed Syed.
Nephrology Nursing Journal September-October 2024 Vol. 51, No. 5 443
, Utilizing Telehealth Education for Persons with Chronic Kidney Disease Stages 4-5:
Eliminating Barriers at the Patient and Provider Level
ing patient-centered transitions to safe and effective treat- Aim
ments for kidney failure. The goal of this study was to offer pre-dialysis tele-
One obstacle precluding substantial improvement in health CKD education in a nonacademic nephrology
home dialysis rates has been identified as lack of pre-dial- office setting using readily available tools to close the
ysis patient education (Chan et al., 2019; Shukla et al., learning gap related to the patient: knowledge of kidney
2019). According to Narva and colleagues (2016), barriers function, steps to slow the progression of CKD, and treat-
to pre-dialysis patient chronic kidney disease (CKD) edu- ment options for kidney failure. Specific aims included:
cation can occur at three levels, the patient level (e.g., low • To determine the best practices to deliver pre-dialysis
health literacy and numeracy, access to CKD informa- CKD education to nephrology office patients regard-
tion), the provider level (e.g., lack of time, lack of agree- ing kidney function, slowing the progression of CKD,
ment on timing and suitability for initiating education), and options for treatment of kidney failure.
and the system level (e.g., limited incentives for educa- • To evaluate patient/caregiver perceived ease of learn-
tion, limited decision support tools, lack of interdiscipli- ing for pre-dialysis CKD education via the telehealth
nary care models). The reimbursement for kidney disease CKD education platform (TCEP) vs. education meth-
education has been available to physicians, advanced ods used in usual care.
practice nurses, and physician assistants through the
Centers for Medicare & Medicaid Services (CMS, n.d.) Methods
since 2010. It is disappointing that provider reimburse-
ment for CKD education does not appear to be the key
to more patient CKD education. Shukla and colleagues Design
(2022) examined the rate of home dialysis initiation in A quasi-experimental interrupted time series compari-
adult Medicare recipients as associated with the available son group design was used to evaluate best practices for
kidney disease education reimbursement. Of the nearly delivery of pre-dialysis education via TCEP. Non-
400,000 Medicare beneficiaries who received their first- equivalent groups were used. A portion of the participants
ever dialysis during the study, only 0.9% received any received current pre-dialysis CKD education as a part of
pre-dialysis education, with lower odds of education for usual nephrology care and the other participants received
persons with African-American race, Hispanic ethnicity, pre-dialysis education via the TCEP. Inclusion of the
or the presence of heart failure or albuminemia. Further patient’s care partner in education was encouraged.
multivariate analysis showed that recipients of the kidney
disease education were twice as likely to begin dialysis Sample/Setting
with a home therapy. Thirty-one patients participated in the study.
While CKD education provided by a multidisciplinary Convenience sampling was used for patients with a diag-
team, typically composed of a nephrologist, advanced nosis of CKD Stages 4-5. The sample was drawn from
practice nurse, dialysis nurse, dietician, and a social work- supporting physicians’ (n = 4) patient list at a single site in
er, has shown improved patient adoption of home dialysis a large urban nephrology practice. A computerized reg-
therapies (Cassidy et al., 2018; Manns et al., 2005, Polner istry was used to identify potential participants based on
et al., 2022), many nephrology teams or providers func- the ICD-10 code. Inclusion criteria for participants were
tion in a nonacademic setting, and access to a true multi- based on an estimated glomeruler filtration rate (eGFR) of
disciplinary team or new innovative options for pre-dialy- less than 30mL/min/1.73m2 and age greater than 18
sis CKD education are limited or not readily accessible. years. Exclusion criteria were limited to disabilities that
CKD education via telehealth is a potential option to limit the patient’s ability to communicate effectively, pri-
teach the patient with CKD much-needed information to mary language that was not English, or history of dialysis
make informed decisions on the management of their kid- or transplantation.
ney disease (Tuot & Boulware, 2017). The setting for the study was a single, large nephrolo-
gy practice in central Florida with 35 nephrologists and 20
Operational Definition advanced practitioners (nurse practitioners and physician
Telehealth is “the use of electronic information and assistants). One primary office location of the practice was
telecommunication technologies to support long-distance used.
clinical health care, patient and professional health-relat-
ed education, health administration, and public health” Procedures
(Health Resources and Services Administration, 2022, p. This study was approved by the university Interna-
1). Allen and colleagues (2024) found that most patients tional Review Board (IRB). Patient verbal consent was
with CKD are amenable to online or digital methods for obtained prior to participation. Small gift cards were
education, with 68% of the patients using the Internet or given to participants after completion of data at each of
other technologies daily (e.g., cell phone or tablet), and the three time points.
33% using some form of social media daily (e.g., All participants received CKD education in one of two
Twitter/X, Facebook). ways: via TCEP or usual care (i.e., literature/handouts,
discussion with the nephrologist, and/or CKD education
444 Nephrology Nursing Journal September-October 2024 Vol. 51, No. 5
